Adjuvant chemotherapy with cisplatin, ifosfamide, and doxorubicin followed by radiotherapy in localized uterine sarcomas: results of a case-control study with radiotherapy alone

Uterine sarcoma is a poor prognosis disease, with a high risk of metastatic relapse. We conducted a study of adjuvant chemotherapy with cisplatin, ifosfamide, and doxorubicin followed by radiotherapy (n=18). The results were then compared in a matched case-controlled study to radiotherapy alone (n=16) or no therapy at all (n=2). Chemotherapy consisted in three cycles of adriamyein-platinum-ifosfamide (API) (doxorubicin 60 mg /m2 on day 1; cisplatin 100 mg /m2 on day 2; ifosfamide 5 g /m2 on day 1+mesna 5 g /m2 on day 1+granulocyte colony-stimulating factor; q 3 weeks). Drug doses were reduced (20% for ifosfamide and cisplatin) four times (four patients) due to hematologic toxicity. Compared to a case-control study of adjuvant radiotherapy alone, results were not decreased by the addition of a toxic chemotherapy.

CONCLUSION

Adjuvant API chemotherapy followed by radiotherapy is a feasible protocol; a multicenter phase III study comparing radiotherapy alone versus API chemotherapy followed by radiotherapy just began in France.

Les métastases ganglionnaires du cancer épithélial de l'ovaire sont-elles chimio-sensibles ? Étude comparative de la lymphadénectomie première ou après chimiothérapie

OBJECTIVE

The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3).

PATIENTS AND METHODS

The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1).

RESULTS

In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates.

DISCUSSION AND CONCLUSIONS

The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.

Steroid metabolism in vitro during final oocyte maturation in white croaker Micropogonias furnieri (Pisces: Scianidae)

Final oocyte maturation (FOM) is a process involving a complex set of genetical, biochemical, and morphological mechanisms. FOM involves the shift of a post-vitellogenic follicle to a pre-ovulated oocyte, which is necessary for fertilization by spermatozoan to occur. This process is regulated by a maturation-inducing steroid (MIS) at the follicular level. In other species of scienids fish the MIS, a hydroxilated derivatives of progestagen 17, 20beta, 21-trihydroxy-4-pregnen-3-one (20beta-S), was identified. Although Micropogonias furnieri is the second fishery resource of Uruguay, basic knowledge about its endocrine process is very scarce. The aim of this work was to investigate what steroids are synthesized in vitro by the oocyte follicle of M. furnieri during the maturation process. Fragments of ovary (1 g) in three stages: post-vitellogenic (PV), maturing (Mtg), and mature (M) were incubated with 1 mug.g-1 of tritiated progesterone (P) at 30, 60, and 180 min. After extraction with ethanol and dichloromethane, steroid metabolites were purified by TLC and rpHPLC. Two progesterone derivatives with identical chromatographic properties of 20beta-S and 17,20beta-dihydroxy-4-pregnen-3-one (17,20beta-P) were purified. In other Teleost fish these steroids are biologically activ as MIS. The 17,20beta-P was clearly detected in Mtg and M stages and confirmed by enzymatic oxidation with enzyme 20beta-HSD. The 20beta-S was strongly detected in all Mtg oocytes. The results do not corroborate 20beta-S as a major hormone synthesized in the ovary in FOM as occurs in other scienid fish. A differential steroid synthesis in the advanced oocyte stages suggests that the 20beta-S is acting as a MIS in M. furnieri.

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.

Les adénocarcinomes du col utérin ont-ils un plus mauvais pronostic que les carcinomes épidermoïdes ?

OBJECTIVE

The objective of this study was to examine the influence of histology on the outcome of patients with cervix carcinoma, treated with radiotherapy and radical surgery.

PATIENTS AND METHODS

Clinical, histological, therapeutical and outcome data of 360 patients with stage IB-II cervix carcinoma patients (45 adenocarcinomas and 315 squamous cell carcinoma) managed between 1985 and 1998 were collected from the database of the Institut Gustave-Roussy.

RESULTS

The incidence of adenocarcinomas slightly increased during the study period (P =0.07). Histological grade was higher for squamous cell carcinoma than for adenocarcinoma (P =0.08). Adenocarcinomas were smaller than squamous cell carcinoma (P =0.06). With only 38% of sterilized hysterectomy specimen vs 52% for squamous cell carcinomas (P =0.07), adenocarcinoma seemed to be less radiosensitive. With a median follow-up of 67 months, histological type did not influence survival.

DISCUSSION AND CONCLUSIONS

Our study demonstrates that radiosensitivity is different between adenocarcinoma and squamous cell carcinoma of the cervix and that surgery may compensate the low radiosensitivity of adenocarcinoma.

Are nodal metastases in ovarian cancer chemoresistant lesions? Analysis of nodal involvement in 105 patients treated with preoperative chemotherapy

BACKGROUND

To report the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy) and patients who underwent lymphadenectomy after chemotherapy.

STUDY DESIGN

The rates of nodal involvement in 205 patients with EOC who underwent complete bilateral pelvic and para-aortic lympadenectomy between 1985 and 2001 were analyzed: 100 women underwent this surgical procedure before chemotherapy (initial surgery) and 105 at the end of chemotherapy (second-look surgery for 77 patients with 6 courses of a platinum-based regimen) or during chemotherapy (interval debulking surgery for 28 patients with 3 courses of a platinum-based regimen containing paclitaxel).

RESULTS

The overall frequency of lymph-node involvement was 35% (35/100) in patients treated with initial surgery, 54% (15/28) in the interval debulking surgery group and 36% (28/77) in the second-look surgery group. In patients with Stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53% (15/28), 58% (15/26) and 48% (20/42). The rates of nodal involvement in patients who underwent lymphadenectomy prior to or after chemotherapy were not statistically different whatever the stage of the disease. Adding paclitaxel to the platinum-based regimen does not seem to improve node sterilization rates.

CONCLUSIONS

The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy. Such results suggest that nodal metastases are not as chemosensitive as peritoneal lesions. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.

Prognostic value of lymphovascular space invasion determined with hematoxylin–eosin staining in early stage cervical carcinoma: results of a multivariate analysis

BACKGROUND

Our aim was to study the prognostic value of the presence of lymphovascular space invasion (LVSI) in patients with stage IB and II cervical carcinoma treated by initial surgery.

PATIENTS AND METHODS

A retrospective analysis was performed on 193 patients who underwent, between 1985 and 1998, an initial radical hysterectomy with pelvic (+/- para-aortic) lymphadenectomy using midline laparotomy for stage IB (180 patients) or II (13 patients) cervical carcinoma. Postoperative therapy was delivered according to prognostic factors.

RESULTS

The rate of LVSI correlated significantly with tumor stage, nodal status and the location of positive nodes. Using univariate analysis, tumor size (<4 or >/= 4 cm), LVS status and nodal status were prognostic factors. At multivariate analysis, two prognostic factors were identified: LVS status and nodal status. In a subgroup of 89 patients with a small tumor (</=2 cm) and absence of nodal or isthmic involvement, the overall survival was significantly correlated with the presence of LVSI.

CONCLUSIONS

LVSI is a frequent occurrence in patients with early stage cervical cancer. It represents an unfavorable prognostic factor in univariate and multivariate analyses. Such results suggest that improvement is needed in the treatment of patients with a small tumor and LVS invasion.

Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients

BACKGROUND

The aim of this series was to study the clinical impact of initial surgical management, particularly of uterine morcellation. on patients treated for uterine sarcoma (US).

PATIENTS AND METHODS

Clinical data of 157 patients treated for US in our institution were analyzed. Data concerning this initial management was available in 123 patients. We consider as "uterine morcellation" the following procedures: hysterectomy (vaginal or laparoscopic) with uterine "morcellation" described in the surgical report, myomectomy, operative hysteroscopy or simple biopsy of the tumor. The clinical outcome considered as related to the initial surgical procedure was the rate of pelvic recurrence at three months.

RESULTS

Of the 123 patients for whom data concerning initial surgical management was available, uterine morcellation was performed in 34 (28%). One-hundred and sixteen patients had a follow-up > or = 3 months after surgery. Recurrence was observed in 87 patients. Six had a pelvic recurrence within three months following the end of the treatment. The rates of pelvic recurrence at three months according or not to uterine morcellation were 3/31 (8.82%) and 3/79 (3.66%) respectively (p = 0.25). The rates of pelvic recurrences at six months were not different in either group (10% versus 10.4%). Overall and disease-free survival were similar in both groups.

CONCLUSION

In this preliminary study, the rates of pelvic recurrence at three months was increased in patients who underwent uterine morcellation for US but this difference was not statistically significant. A prospective study should be performed in order to clarify the prognostic value of initial surgery in patients treated for US and to recommend an adequate surgical management for patients in whom the diagnosis of uterine sarcoma is suspected before the surgical procedure.

[Spontaneous otogenic pneumocephalus]

Otogenic pneumocephalus is uncommon. Typical causes include trauma, tumor, infection, and nasosinusal or mastoid surgery but spontaneous otogenic pneumocephalus is very exceptional. We report a case of spontaneous otogenic pneumocephalus located in the left temporal lobe revealed by sudden onset aphasia. The temporal pneumatocele was cured through an epidural subtemporal approach with needle puncture of the aeroma and duroplasty. Two years after surgery, no recurrence was observed and the patient remained symptom free.

Prognostic factors for patients with advanced stage serous borderline tumours of the ovary

BACKGROUND

The aim of this study was to determine the prognostic factors for patients with advanced stage, low malignant potential ovarian tumour (LMPOT).

PATIENTS AND METHODS

A retrospective review of 80 patients with serous LMPOT and peritoneal implants treated at or referred to our institution was carried out.

RESULTS

Sixty-five patients had non-invasive implants. Fifteen patients had invasive implants. Twenty-nine patients had stage II and 51 patients had stage III disease. Three patients died of evolutive invasive disease and four of complications of treatment. The only prognostic factor of progression to 'evolutive invasive disease' is the pathologic subtype of peritoneal implants. The 5-year rates of evolutive invasive disease in patients with non-invasive implants and invasive implants were 2% and 31%, respectively (P <0.002).

CONCLUSIONS

In this series, the only prognostic factor for patients with advanced stage borderline tumour is the type of peritoneal implant. More patients died of the treatment's complications than of the disease itself. The patients' prognosis with non-invasive implants seems to be excellent, and conservative management could be discussed in younger patients.

Results of interval debulking surgery in advanced stage ovarian cancer: an exposed-non-exposed study

BACKGROUND

To study the results of interval debulking surgery (IDS) in patients treated for 'unresectable' advanced stage ovarian cancer compared with primary debulking surgery (PDS) followed by chemotherapy.

PATIENTS AND METHODS

An exposed-non-exposed study including a group of 34 patients who underwent an IDS and were matched to an historic control group of 34 patients treated with PDS.

RESULTS

Optimal cytoreductive surgery was achieved in 94% (32 out of 34) of patients in both groups. The rates of post-operative morbidity, blood transfusion and median length of hospitalisation were significantly reduced in the study (IDS) group, but survival did not differ in both groups.

CONCLUSIONS

IDS in patients with advanced stage ovarian cancer offers the same chance of survival as PDS, but it is better tolerated.

[Acoustic neuromas and serviceable hearing: choosing the surgical approach]

The principal objectives of acoustic neuroma surgery in the order of priority are absence of mortality and neurological morbidity, total removal of the lesion, preservation of facial function, and preservation of hearing. The aim of this work was to evaluate the selection criteria and the therapeutic strategy for hearing preservation in acoustic neuroma management. This retrospective study included 436 consecutive patients referred to our department for an acoustic neuroma. The population comprised 365 patients (84%) treated surgically, 66 patients (15%) managed conservatively, and 5 irradiated patients (1%). The mean age was 54 years (range: 13-87). The mean follow-up period was 24 months (range: 1-120). The surgical approaches were translabyrinthine in 294 (81%), retrosigmoid in 37 (10%), and through the middle fossa in 34 cases (9%). Approaches preserving the labyrinth were employed in patients aged less than 60 years with lesions measuring <or=2 cm and a serviceable hearing (pure tone average <50 dB and speech discrimination score >or=50%). A serviceable hearing was preserved in 53% of the cases with a serviceable hearing in 44% of the cases. Postoperative normal or subnormal facial function was obtained in 72 to 98% of cases depending on tumor size. Two cases (0.5%) of recurrence were reported. In conclusion, our surgical strategy based on age, tumor size and pre-operative hearing function permitted hearing preservation in 50% of selected cases, a high rate of facial function preservation and a low risk of recurrence.

[Results and fertility after conservative treatment of invasive epithelial ovarian cancer]

OBJECTIVE

The aim of this study is to assess the clinical outcome and fertility in patients managed conservatively for epithelial ovarian cancer (EOC).

PATIENTS

Datas of 42 patients treated conservatively for EOC were reviewed. Thirty-seven followed-up patients with complete data were analyzed. Optimal surgical staging was performed in two cases during the initial surgery and in 33 patients during a reassessment surgery. Six patients underwent a hysterectomy during this restaging surgery.

RESULTS

Among 31 patients treated conservatively following the restaging surgery, the FIGO staging distribution was: 24 stage IA (grade 1 n = 10; grade 2 n = 12; grade 3 n = 2); two stages IC; two stage II and two patients with initial stage unknown. Ten patients recurred (eight on the remaining ovary). The disease free survival at five years for patients with stage IA grade 1 and two tumors were respectively 89 and 66%. All patients with stage > IA recurred. Only five pregnancies (four spontaneous and one following IVF procedure) were obtained.

CONCLUSION

Conservative surgery for patients with EOC could be considered in young patient with stage IA grade 1 disease adequately staged and desiring to preserve fertility potential but should not performed in patients with FIGO stage > IA.

Novel mixed ligand technetium complexes as 5-HT1A receptor imaging agents

The synthesis, characterization and biological evaluation of two novel 3 + 1 mixed ligand 99mTc-complexes, bearing the 1-(2-methoxyphenylpiperazine) moiety, a fragment of the true 5-HT1A antagonist WAY 100635, is reported. Complexes at tracer level 99mTcO[(CH3CH2)2NCH2CH2N(CH2CH2S)2][o-CH3OC6H4N(CH2CH2)2NCH2CH2S], 99mTc-1, and 99mTcO[((CH3)2CH)2NCH2CH2N(CH2CH2S)2][o-CH3OC6H4N (CH2CH2)2NCH2CH2S], 99mTc-2, were prepared using 99mTc-glucoheptonate as precursor. For structural characterization, the analogous oxorhenium complexes, Re-1 and Re-2, were prepared by ligand exchange reaction using ReOCl3(PPh3)2 as precursor, and characterized by elemental analysis and spectroscopic methods. Complex Re-1 was further characterized by crystallographic analysis. Labeling was performed with high yield (>85%) and radiochemical purity (>90%) using very low ligand concentration. The structure of 99mTc complexes was established by comparative HPLC using the well-characterized oxorhenium analogues as references. In vitro binding assays demonstrated the affinity of these complexes for 5-HT1A receptors (IC50 : 67 and 45 nM for Re-1 and Re-2 respectively). Biological studies in mice showed the ability of 99mTc-1 and 99mTc-2 complexes to cross the intact blood-brain barrier (1.4 and 0.9% dose/g, respectively at 1 min post-inj.). The distribution of these complexes in various regions in rat brain is inhomogeneous. The highest ratio between areas reach and poor in 5-HT1A receptors was calculated for complex Tc-1 at 60 min p.i. (hippocampus/cerebellum = 1.7).

[Development of nutritional obesity in transgenic mice with an adrenergic receptivity in adipose tissue comparable with that of humans]

Obesity is characterized by an excessive development of fat mass which is a consequence of increased fat cell size and/or fat cell number. Several hormones and neurotransmitters are regulators of adipose tissue development and metabolism. Among them, catecholamines play a major role by acting through alpha 2- and beta-adrenergic receptors. Stimulation of alpha 2-adrenergic receptors induce inhibition of lipolysis in mature adipocytes as well as preadipocyte proliferation. The antilipolytic effect mediated by alpha 2-adrenergic receptors is in part responsible for the weak lipid mobilization of some fat deposits in humans (subcutaneous fat in particular). Changes in beta- and alpha 2-adrenergic receptors ratio and function have been proposed to explain the lipolytic disturbances described in some obese subjects. Human and rodent adipocytes differ considerably with respect to the balance between beta- and alpha 2-adrenergic receptors. Human adipocytes express mainly alpha 2- but very few beta 3-adrenergic receptors while the reverse is true for rodent adipocytes. Since no suitable animal model was available to study the contribution of alpha 2/beta-adrenergic balance in adipocytes in vivo, we combined gene targeting and transgenic approaches to create a mice with increased alpha 2/beta-adrenergic ratio in adipose tissue. Specifically, we have generated transgenic mice strains on a beta 3-adrenergic receptor knock-out background which express human alpha 2-adrenergic receptors. No particular phenotype was observed in mice maintained in normal diet whereas when fed a high fat diet, transgenic mice increased significantly body weight and fat mass. These results underline the physiologic relevance of the interaction of the presence of alpha 2-adrenergic receptors with a high fat diet in the control of adipose tissue development.

Hearing restoration with auditory brainstem implants after radiosurgery for neurofibromatosis type 2

The auditory brainstem implant (ABI) is designed to restore useful auditory sensations in patients with neurofibromatosis Type 2 (NF2). The implantation is usually performed at the time of tumor removal in patients who do not undergo radiation treatment. The authors evaluated the performance of ABIs in three patients with NF2 in whom vestibular schwannoma continued to grow after radiation treatment. These three patients with NF2 received a 21-channel ABI; a translabyrinthine approach was used for both the tumor removal and the ABI placement. The interval between radiosurgery and the tumor removal plus device implantation ranged from 2 to 11 years. In all cases, the tumor was growing and the patients presented with total deafness. The mean number of active electrodes in these three patients was equivalent to the average results reported in other patients who received ABIs. The patients in this study used the ABI regularly for everyday life and obtained useful levels of environmental sound recognition. It is concluded that hearing function can be rehabilitated using ABIs in patients with NF2, even if radiosurgery fails to control the tumor growth.