The influence of conservative surgical practices for malignant ovarian germ cell tumors

OBJECTIVE

To evaluate demographics, survival, and surgical trends for patients with malignant ovarian germ cell tumors.

METHODS

SEER data abstracted from 1988 to 2001 and analyzed using Kaplan-Meier and Cox regression models.

RESULTS

Of 760 patients, the median age was 23 years. Seventy-six percent of patients presented with stage I-II disease, and 24% with stage III-IV. Fifty-five percent were immature teratomas, 32% dysgerminomas, and 13% yolk sac tumors. Fertility-preserving surgery was performed in 41.2% (n = 313) of patients. In those <45 years old, the use of fertility-preserving surgery increased from 40.5% to 44.5% to 48.4% over the time periods 1988-1992, 1993-1997, 1998-2001 (P = 0.25). The survival of patients who underwent fertility-preserving surgery was not statistically different compared to those who underwent standard surgery (P = 0.26). Patients with stage I-II disease had improved survival compared to stage III-IV disease (97.6% vs. 85.5%, P < 0.001). The overall survival of women with dysgerminomas, immature teratomas, and yolk sac tumors was 99.5%, 94.3%, and 85.4%, respectively (P < 0.001). In multivariate analysis, older age, advanced stage, and yolk sac tumor histology predicted for poorer survival.

CONCLUSION

Our data suggests that the use of fertility-preserving surgery with concomitant surgical staging for germ cell cancers has increased without compromising survival.

Obesity and risk of biochemical failure for patients receiving salvage radiotherapy after prostatectomy

PURPOSE

Obesity has been proposed as an independent risk factor for patients undergoing surgery or radiotherapy (RT) for prostate cancer. Using body mass index (BMI) as a measure of obesity, we tested its role as a risk factor for patients receiving salvage RT after prostatectomy.

METHODS AND MATERIALS

Rates of subsequent biochemical relapse were examined in 90 patients who underwent salvage RT between 1984 and 2004 for biochemical failure after radical prostatectomy. Median follow-up was 3.7 years. The BMI was tested as a continuous and categorical variable (stratified as <25, 25-<30, and >or=30 kg/m(2)). Univariate and multivariate proportional hazards regression analyses were performed for clinical, pathologic, and treatment factors associated with time to relapse after salvage RT.

RESULTS

There were 40 biochemical failures after salvage RT with a median time to failure of 1.2 years. The BMI was not associated with adverse clinical, pathologic, or treatment factors. On multivariate analysis, obesity was independently significant (hazard ratio [HR], 1.2; p = 0.01), along with RT dose (HR, 0.7; p = 0.003) and pre-RT prostate-specific antigen level (HR, 1.2; p = 0.0003).

CONCLUSIONS

This study is weakly suggestive that obesity may be a risk factor for salvage RT patients. Whether this results from greater biologic aggressiveness or technical inadequacies cannot be answered by this study. Given the very high failure rate observed for severely obese patients, we propose that technical difficulties with RT are at play. This hypothesis is supported by the RT literature and could be prospectively investigated. Techniques that optimize targeting, especially in obese patients, perhaps seem warranted at this time.

Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study

BACKGROUND

The purpose was to identify the factors predictive of recurrence and survival in patients with high-risk (stage I, grade 3; stage IC, stage II, or clear cell) epithelial ovarian cancer after adjuvant therapy.

METHODS

Data was extracted from patients who underwent primary surgery followed by adjuvant therapy in 2 randomized trials by the Gynecologic Oncology Group (Protocols 95 and 157). Kaplan-Meier survival estimates and Cox proportional hazards model adjusted for covariates were used for analyses.

RESULTS

Of 506 patients (median age = 56.2 years), 347 (68.6%) had stage I and 159 (31.4%) had stage II cancers. The 5-year recurrence-free (RFS) and overall survivals (OS) were 75.5% and 81.7%, respectively. On multivariate analysis, older age, higher stage, higher grade, and malignant cytology were independent prognostic factors predictive for recurrence and poorer survival. The risk of recurrence was higher for those >/=60 versus < 60 years (hazards ratio [HR] = 1.57, 95% confidence interval [CI], 1.12-2.19), stage II (stage II: HR = 2.70, 95% CI, 1.41-5.16) versus stage IA or IB, grade 2 (HR = 1.84, 95% CI, 1.04-3.27) and grade 3 (HR = 2.47, 95% CI, 1.39-4.37) versus grade 1, and positive versus negative cytology (HR = 1.72, 95% CI, 1.21-2.45). By using these factors in a prognostic index, those with low-risk (no or 1 risk factor), intermediate-risk (2 factors), and high-risk (3-4 risk factors) disease had survivals of 88%, 82%, and 75%, respectively (P < .05).

CONCLUSIONS

Age, stage, grade, and cytology are important prognostic factors in high-risk early-stage epithelial ovarian cancer. This information may be used in the design of future clinical trials.

Do clear cell ovarian carcinomas have poorer prognosis compared to other epithelial cell types? A study of 1411 clear cell ovarian cancers

OBJECTIVE

To compare the clinico-pathologic characteristics and survival of women with clear cell versus other epithelial ovarian cancers.

METHODS

Data were obtained from the Surveillance, Epidemiology and End Results Program between 1988 and 2001 and analyzed using Kaplan-Meier and Cox proportional hazards models.

RESULTS

Of 28,082 women with epithelial ovarian cancer, 1411 (5%) had clear cell, 13,835 (49.3%) papillary serous, 3655 (13%) endometrioid, 2711 (9.7%) mucinous, and 6470 (23%) had unspecified histologies. The median age of overall patients was 64 years; with clear cell patients presenting at younger age (55 years). The proportion of clear cell histology was significantly higher in Asians versus Whites, Blacks, and others (11.1% versus 4.8%, 3.1%, and 5.5%; p<0.001). Clear cell carcinoma is more likely to be diagnosed at early-stage (67.3%) compared to 19.2% in serous, 61.6% endometrioid, and 61.3% in mucinous carcinomas (p<0.005). Retroperitoneal lymph node metastases were found in 13.6% of serous carcinomas, 7.9% clear cell, 7.3% endometrioid, and 3.8% of mucinous (p<0.001). Adjusted for stage, the 5-year disease-specific survival of patients with clear cell carcinoma is worse compared to serous: 85.3% vs. 86.4% for stage I, 60.3% vs. 66.4% stage II, 31.5% vs. 35.0% stage III, and 17.5% vs. 22.2% for stage IV, respectively (p<0.001). On multivariate analysis, age, stage, grade, histology, and surgical treatment were independent predictors of disease-specific survival.

CONCLUSIONS

Our data suggest that women with clear cell ovarian cancer present at a younger age, are more likely to be Asian, and have a poorer prognosis compared to serous cancers.

Prognostic factors and survival in 1396 patients with uterine leiomyosarcomas: emphasis on impact of lymphadenectomy and oophorectomy

BACKGROUND

The objectives of the current study were to determine the prognostic factors associated with disease-specific survival (DSS) and to analyze the role of lymphadenectomy (LND) and oophorectomy in the management of uterine leiomyosarcomas (LMS).

METHODS

Data were abstracted from the Surveillance, Epidemiology, and End Results database (1988-2003). Kaplan-Meier and Cox proportional hazards regression models were used for analyses.

RESULTS

The median age of the 1396 patients was 52 years. There were 951 patients (68.1%) with International Federation of Gynecology and Obstetrics (FIGO) stage I disease, 43 patients (3.1%) with stage II disease, 99 patients (7.1%) with stage III disease, and 303 patients (21.7%) with stage IV disease. Distribution by tumor grade included 87 patients with grade 1 tumors, 208 with grade 2, and 509 patients with grade 3 tumors. The 5-year DSS rates for patients with stage I, II, III, and IV disease were 75.8%, 60.1%, 44.9%, and 28.7%, respectively. Lymph node metastases were identified in 23 of 348 patients (6.6%) who underwent LND. The 5-year DSS rate was 26% in patients who had positive lymph nodes compared with 64.2% in patients who had negative lymph nodes (P < .001). Of 341 patients aged <50 years with stage I or II disease, 240 (70.4%) underwent oophorectomy. There was no difference in 5-year DSS based on oophorectomy. On multivariate analysis, older age at diagnosis, more recent year of diagnosis, African-American race, higher tumor grade, higher stage of disease, and lack of primary surgical treatment all were associated significantly with worse survival.

CONCLUSIONS

Independent predictors of DSS in patients with uterine LMS included age, race, stage, grade, and primary surgery. Oophorectomy was not found to have an independent impact on survival.

Racial disparities in surgical treatment and survival of epithelial ovarian cancer in United States

OBJECTIVE

To compare the racial differences in treatment and survival of epithelial ovarian cancer patients.

METHODS

Data were obtained from the Surveillance, Epidemiology, and End Results Program between 1988 and 2001 and analyzed using Kaplan-Meier methods and Cox proportional hazards regression.

RESULTS

Of the 24,038 women, 22,407 (93.2%) were non-Hispanic White, and 1,631 (6.8%) were African-American. Median age of Whites versus African-Americans was 65 versus 63 years, respectively (P < 0.001). Of the patients with early-stage (I-II) disease, 38.8% of Whites underwent lymphadenectomy with their primary surgery compared to only 32.8% of African-Americans (P = 0.005). In the overall study group, the 5-year disease-specific survival of Whites was significantly higher compared to the African-Americans (44.1% vs. 40.7%, P = 0.001). On multivariable analysis, age, race, stage, cell type, and grade of disease were all independent prognostic factors for survival.

CONCLUSION

Our data suggest that race is an independent prognostic factor for survival in epithelial ovarian cancer. In addition, African-Americans with early-stage cancer were less likely to undergo lymphadenectomy with their staging procedure. Furthermore, patient/physician education is needed to increase the number of patients undergoing surgical staging procedures for epithelial ovarian cancer.

Analysis of Phase II Studies on Targeted Agents and Subsequent Phase III Trials: What Are the Predictors for Success?

Purpose

To identify the characteristics of phase II studies that predict for subsequent “positive” phase III trials (those that reached the proposed primary end points of study or those wherein the study drug was superior to the standard regimen investigating targeted agents in advanced tumors.

Methods

We identified all phase III clinical trials of targeted therapies against advanced cancers published from 1985 to 2005. Characteristics of the preceding phase II studies were reviewed to identify predictive factors for success of the subsequent phase III trial. Data were analyzed using the χ2 test and logistic regression models.

Results

Of 351 phase II studies, 167 (47.6%) subsequent phase III trials were positive and 184 (52.4%) negative. Phase II studies from multiple rather than single institutions were more likely to precede a successful trial (60.4% v 39.4%; P < .001). Positive phase II results were more likely to lead to a successful phase III trial (50.8% v 22.5%; P = .003). The percentage of successful trials from pharmaceutical companies was significantly higher compared with academic, cooperative groups, and research institutes (89.5% v 44.2%, 45.2%, and 46.3%, respectively; P = .002). On multivariate analysis, these factors and shorter time interval between publication of phase II results and III study publication were independent predictive factors for a positive phase III trial.

Conclusion

In phase II studies of targeted agents, multiple- versus single-institution participation, positive phase II trial, pharmaceutical company-based trials, and shorter time period between publication of phase II to phase III trial were independent predictive factors of success in a phase III trial. Investigators should be cognizant of these factors in phase II studies before designing phase III trials.

Trends in demographic and clinical characteristics in women diagnosed with corpus cancer and their potential impact on the increasing number of deaths

OBJECTIVE

The purpose of this study was to determine factors responsible for the increasing number of deaths from corpus cancer over three time periods.

STUDY DESIGN

Data were collected from the Surveillance, Epidemiology and End Results database from 1988-2001. Kaplan-Meier and Cox proportional hazards regression analyses were performed.

RESULTS

Of 48,510 women with corpus cancer, there was an increase in the proportion of patients dying from advanced cancers (52.1% to 56.0% to 68.8%; P < .001), grade 3 disease (47.5% to 53.3% to 60.6%; P < .001), serous tumors (14.3% to 18.4% to 16.6%; P < .001), and sarcomas (19.1% to 20.4% to 27.2%; P < .001) over time. On multivariate analysis, older age, African American race, lack of primary staging procedures, advanced-stage, high-grade, and non-endometrioid histology were independent prognostic factors for worse survival.

CONCLUSION

Our data suggest that the increase in mortality in women with corpus cancer over the last 14 years may be related to an increased rate of advanced-stage cancers and high-risk histologies.

Prognostic factors and risk of extrauterine metastases in 3867 women with grade 1 endometrioid corpus cancer

OBJECTIVE

The purpose of this study was to evaluate the role of surgical staging in patients with grade 1 endometrioid uterine cancer.

STUDY DESIGN

Data were extracted from Surveillance, Epidemiology, and End Results Program from 1988 to 2001. Kaplan-Meier and Cox proportional hazards analyses were used to determine predictors for disease-specific survival.

RESULTS

Twelve thousand seven hundred and twelve women were reported with endometrioid carcinoma, including 3867 with grade 1 disease, of which 25.5% had stage IC or more advanced disease, 15.4% with disease extending beyond the uterine corpus, 7.3% with extrauterine metastases, and 3.3% with lymph node metastases. On multivariate analysis, younger age and earlier stage remained as significant prognostic factors for improved survival.

CONCLUSION

Since grade 1 endometrioid uterine cancers have a 15.4% risk of extrauterine spread, a complete surgical staging procedure is recommended when clinically feasible. Younger age and earlier stage are significant prognostic factors for improved survival.

Radiotherapy after prostatectomy: is the evidence for dose escalation out there?

PURPOSE

To study the effective doses of radiotherapy (RT) after prostatectomy in search for evidence of a dose-response.

METHODS AND MATERIALS

Original and available data from published studies of adjuvant and salvage RT after prostatectomy were analyzed in the context of biochemical tumor control probability (TCP) dose-response curves. Comparisons were made with dose-escalation studies of radical RT for localized disease. Arguments based on a microscopic vs. macroscopic disease dose-response relationships were used to interpret the clinical data.

RESULTS

The tumor control rates after salvage RT were consistent with the TCP dose-response curve of radical RT, suggesting the presence of macroscopic-equivalent disease among salvage patients. For radical RT, the dose to achieve 50% biochemical tumor control was 65.9 Gy (95% confidence interval [CI], 64.8-66.8) and the Slope(50) was 2.6%/Gy (95% CI, 2.3-3.0). For salvage RT, the corresponding values were 66.8 Gy (95% CI, 65.1-68.4) and 3.8%/Gy (95% CI, 2.5-7.6). For a comparable TCP, the dose for adjuvant RT was approximately 6 Gy lower, consistent with one-tenth the burden of local disease. The present doses for adjuvant or salvage RT in the range of 60-70 Gy appear to be still on the steep part of the TCP dose-response curve.

CONCLUSIONS

The effective doses and dose-response relation observed with RT after prostatectomy are consistent with the presence of macroscopic-equivalent disease for salvage patients and about a tenth of the residual disease for adjuvant patients. Greater doses would potentially achieve significantly greater disease-free control rates. A randomized trial with 250 patients comparing 64 vs. 70 Gy for salvage RT or 60 vs. 66 Gy for adjuvant RT would be capable of addressing this issue.

Role of complete lymphadenectomy in endometrioid uterine cancer

Although surgical pathological staging is the standard of care for uterine carcinoma, the benefits of a complete lymphadenectomy remain controversial. Evidence suggests that this procedure provides prognostic information and directs the use of appropriate adjuvant treatment in patients who are node-positive. Furthermore, it eliminates the need for adjuvant treatment in low-risk patients with negative nodes and no extrauterine spread of disease. Although the complications associated with this procedure raise the question as to whether all low-risk patients need a complete lymphadenectomy, the limitations of preoperative and intraoperative pathological analyses mean that lymphadenectomy in low-risk patients might still have merit. Future advances are warranted to enhance preoperative radiological and intraoperative pathological assessment to establish the risk of nodal disease. In this review, we assess the evidence on the prognostic and therapeutic benefits of a complete versus selective lymphadenectomy. Moreover, we discuss the complications associated with lymphadenectomy and identify subsets of low-risk patients who might not need to undergo this procedure.

Factors associated with the suboptimal treatment of women less than 55 years of age with early-stage ovarian cancer

OBJECTIVES

A significant number of young patients with early-stage ovarian cancer did not receive chemotherapy based on standard practice guidelines. We investigated factors associated with the suboptimal treatment in these women.

MATERIALS AND METHODS

Data were obtained from California Cancer Registry from 1994 to 1996. Kaplan-Meier and Cox proportional hazard methods were used.

RESULTS

Of 135 younger (<55 years) patients with stages IC-II epithelial ovarian cancers, 29 (21.5%) did not receive chemotherapy (group A) while the remaining 106 (78.5%) had adjuvant chemotherapy (group B). Women in group A were more likely to live in poor neighborhoods (58.6% vs. 38.7%; p=0.055), less likely to be seen by a gynecologic oncologist (13.8% vs. 39.6%; p=0.009), and had more grade 1 and 2 tumors (58.6% vs. 37.8%; p=0.049). The 5-year disease-specific survival of group A was 70.5% compared to 76.5% in group B (p=0.252). Of note, patients residing in poor neighborhoods had a statistically significant improvement in survival (from 65.5% to 86.0%; p=0.012) associated with chemotherapy, but this difference was not noted for women in non-poor neighborhoods (77.1% vs. 70.9%; p=0.574). On multivariate analysis, those treated by gynecologic oncologists were more likely to receive chemotherapy (95% CI:1.33-12.63; p=0.006).

DISCUSSION

A significant number of young women with stages IC-II epithelial ovarian cancer did not receive chemotherapy. The factors associated with this suboptimal treatment of young women with stages IC-II ovarian cancer include living in poor neighborhoods and lack of care by a gynecologic oncologist.

Long-Term Survivors Using Intraoperative Radiotherapy for Recurrent Gynecologic Malignancies

PURPOSE

To analyze the outcomes of therapy and identify prognostic factors for patients treated with surgery followed by intraoperative radiotherapy (IORT) for gynecologic malignancies at a single institution.

METHODS AND MATERIALS

We performed a retrospective review of 36 consecutive patients treated with IORT to 44 sites with mean follow-up of 50 months. The primary site was the cervix in 47%, endometrium in 31%, vulva in 14%, vagina in 6%, and fallopian tubes in 3%. Previous RT had failed in 72% of patients, and 89% had recurrent disease. Of 38 IORT sessions, 84% included maximal cytoreductive surgery, including 18% exenterations. The mean age was 52 years (range, 30-74), mean tumor size was 5 cm (range, 0.5-12), previous disease-free interval was 32 months (range, 0-177), and mean IORT dose was 1,152 cGy (range, 600-1,750). RT and systemic therapy after IORT were given to 53% and 24% of the cohort, respectively. The outcomes measured were locoregional control (LRC), distant metastasis-free survival (DMFS), disease-specific survival (DSS), and treatment-related complications.

RESULTS

The Kaplan-Meier 5-year LRC, DMFS, and DSS probability for the whole group was 44%, 51%, and 47%, respectively. For cervical cancer patients, the Kaplan-Meier 5-year LRC, DMFS, and DSS estimate was 45%, 60%, and 46%, respectively. The prognostic factors found on multivariate analysis (p <or= 0.05) were the disease-free interval for LRC, tumor size for DMFS, and cervical primary, previous surgery, and locoregional relapse for DSS. Our cohort had 10 Grade 3-4 complications associated with treatment (surgery and IORT) and a Kaplan-Meier 5-year Grade 3-4 complication-free survival rate of 72%.

CONCLUSIONS

Survival for pelvic recurrence of gynecologic cancer is poor (range, 0-25%). IORT after surgery seems to confer long-term local control in carefully selected patients.

Vulvar Melanoma

OBJECTIVES

To determine the prognostic factors associated with the survival of vulvar melanoma patients.

METHODS

Data were obtained from the Surveillance Epidemiology and End Results database from 1973 to 2003. Kaplan-Meier survival curves and Cox regression models were used for analysis.

RESULTS

Of the 644 vulvar melanoma patients, the median age was 68 years. Of these 572 women were white, 28 were Hispanic, 18 were African-American, and 14 were Asian. A total of 302 had localized disease, 168 had regional disease, and 28 had distant disease. Of the participants who underwent surgical resection, 171 (26.6%) had conservative surgery, 164 (25.5%) had radical excision, and 241 (37.5%) had unspecified surgical resections. One hundred seventy-nine (27.8%) had lymph node resections, and 33 patients had concurrent radiation therapy. Nodal metastases were identified in 58 (9%) of the participants. The 5-year disease-specific survival rates for those with localized, regional, and distant disease were 75.5%, 38.7%, and 22.1%, respectively (P<.001). Women aged 68 years or younger had a better survival rate than older patients (72.0% compared with 47.7%; P<.001). Those with 0, 1, and 2 or more positive lymph nodes had survival rates of 68.3%, 29%, and 19.5%, respectively (P<.001). In a multivariable analysis, younger age, localized disease, and negative lymph nodes were independent prognostic factors for improved survival.

CONCLUSION

Age, stage, and lymph node involvement were significant factors for survival in vulvar melanoma.

LEVEL OF EVIDENCE

III.

The outcomes of 27,063 women with unstaged endometrioid uterine cancer

BACKGROUND

Over two-thirds of patients with endometrioid uterine cancer in the Surveillance, Epidemiology and End Results program from 1988 to 2001 did not undergo a lymphadenectomy. These patients were compared to those who had a lymphadenectomy.

METHODS

Kaplan-Meier methods and Cox proportional hazards regression analyses were employed.

RESULTS

Of 39,396 women (median age: 65 years) with endometrioid uterine cancers, 12,333 (31.3%) underwent surgical staging procedures including lymphadenectomy. The remainder did not receive a lymphadenectomy. The 5-year disease-specific survival (DSS) of stages I-IV women who underwent lymphadenectomy were 95.5%, 90.4%, 73.8%, and 53.3% compared to 96.6%, 82.2%, 63.1%, and 26.9% in those without lymphadenectomy (p>0.05 for stage I; p<0.001 for stages II-IV). In stage I patients, those who did not receive lymphadenectomy had a higher proportion of tumors with grade 1 histology and/or disease limited to the endometrium compared to those who underwent lymphadenectomy (54.8 % vs. 34.7%; p<0.001, grade 1 disease; 26.6% vs. 15.9%; p<0.001, no myometrial invasion). In patients with stage I grade 3 disease, those who underwent lymphadenectomy had a better 5-year DSS than those without lymphadenectomy (90% vs. 85%; p=0.0001); however, no benefit for lymphadenectomy was seen for patients with stage I grade 1 (p=0.26) and grade 2 (p=0.14) disease. On multivariable analysis, younger age, Caucasian race, early-stage disease, low grade histology, and lymphadenectomy were independent prognostic factors for improved disease-specific survival.

CONCLUSIONS

Our data suggest that lymphadenectomy is associated with an improved survival in stage I grade 3 and more advanced endometrioid uterine cancers.

The impact of the absolute number and ratio of positive lymph nodes on survival of endometrioid uterine cancer patients

The aim of the study was to determine the impact of the absolute number and ratio of positive lymph nodes on the survival in node-positive endometrioid uterine cancer. Data were obtained from the National Cancer Institute Registry from 1988 to 2001. Analyses were performed using Kaplan–Meier and Cox proportional hazard methods. A total of 1222 women were diagnosed with stage IIIC-IV node-positive endometrioid corpus cancer. The 5-year disease-specific survival of women with 1, 2–5, and >5 positive nodes were 68.1, 55.1, and 46.1%, respectively (P<0.001). Increasing lymph node ratio, expressed as a percentage of positive nodes to total nodes identified (⩽10, >10–⩽50, and >50%), was associated with a decrease in survival from 77.3 to 60.7 to 40.9%, respectively (P<0.001). The absolute number of positive nodes and the lymph node ratio remained significant after adjusting for stage (IIIC vs IV) and the extent of lymphadenectomy (⩽20 vs >20 nodes). On multivariate analysis, the absolute number of positive nodes and lymph node ratio were significant independent prognostic factors for survival. Increasing absolute number of positive nodes and lymph node ratio are associated with a poorer survival in women with node-positive uterine cancers. The stratification of node-positive uterine cancer for prognostic and treatment purposes warrants further investigation.

Influence of the gynecologic oncologist on the survival of ovarian cancer patients

OBJECTIVE

To estimate the influence of gynecologic oncologists on the treatment and outcome of patients with ovarian cancer.

METHODS

Data were obtained from California Cancer Registry from 1994 to 1996. Kaplan-Meier and Cox proportional hazard methods were used for analyses.

RESULTS

Of 1,491 patients, the median age was 65 years (range: 13-100). Only 34.1% received care by gynecologic oncologists (group A) while 65.9% were treated by others (group B). Women in group A were more affluent (P<.001), were more educated (P=.036), were classified as white-collar employees (P=.128), and lived in urban regions (P<.001) compared with group B. Patients who saw gynecologic oncologists were more likely to have surgery as their initial treatment (91.9% versus 69.1%; P<.001), present with advanced (stage III-IV) cancers (78.2% versus 70.5%; P<.001), have more grade 3 tumors (61.7% versus 39.9%; P=.048), and receive chemotherapy (90.0% versus 70.1%; P<.001). Women in group B had a fourfold higher risk of having unstaged cancers (8.0% versus 2.1%; P<.001). The 5-year disease-specific survival of group A patients was 38.6% compared with 30.3% in group B (P<.001). On multivariable analysis, early stage, lower grade, and treatment by gynecologic oncologists were independent prognostic factors for improved survival. After adjusting for surgery and chemotherapy, there was no improvement in survival associated with care by gynecologic oncologists (hazard ratio=0.90, 95% confidence interval 0.78-1.03; P=.133).

CONCLUSION

In this study of 1,491 women, those who were treated by gynecologic oncologists were more likely to undergo primary staging surgery and receive chemotherapy. Stage, grade of disease, and treatment by gynecologic oncologists were important prognosticators.

Lymphadenectomy in endometrioid uterine cancer staging

BACKGROUND

The purpose of the current study was investigate the association between the number of lymph nodes examined and the probability of detecting at least a single lymph node involved by metastatic disease in patients with endometrioid corpus cancer.

METHODS

Demographic, clinicopathologic, and surgical information were obtained from the National Cancer Institute between 1990 and 2001. A logistic regression model was used to investigate the relation between the number of lymph nodes identified and the probability of detecting at least a single positive lymph node.

RESULTS

Of 11,443 patients, the median age was 64 years (range, 22-74 years). In all, 78.7% had stage I disease, 10.3% had stage II disease, and 11.0% had stage III disease; 31.5% had grade 1 histology, 40.6% had grade 2 histology, and 24.3% had grade 3 histology. The median number of lymph nodes reported was 9 (range, 1-90 lymph nodes). The median number of lymph nodes and the percent of patients with positive lymph nodes have increased from 1988 to 2001. An increasing number of lymph nodes removed was associated with a higher likelihood of identifying those with lymph node metastases. Based on the logistic regression model, the largest increase in probability of detecting at least a single positive lymph node was observed when 21 to 25 lymph nodes were resected (odds ratio [OR] of 1.45; 95% confidence interval [95% CI], 1.08-1.94 [P < .01]). Removing greater than 25 lymph nodes did not improve the statistical probability (OR of 1.23; 95% CI, 0.94-1.61 [P = .13]).

CONCLUSIONS

The current study data suggest that the removal of 21 to 25 lymph nodes significantly increases the probability of detecting at least 1 positive lymph node in endometrioid uterine cancer. The definition of an adequate lymphadenectomy deserves further investigation.

Prognostic factors for outcomes and complications for primary squamous cell carcinoma of the vagina treated with radiation

PURPOSE

To analyze the results of treatment and identify prognostic factors for primary squamous cell carcinoma (SCCA) of the vagina managed with radiotherapy at a single institution.

MATERIALS AND METHODS

Seventy-eight patients were analyzed in this retrospective series. Mean characteristics: follow-up 89 months; age 65 years (range 33-99); tumor size 3.8 cm (0.3-10); treatment hemoglobin 12.4 g/dl (range 8.7-14.4); and tumor dose 72 Gy (range 6-127). In addition, 49% of our cohort had a prior hysterectomy. The FIGO stage distribution: I (42%); II (29%); III (17%); and IVA/B (11%). Sixty-two percent of patients were treated with a combination of external beam radiation (EBRT) and brachytherapy, 22% with EBRT alone and 13% with brachytherapy alone.

RESULTS

Kaplan-Meier (KM) 5-year pelvic control, distant metastasis free survival and disease specific survival probabilities: stage I, 83%, 100%, and 92%; stage II, 76%, 95%, and 68%; stage III, 62%, 65%, and 44%; and stage IV, 30%, 18%, and 13%. On multivariate analysis: stage; treatment hemoglobin; and prior hysterectomy were prognostic for DSS (p<0.05). The KM 5-year grade 3/4 (G3/4) complication free estimate of our cohort was 84%. G3/4 complications: tumor size and tumor dose were independently predictive (p<0.05).

CONCLUSIONS

Radiotherapy as a single modality for early stage primary vaginal SCCA produces good results. Advanced stage disease necessitates a combined modality approach and/or new methods. Treatment Hg levels appear to be clinically significant and studies on correction of anemia during treatment are warranted.

The potential therapeutic role of lymph node resection in epithelial ovarian cancer: a study of 13918 patients

The aim of the study is to determine the role of lymphadenectomy in advanced epithelial ovarian cancer. The data were obtained from the Surveillance, Epidemiology and End Results (SEER) program reported between 1988 and 2001. Kaplan–Meier estimates and Cox proportional hazards regression models were used for analysis. Of 13 918 women with stage III–IV epithelial ovarian cancer (median age: 64 years), 87.9% were Caucasian, 5.6% African Americans, and 4.4% Asians. A total of 4260 (30.6%) underwent lymph node dissections with a median number of six nodes reported. For all patients, a more extensive lymph node dissection (0, 1, 2–5, 6–10, 11–20, and >20 nodes) was associated with an improved 5-year disease-specific survival of 26.1, 35.2, 42.6, 48.4, 47.5, and 47.8%, respectively (P<0.001). Of the stage IIIC patients with nodal metastases, the extent of nodal resection (1, 2–5, 6–10, 11–20, and >20 nodes) was associated with improved survivals of 36.9, 45.0, 47.8, 48.7, and 51.1%, respectively (P=0.023). On multivariate analysis, the extent of lymph node dissection and number of positive nodes were significant independent prognosticators after adjusting for age, year at diagnosis, stage, and grade of disease. The extent of lymphadenectomy is associated with an improved disease-specific survival of women with advanced epithelial ovarian cancer.