Intestinal operations during surgical procedures for epithelial ovarian cancer

Fifty-two intestinal operations were performed during 45 laparatomies in 43 non-obstructed ovarian cancer patients. The histology of the tumor was serous in 29/43 cases (67.5%). The gross postoperative morbidity rate was 15.5% and postoperative mortality rate 6.9%. The 5-year survival was 28.3%, and was not affected by the time of intestinal surgery (during the first or following laparotomies). As a result, intestinal surgery in advanced ovarian cancer patients is feasible without an undue increase in morbidity. However, it must be carefully tailored because, though contributing to the quality of life of these patients, it does not seem to affect their survival, at least in this retrospective series.

Surgical staging for epithelial ovarian tumors of low malignant potential

From January 1975 to December 1991, 34 patients with a diagnosis of epithelial ovarian tumors of low malignant potential (LMP) were admitted to the Istituto Nazionale Tumori of Milan. Eighteen of them (group 1) underwent complete staging laparotomy and retroperitoneal para-aortic and pelvic lymphadenectomy, as for ovarian cancer. In the remaining 16 cases (group 2), the surgical treatment ranged from unilateral oophorectomy to incomplete staging procedure. In group 1, nine patients (50%) were found to have retroperitoneal nodal involvement. In group 2, all patients had stage I disease. Patients were followed up for 20-222 months (mean 108, median 86). There were two recurrences in group 2 (after 5 years) and none in group 1 (NS). Currently all patients are alive and disease free. Nine of 18 group 1 patients were upstaged to stage III on the basis of lymph node involvement only. However, at least in this retrospective series, lymph node metastases did not affect prognosis or survival.

The intramuscular administration of granulocyte colony-stimulating factor as an adjunct to chemotherapy in pretreated ovarian cancer patients: an Italian Trials in Medical Oncology (ITMO) Group pilot study

No published data are available concerning the activity and tolerability of intramuscularly administered granulocyte colony-stimulating factor (G-CSF) in humans. To fill this gap, 19 patients with advanced ovarian cancer previously treated with at least one first-line chemotherapy cycle received the following myelosuppressive regimen: mitoxantrone (DHAD) 12 mg m-2 i.v. on day 1; ifosfamide (IFO) 4 g m-2 i.v. on days 1 and 2; mesna 800 mg m-2 i.v. t.i.d. on days 1 and 2. G-CSF (Filgrastim) was given at a dose of 5 micrograms/kg/day i.m. from day 6 to day 19, its pharmacokinetics being assessed in five patients. The neutrophil nadir was observed after a mean period of 8 days, and the neutrophil count was < 1.0 x 10(3) mm-3 for a mean of 6 days during the cycle of chemotherapy. The neutrophil count fell after the withdrawal of G-CSF on the 19th day of treatment. The difference in absolute neutrophil count between day 19 and day 21 was statistically significant (P = 0.0001); nevertheless, at day 21 no WHO grade 3-4 neutropenia was reported. DHAD and IFO were respectively given at 95% and 93% of the planned dose. The pharmacokinetics of G-CSF i.m. seems to be similar to that of the drug given subcutaneously. No evidence of cumulative myelosuppression was observed. G-CSF was well tolerated and no complications were observed at the injection sites. In conclusion, if the results obtained in this pilot study regarding the activity of i.m. G-CSF are confirmed by a randomised trial, the intramuscular administration of G-CSF could become a valid alternative for patients who dislike the subcutaneous route and who are being treated with chemotherapy that does not induce profound thrombocytopenia.

Folate binding protein distribution in normal tissues and biological fluids from ovarian carcinoma patients as detected by the monoclonal antibodies MOv18 and MOv19

Folate-binding proteins (FBP), which are molecules relevant in folate metabolism, are overexpressed in ovarian carcinomas, as detected by the monoclonal antibodies (MAb) MOv18 and MOv19, which recognise two different epitopes of the gp38/FBP. In this paper, features of the FBP such as the distribution on normal tissues and the release in biological fluids of normal and tumour origin have been investigated. Immunohistochemical analyses on frozen sections of normal tissues showed the presence of the gp38/FBP on some epithelia. The reactivity of both the MAb on Fallopian tubes was intense and comparable to that observed on ovary carcinoma sections. The kidney, bronchial glands, alveolar epithelium of the lung, oesophagus, stomach, pancreas, breast and thyroid showed different levels of staining. By MOv18/MOv19 double-determinant immunoradiometric assay (DDIRMA), the gp38/FBP was found in soluble form in ascitic fluid, serum and urine of nude mice in which the human ovary carcinoma cell line IGROV1 grew as ascitic carcinomatosis. In human biological fluids, the gp38/FBP was detected in ascites of 60% of ovarian carcinoma patients, and in 29% of those with other carcinomas, but not in patients with non-epithelial tumours or with other non-tumoral pathologies. The mean serum arbitrary units (a.u.)/ml values of ovary carcinoma patients were significantly different to those of healthy donors or patients with endometriosis (P < 0.005 and P < 0.01, respectively), but not when compared to the sera of lung carcinoma patients. In addition, the sensitivity of DDIRMA was poor, since only 24% of the ovary carcinoma patients were positive with this assay. When a restricted number of cases selected for the presence of tumour cells in the ascites was examined, the percentage of DDIRMA-positive sera and ascites rose to 41 and 94%, respectively. In the urine, a strong reactivity was observed in the samples of both normal and tumour origin.

The role of appendectomy in surgical procedures for ovarian cancer

To assess the role of appendectomy in the surgical procedures for ovarian cancer, we evaluated retrospectively the clinical charts of 435 patients who underwent surgery after diagnosis of ovarian cancer. The appendix was removed in 160 cases and pathological examination revealed 37 with metastatic implants (23%). All the patients with appendiceal metastases showed advanced disease (stages III-IV) with an incidence of 43%. Ninety-one percent (31/34) of the tumors with appendiceal involvement at the staging operation were of the serous cell type and grade II or III. No case with early stage, right ovary carcinoma showed appendiceal metastatic foci, denying the existence of a preferential lymphatic pathway. Microscopic involvement was found only in 4 patients with advanced disease (11.7%). No intra- or postoperative complication directly related to the appendectomy was recorded. We conclude, with these results, that appendectomy should be part of the cytoreductive operation for ovarian cancer.

A preoperative single course of high-dose cisplatin and bleomycin with glutathione protection in bulky stage IB/II carcinoma of the cervix

One course of preoperative chemotherapy including high-dose cisplatin (40 mg/m2 daily for 5 consecutive days) with glutathione protection and bleomycin (15 mg on days 2, 8 and 9) was administered to 27 patients with bulky operable cervical carcinoma (stage IB/II) in a pilot study. In all patients the tumor diameter was greater than 4 cm. Surgery (radical hysterectomy with pelvic and para-aortic lymphadenectomy) was planned within one month of chemotherapy. In 27 evaluable patients, nausea/vomiting was the most pronounced side effect. Significant (but transient) increases in serum transaminases were detected in 19 patients. Electrolyte imbalance (hypokalemia) was detected in 6 patients (one with hypocalcemia). These reversible effects were not associated with other signs of renal toxicity. Objective clinical responses were observed in 21 patients, 18 of them partial and 3 complete responders (pathologically confirmed in 2). Radical hysterectomy with pelvic and para-aortic lymphadenectomy was performed with no particular complications. The shrinking of bulky tumor made the operation easier, especially in parametrial resections. High-dose cisplatin chemotherapy prior to surgery is feasible with acceptable toxicity. The encouraging results of this study warrant further investigations to define the role of neoadjuvant therapy.

Potentials of cell kinetics in the management of patients with ovarian cancers

The relevance of 3H-thymidine labeling index (3H-dt LI) on clinical outcome was evaluated on 85 patients with advanced ovarian cancers treated with carboplatin or cisplatin alone (39 cases) or cisplatin in association with doxorubicin and/or cyclophosphamide (46 cases). 3H-dT LI of the primary tumour was significantly related to the 3-year probability of survival in patients treated by monochemotherapy (low LI, 63%; high LI, 21%; P = 0.013) but not in those treated with polychemotherapy. Analysis of the relation between cell kinetics and clinical outcome as a function of treatment showed that in patients with rapidly proliferating tumours the 3-year survival was significantly higher following polychemotherapy than monochemotherapy (51 vs. 21%; P = 0.04). In patients with slowly proliferating tumours no significant difference in survival was observed following the two types of treatment for the overall series, whereas in patients not achieving a complete response survival was significantly higher following monochemotherapy than polychemotherapy (61 vs. 9%; P = 0.008).

Regulation of progesterone receptor gene expression

The levels of progesterone receptor (PR) mRNA, PR protein, and [3H]R5020 binding activity were measured in parallel experiments conducted on a T47D subline expressing the estrogen receptor. A significant increase of PR mRNA levels could be detected within 6 h of exposure of the cells to estradiol (10(-8) M). The changes in mRNA, however, did not lead to any variation of PR protein levels of [3H]R5020 binding activity. A parallel analysis of PR mRNA and [3H]R5020 binding was then performed in a series of tumor biopsies. In estrogen receptor-positive and PR-positive tissues a correlation among the two values was found. It is postulated that the above mentioned data could reflect the existence of a difference in the mechanisms controlling the numerous steps of the PR synthesis in the various hormone-responsive tissues. This variability could allow an organ-specific response to the cyclic changes of circulating hormone.

Pelvic and para-aortic lymphadenectomy in cancer of the ovary

The role of the lymphadenectomy in ovarian carcinoma is widely discussed. The natural history of disease, its tendency to spread to peritoneal cavity and the lack of any reported series of careful node dissections undertaken during surgical exploration has made it difficult to establish the real significance of nodal metastatization and the optimal therapeutic approach for patients with positive nodes. At the Istituto Nazionale Tumori, Milan, 341 patients with ovarian carcinoma have been subjected to lymph node dissection. In 253 cases in which lymphadenectomy has been carried out during first surgery, the lymphonodal diffusion has been evaluated by stage, grading and histology. The incidence of lymphonodal metastases increased with the diffusion of the primitive tumour and this is particularly evident for the serous adenocarcinoma. From our data (as shown in our series of 173 cases Stage III with peritoneal and retroperitoneal diffusion) the lymphonodal involvement has to be considered as a negative prognostic factor, influencing survival in a statistically significant way. In the 88 patients subjected to radical lymphadenectomy during second-look surgery, after chemotherapy, a smaller percentage of positive nodes was observed as compared to untreated cases but, on the other hand, we documented a portion of positive nodes not sterilized by sistemic therapy. All this data confirm the necessity to perform radical lymphadenectomy not only as a staging procedure (because of low sensitivity of lymphangiography) but also as a therapeutic one for some patients.