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.

Surgical procedure in patients with ovarian cancer diagnosed at the time of prophylactic oophorectomy Analysis of two cases, literature review and surgical implications

The aim of this study was to discuss the surgical management for ovarian or tubal cancers diagnosed at the time of prophylactic oophorectomy. Two patients with BRCA1 & BRCA2 mutations carriers had ovarian cancer diagnosed during laparoscopic oophorectomy. Conversion to laparotomy was performed in order to complete surgery (hysterectomy, multiple peritoneal biopsies, omentectomy, pelvic and para-aortic lymphadenectomy). These two patients were upstaged on the basis of para-aortic lymphadenectomy and had massive nodal spread into para-aortic area. One of them had no intra-peritoneal disease and the other one had minor peritoneal disease (only one positive pelvic biopsy in the Douglas pouch). These two patients are alive, one of them with 3.5 years of follow-up after the end of adjuvant treatment. In order to ensure the exact spread of the disease. Lymphadenectomy should be performed in patients with ovarian cancer diagnosed at the time of prophylactic surgery.

Clinical outcome after laparoscopic pure management of borderline ovarian tumors: results of a series of 34 patients

BACKGROUND

The aim of this study was to assess clinical outcome after laparoscopic treatment of borderline ovarian tumor (BOT).

PATIENTS AND METHODS

Thirty-four patients treated initially and/or for recurrent disease using a laparoscopic approach for BOT from 1984 to January 2002.

RESULTS

Thirty-four patients underwent laparoscopic pure treatment (without conversion by laparotomy and/or reassessment surgery by laparotomy) for BOT. Conservative treatment was performed in 31 (91%) patients. Median follow-up time was 45 months (range 6-228). Six (17%) patients recurred (in the remaining ovary following conservative surgery in five patients and in the peritoneum in one patient). Two port-site metastases were observed. None of the patients had recurrent disease in the form of ovarian carcinoma. Nine spontaneous pregnancies were observed in six patients from a group of 15 patients desiring pregnancy. All patients are alive today and disease-free.

CONCLUSION

These results seem to demonstrate that laparoscopic treatment can be safely performed in young patients with early stage BOT. Such a procedure is then feasible, but should be evaluated in patients with BOT and peritoneal implants.

[Cancer and pregnancy: the medical oncologist's point of view]

Having to start chemotherapy during pregnancy remains a rare event. The decision to proceed with this treatment depends on the drugs used, the time of exposure for the fetus and the gestational age at the time of exposure. The mutagenic potential of the chosen drug has to be known. The risk for the child can then be established without compromising the mother's chances of survival or well-being. This type of situation generally arises in women with breast cancer, leukemia or lymphoma. The first trimester of pregnancy, which corresponds to organogenesis is the most critical period for the fetus. The greatest risk of malformation occurs with anti-metabolite drugs. Chemotherapy can also expose the child to direct in utero toxicity. Myelosuppression is the most common toxic effect, sometimes giving rise to infections and/or fetal hemorrhage. The long-term risks of cancer on the mother's subsequent fertility or the child's intellectual development are not well-known. Such factors must be examined in prospective studies and registered in a specific database.

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.

Modalités et limites du traitement conservateur des adénocarcinomes in situ du col utérin : analyse de neuf cas et revue de la littérature

OBJECTIVE

The aim of this study is to assess the results of conservative management of adenocarcinoma in situ (AIS) of the uterine cervix in young patients.

PATIENTS AND METHODS

Data of 16 patients treated for AIS were reviewed: 10 were treated initially conservatively (cold knife conization in five patients, loop excision in three patients and cervical amputation in two patients) and six radically. One patient treated initially conservatively with loop excision and positive margins underwent a completion surgery (hysterectomy).

RESULTS

None patient had recurrence whatever the type of surgery (radical or conservative) with a mean follow-up of 74 months. Two pregnancies were observed.

DISCUSSION AND CONCLUSIONS

Conservative surgery for patients with AIS could be considered in young patients. But [for] reviewing literature several conditions should be respected: careful follow-up after conservative treatment; cold knife conization; length of cone specimen >25 mm and free margins. If those criteria are respected the risk of recurrent disease under the form of invasive carcinoma is low.

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.

Surveillance de l’endomètre des femmes sous tamoxifène

Tamoxifen estrogenic action in the uterus induces several uterine diseases, benign and/or malignant ones. The risk of endometrial adenocarcinoma is multiplied by two to three in post-menopausal women. It is mainly linked with the doses and the length of the treatment. However, the global benefit of that drug is not questioned anymore. What matters now though is to find the best way to follow patients on tamoxifen. As a matter of fact, there is no such thing as a consensus that would include specific tests, nor a surveillance protocol in women on tamoxifen. Most teams do not propose any special follow-up. Some patients already show uterine anomalies prior to the beginning of tamoxifen treatment. A yearly gynecologic examination, together with a cervico-vaginal smear, is enough when there are no specific endometrial adenocarcinoma risk factors, nor anomalies detected during the pre-therapeutical evaluation, nor clinical symptomatology. In case of risk factors, or cervical stenosis, or again initial abnormalities though, a yearly transvaginal sonography may be proposed. There is no need for other exploratory examinations if the results are satisfying. In case of symptoms, anomalies in the cervico-vaginal smears, intra-uterine liquid retention with a stenosed cervix, or suspicious endometrial thickness, then an endometrial sampling must be carried out. MRI could be of interest in asymptomatic patients with unclear ultrasonography images. Follow-up must be continued after interruption of tamoxifen. It is important to inform patients about the additional risks of developing an endometrial cancer because of tamoxifen, while still being reassuring. Besides, it is absolutely necessary to recommend them to take quickly medical advice in case of gynecologic symptoms.

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.

CT findings in two cases of port-site metastasis after laparoscopy for ovarian cancer

CASES

Two patients with histologically proven port-site metastasis following laparoscopic procedures for ovarian cancer underwent a CT scan. These two patients were initially treated for a stage IA and III ovarian cancer. Port-site recurrence occurred six and 19 weeks following the laparoscopic procedure. In one patient, the abdominal wall recurrence was associated with peritoneal carcinosis. In both patients, CT scan revealed the presence of an heterogeneous nodular lesion inside the left oblique muscle. Histologic analysis confirmed the diagnosis of port-site recurrence.

CONCLUSIONS

Port-site metastases could be observed in the treated patients with a laparoscopic approach for ovarian cancer. When this diagnosis is clinically suspected, a CT scan should be performed in order to precise the diagnosis of port-site metastasis and to evaluate potential intra-abdominal recurrent disease. However, only histologic examination can confirm a diagnosis of port-site recurrence.

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.