Cisplatin-based chemotherapy regimen (DECAV) for uterine sarcomas

Uterine sarcomas are an extremely rare event. There is no standard therapy for cases of relapse, although chemotherapy is commonly used. We studied the use of a cisplatin-based chemotherapy regimen for uterine sarcomas with an unusually long follow-up. Thirty-nine women with a median age of 50 years (32-71) entered the study. Histologically, leiomyosarcomas (26), carcinosarcomas (8), and stromal sarcomas (5) were represented. Group 1 consisted of patients undergoing adjuvant therapy (for initial disease, eight patients; for pelvic recurrence, two patients); Group 2 consisted of patients with advanced disease (locoregional after initial local therapy, five patients; local recurrence, six patients) or metastatic disease (stage IV, four patients; recurrence, 14 patients). DECAV therapy consisted of doxorubicin 50 mg/m2 d1, dacarbazine (DTIC) 200 mg/m2/d d1-3, vindesine 2 mg/day d1-2, cisplatin 100 mg/m2 d3, and either cyclophosphamide (CPM) 200 mg/m2/d d1-3 (n = 21), or ifosfamide (IFM) 2 g/m2/d d1-3 with mesna every 4 weeks Toxicity included 18 hospital stays for cytopenia (nine patients), including 13 cases of febrile neutropenia. Twenty blood transfusions in 10 patients and 12 platelet transfusions in seven patients were required. One toxicity-related death (hemorrhage) occurred. The overall response rate was 54% (3 complete response, 11 partial response) with a median duration of 13 months (4-36). Median overall survival was 14 month overall, 45 months for Group 1 and 13 months for Group 2. We conclude that the DECAV regimen is clearly active in uterine sarcomas but is too toxic to be recommended routinely.

[Prognostic factors and treatment for advanced-stage borderline ovarian tumors]

OBJECTIVE

The aim of this review is to study the incidence, the prognostic factors and the treatment of patients with advanced stage borderline ovarian tumor (BOT) associated with extra-ovarian disease (peritoneal implants and/or nodal disorders).

METHODS

Review of literature data.

RESULTS

BOT were associated with peritoneal implants in 15% to 40%. The strongest prognostic factors are the histologic subtype of peritoneal implants and the presence of residual disease. The surgical treatment is the gold standard with resection of all peritoneal disease. This surgery could be conservative in selected cases in order to preserve fertility. Noninvasive peritoneal implants do not seem to be chemosensitive lesions.

CONCLUSION

Histologic subtype of peritoneal implants is the most important prognostic factors in patients with serous BOT and extra-ovarian spread. The prognosis of patients with noninvasive implants is good. Treatment is based on surgery. The (only) indication of adjuvant therapy is BOT associated with invasive implants.

Cisplatin-based chemotherapy regimen (DECAV) for uterine sarcomas

Uterine sarcomas are an extremely rare event. There is no standard therapy for cases of relapse, although chemotherapy is commonly used. We studied the use of a cisplatin-based chemotherapy regimen for uterine sarcomas with an unusually long follow-up. Thirty-nine women with a median age of 50 years (32–71) entered the study. Histologically, leiomyosarcomas (26), carcinosarcomas (8), and stromal sarcomas (5) were represented. Group 1 consisted of patients undergoing adjuvant therapy (for initial disease, eight patients; for pelvic recurrence, two patients); Group 2 consisted of patients with advanced disease (locoregional after initial local therapy, five patients; local recurrence, six patients) or metastatic disease (stage IV, four patients; recurrence, 14 patients). DECAV therapy consisted of doxorubicin 50 mg/m2 d1, dacarbazine (DTIC) 200 mg/m2/d d1–3, vindesine 2 mg/day d1–2, cisplatin 100 mg/m2 d3, and either cyclophosphamide (CPM) 200 mg/m2/d d1–3 (n = 21), or ifosfamide (IFM) 2 g/m2/d d1–3 with mesna every 4 weeks

Toxicity included 18 hospital stays for cytopenia (nine patients), including 13 cases of febrile neutropenia. Twenty blood transfusions in 10 patients and 12 platelet transfusions in seven patients were required. One toxicity-related death (hemorrhage) occurred. The overall response rate was 54% (3 complete response, 11 partial response) with a median duration of 13 months (4–36). Median overall survival was 14 month overall, 45 months for Group 1 and 13 months for Group 2. We conclude that the DECAV regimen is clearly active in uterine sarcomas but is too toxic to be recommended routinely.

[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.

Tamoxifen-related uterine carcinosarcomas occur under/after prolonged treatment: report of five cases and review of the literature

The risk of tamoxifen-related endometrial adenocarcinoma is well established with daily dose and treatment duration of adjuvant tamoxifen as risk factors. There have also been in the past years, a few descriptions of uterine nonepithelial malignancies occurring after tamoxifen. We describe five recent cases of uterine carcinosarcomas occurring under/after tamoxifen administered in an adjuvant setting. None of these patients had received prior pelvic radiation therapy. Their median age at the diagnosis of breast cancer was 58 years (41-68), and 69 years (50-84) at the diagnosis of uterine carcinosarcoma. The median length of exposure to tamoxifen was 9 years (5-20), and the median time from the initiation of tamoxifen to the diagnosis of the uterine malignancy (latency period) 9 years (7-20). All patients presented with an advanced stage (IIA-IVA). Our data, together with those of the literature, plead for a causal role of a prolonged exposure to tamoxifen on the subsequent development of uterine carcinosarcoma. The long latency period observed even in patients receiving only 5 years of treatment leads us also to consider a prolonged gynecologic follow-up of the patients.

Phase I-II and pharmacokinetic study of gemcitabine combined with oxaliplatin in patients with advanced non-small-cell lung cancer and ovarian carcinoma

BACKGROUND

The aim of this study was to determine the toxicity profile, the recommended dose (RD) and the pharmacokinetic parameters, and to evaluate the antitumor activity of gemcitabine combined with oxaliplatin in patients with advanced non-small-cell lung cancer (NSCLC) and ovarian carcinoma (OC).

METHODS

Gemcitabine was administered as a 30-min infusion followed by a 2-h infusion of oxaliplatin, repeated every 2 weeks. Doses of gemcitabine and oxaliplatin ranged from 800 to 1500 and 70 to 100 mg/m(2), respectively.

RESULTS

Forty-four patients (26 males, 18 females; median age 55 years) including 35 NSCLC (five platinum pretreated) and nine OC patients (all platinum pretreated) received a total of 355 cycles. All patients were evaluable for toxicity. No dose-limiting toxicity at any dose level occurred during the first two cycles; therefore, the highest dose-level of gemcitabine (1500 mg/m(2)) and oxaliplatin (85 mg/m(2)) was considered as the RD. Hematological toxicity was moderate amongst the 22 patients treated (167 cycles) at that dose level. Thirteen cycles were associated with grade 3-4 non-febrile neutropenia in six patients, and eight cycles with grade 3-4 thrombocytopenia in two patients. Other toxicities were mild to moderate, consisting of asthenia and peripheral neurotoxicity. Four of the 35 patients treated with oxaliplatin 85 mg/m(2) experienced grade 3 neurotoxicity requiring treatment discontinuation at cycle 10. In the range of the doses used, gemcitabine and its main metabolite 2',2'-difluorodeoxyuridine appeared not to be affected by oxaliplatin 70-100 mg/m(2). Of the 44 patients evaluable for activity, 12 NSCLC patients experienced objective responses (one complete and 11 partial responses) and three OC patients showed tumor stabilization lasting for 6 months with a 50% decrease of CA 125 level. Two partial responses (NSCLC) and one tumor stabilization (OC) occurred in platinum-resistant patients.

CONCLUSIONS

The combination of gemcitabine and oxaliplatin could be safely administered on an out-patient schedule in patients with advanced NSCLC and OC. The RD was gemcitabine 1500 mg/m(2) and oxaliplatin 85 mg/m(2) every 2 weeks. Promising antitumor activity was reported in patients with NSCLC and platinum-pretreated OC, and thus, deserves further evaluation.

[Prognosis and fertility after conservative treatment for ovarian tumors of limited malignity: review of 68 cases]

The aim of this retrospective study was to evaluate the rate of recurrence and the reproductive outcome after surgical conservative treatment of low malignant ovarian tumors (LMOT).

MATERIAL AND METHODS

Sixty-eight patients with 50 Stage I LMOT and 18 LMOT with peritoneal implants treated conservatively at institut Gustave-Roussy, between January 1969 and December 2000. Fifty-nine patients had an unilateral adnexectomy (associated twelve times with a contralateral cystectomy), Seven had a bilateral cystectomy and two an unilateral cystectomy. Five patients received adjuvant therapy.

RESULTS

With a median follow-up of 71.5 months, 16 patients recurred and one had evolutive peritoneal disease. The histologic pattern of ovarian recurrences was always of borderline type. The histologic patterns of peritoneal recurrence was similar to those initially diagnosed except in one case. Peritoneal implants, exophytic tumor and serous type tumor were significatively associated with a higher 5-year recurrence rate. Recurrence was more frequent after cystectomy than unilateral adnexectomy (p = 0.13). None of patients treated conservatively recurred under the form of ovarian carcinoma. None patient died of tumor. Nineteen patients experienced 26 pregnancies: 24 were spontaneous in a median delay of 19 months. Seven infertile patients underwent ovarian stimulation. None recurred after infertility treatments. The 2-year and 5-year cumulative pregnancy rate were respectively 41.9% and 59.8%. Four patients experienced a pregnancy after a conservative treatment of their recurrence.

CONCLUSION

Despite a high recurrence rate, especially in stage II and III serous LMOT, conservative treatment of LMOT does not affect survival and should be considered in young patients. Such treatment is not advised in case of invasive peritoneal implants. Spontaneous pregnancy rate is good but the frequent infertility associated with these tumors can afterwards require ovarian stimulation. Limited number of stimulation cycles is acceptable in such patients.

Tamoxifen-related uterine carcinosarcomas occur under/after prolonged treatment: Report of five cases and review of the literature

The risk of tamoxifen-related endometrial adenocarcinoma is well established with daily dose and treatment duration of adjuvant tamoxifen as risk factors. There have also been in the past years, a few descriptions of uterine nonepithelial malignancies occuring after tamoxifen. We describe five recent cases of uterine carcinosarcomas occurring under/after tamoxifen administered in an adjuvant setting. None of these patients had received prior pelvic radiation therapy. Their median age at the diagnosis of breast cancer was 58 years (41–68), and 69 years (50–84) at the diagnosis of uterine carcinosarcoma. The median length of exposure to tamoxifen was 9 years (5–20), and the median time from the initiation of tamoxifen to the diagnosis of the uterine malignancy (latency period) 9 years (7–20). All patients presented with an advanced stage (IIA-IVA). Our data, together with those of the literature, plead for a causal role of a prolonged exposure to tamoxifen on the subsequent development of uterine carcinosarcoma. The long latency period observed even in patients receiving only 5 years of treatment leads us also to consider a prolonged gynecologic follow-up of the patients.

Ovarian metastasis on transposed ovary in patients treated for squamous cell carcinoma of the uterine cervix: report of two cases and surgical implications

BACKGROUND

To discuss risk factors for ovarian metastasis in a transposed ovary in patients treated for cervical cancer.

CASES

Cases were two patients with ovarian metastasis in a transposed ovary in a series of 107 patients. These two patients were treated for a Stage IB squamous cell cervical cancer and presented with a tumor devoid of extrauterine spread (absence of nodal involvement or distant metastases) but with involvement of the uterine corpus. Furthermore, lymphovascular space involvement (LVSI) in the cervix or paracervix was present in both patients.

CONCLUSIONS

Ovarian transposition should be performed in patients < or =40 years of age with a small invasive cervical carcinoma (< 3 cm) treated by primary surgery. This procedure should not be performed in patients with bulky tumor and/or in patients with LVSI.

Are serum inhibin concentrations new markers of placental tumours in the course of chemotherapy?

BACKGROUND

The study was conducted to evaluate whether the detection of serum molecular forms of inhibin (A and B) could be useful for the diagnosis, prognosis and follow-up of placental tumours.

METHODS

A total of 17 patients with hydatidiform mole (n = 13), invasive mole (n = 1) or choriocarcinoma (n = 3) were studied; serum concentrations of inhibins A and B, human chorionic gonadotrophin (HCG) and its free beta subunit (HCGbeta) were measured before chemotherapy (after mole evacuation for eight patients) and also during the course of chemotherapy (for 10 patients).

RESULTS

After evacuation or before chemotherapy for refractory disease, serum inhibin A and B concentrations were found to be increased in 10/17 and 4/17 patients, when HCG and HCGbeta were high in all patients. In 10 patients with a follow-up during treatment, nine had a high concentration of inhibin A which correlated with those of HCG and HCGbeta. Normalization of inhibin A was faster than that of HCG and HCGbeta for three and six patients respectively. There was no correlation between changes of inhibin B and HCGbeta concentrations.

CONCLUSIONS

Our results suggest that inhibins A and B are not useful markers and that HCG determination still remains the most useful marker for diagnosis and follow-up of placental tumours.

Results of conservative treatment in epithelial ovarian carcinoma

BACKGROUND

The objective of this study was to assess and evaluate the clinical outcome and fertility in patients treated conservatively for epithelial ovarian carcinoma (EOC).

METHODS

Thirty-one patients treated with conservative management EOC were followed up. Optimal surgical staging was performed in 2 cases during the initial surgery and in 27 patients during a reassessment surgery. Six patients underwent hysterectomy during this restaging surgery.

RESULTS

Among 25 patients treated conservatively after the restaging surgery, the International Federation of Gynecology and Obstetrics (FIGO) staging distribution was 19 Stage IA (Grade 1, n = 9; Grade 2, n = 10), 1 Stage IC, 2 Stage II, and 3 patients with initial stage unknown. Seven patients had recurrence (five on the remaining ovary). The disease free survival rate at 5 years for patients with Stage IA Grade 1 and 2 tumors were 89% and 71%, respectively. All patients with Stage IA or higher disease experienced recurrence. Only four pregnancies (three spontaneous and one after in vitro fertilization procedure) were obtained.

CONCLUSIONS

Conservative surgery for patients with EOC could be considered in young patients with Stage IA Grade 1 disease adequately staged and desiring to preserve fertility potential. This procedure should not performed in patients with disease staged higher than FIGO Stage IA.

Prevention of menstruation with leuprorelin (GnRH agonist) in women undergoing myelosuppressive chemotherapy or radiochemotherapy for hematological malignancies: a pilot study

Vaginal bleeding during aplasia can induce transfusion support, infection and discomfort. Oral and intramuscular hormonotherapy can be toxic and/or difficult to manage (mucositis). This single-center pilot study evaluated the efficacy and safety of leuprorelin (L) in preventing heavy vaginal bleeding in 20 nonmenopausal women with leukemia, lymphoma or myeloma and foreseable therapy-induced thrombocytopenia. Until platelet recovery, patients received subcutaneous injections of L, with concomitant nomegestrol acetate (NA) during the first 35 days to prevent flare-up. Median age was 33 years (18-48). Platelet nadir was < 20 x 10(9)/l in 17 patients; 103 L injections were performed (median per patient: 4 [1-14]). No moderate or severe adverse event was related to hormonal therapy. Seventeen patients did not experience any clinically or therapeutically relevant bleeding. Eleven spottings and 8 metrorrhagias (mean duration: 3 days) occurred in 11 patients, requiring enhanced NA in 3 cases (baseline platelet count was < 20 x 10(9)/l in 1 pt, premature termination of NA [the single platelet transfusion for metrorrhagia] in 1 pt, and endometrial hyperplasia (EH) in the third). In patients without EH, only 5 spottings were observed after the third injection, without neither clinical nor therapeutic impact (63 injections). In conclusion, leuprorelin administration is safe and effective in preventing vaginal bleeding. The sustained-release form and subcutaneous administration offer quality of life advantages.

Value and cost evaluation of routine follow-up for patients with clinical stage I/II endometrial cancer

The aim of the study was to determine the value and the costs of routine follow-up for the detection of recurrences in patients treated for endometrial cancer. Between 1986 and 1995, 390 women with clinical stage I/II endometrial carcinoma were treated with combined surgery-radiation therapy. After treatment, follow-up was based on the clinical examination, a systematic Papanicolaou (Pap) smear and radiography (chest X-ray and abdomino-pelvic ultrasonography). 27 patients relapsed: 22 patients had symptoms and 5 were asymptomatic. None of the patients had recurrence detected on the routine Pap smear nor on the systematic chest X-ray. In conclusion, the follow-up of patients treated for endometrial cancer based on routine Pap smears and systematic radiography does not permit earlier detection of recurrences. Follow-up should simply include a clinical examination whose frequency should be based on prognostic factors. Approximately two-thirds of this cost was due to systematic examinations (Pap smears and radiography). Our results indicate that such expenditure could be avoided.

Neuroendocrine small cell carcinoma of the uterine cervix: what disease? What treatment? Report of ten cases and a review of the literature

Neuroendocrine small cell carcinoma of the uterine cervix (NESCCC) is an entity with very aggressive behaviour. The optimal initial therapeutic approach to this rare disease has not yet been clearly defined. We reviewed our experience of this disease over the past 10 years with regard to chemosensitivity. Since 1988, ten patients (mean age 33 years; range 24-47) have been diagnosed with NESCCC and treated in our institutions. Disease stage at presentation was IA (one), IB (five, two with lymph node involvement), IIB (one), IIIB (one), and IV (two). One patient had metastatic disease at presentation; three developed metastases during initial treatment. Eight patients underwent surgery and eight received radiation therapy. Six patients received pre- or postoperative cisplatinumvepeside (PE) combination chemotherapy, either alone or concurrently with radiation therapy. PE alone as primary chemotherapy led to disease stabilization in the two patients so treated; concurrent PE and radiation therapy resulted in a pathological complete response in one patient. Eight patients relapsed within 16 months and died of their disease within 29 months from the initial diagnosis. Two patients are alive with no evidence of disease at 13 and 53 months. Our series confirms the previously described very poor prognosis of NESCCC, despite initial aggressive multidisciplinary treatment. It may be that the introduction of chemotherapy, especially combined primary chemoradiotherapy, might allow patients to do a little better, although at the moment there is no good evidence one way or the other.

Retroperitoneal drainage after complete Para-aortic lymphadenectomy for gynecologic cancer: a randomized trial

OBJECTIVE

To determine the relationship between retroperitoneal drainage after complete para-aortic lymphadenectomy for gynecologic cancer and subsequent development of lymphocysts.

METHODS

Eighty women undergoing complete para-aortic lymphadenectomy up to the level of the left renal vein for ovarian (n = 43) or cervical carcinoma (n = 37) were randomly assigned to receive drainage or no drainage of the para-aortic area. Most of patients had pelvic drainage. Abdominopelvic ultrasonography was done 8 to 12 days after surgery. Postoperative complications, duration of hospital stay, and characteristics of asymptomatic lymphocysts were studied.

RESULTS

Forty-two women had para-aortic drainage and 38 did not. Complications occurred in 15 patients who had drainage and in 5 patients who did not have drainage (36% versus 13%; P <.02). Three patients (8%) in the undrained group had complications potentially related to drainage (symptomatic lymphocysts or ascites) compared with 11 (26%) in the drained group (chi(2) = 4.6; P <.05). Median duration of the hospital stay was 9 days in the undrained group and 11 days in the drained group (P <.03). The number of asymptomatic para-aortic lymphocysts detected during the ultrasonography was 9 (24%) in the undrained and 2 (5%) in the drained group (chi(2) = 4.6; P <.05).

CONCLUSIONS

The number of asymptomatic para-aortic lymphocysts was higher in patients who did not undergo drainage, but morbidity and the duration of hospitalization were increased in these patients. Routine drainage of the retroperitoneum after para-aortic lymphadenectomy should be abandoned.

Clinical outcomes and fertility after conservative treatment of ovarian borderline tumors

OBJECTIVE

To assess clinical outcome and fertility in patients treated conservatively for a low malignant potential (LMP) ovarian tumor.

DESIGN

Retrospective study.

SETTING

Gynecologic oncology department of a cancer care center in France.

PATIENT(S)

Forty-four patients treated with conservative management for a stage I (n = 32) or stage II or III (n = 12) LMP tumor.

INTERVENTION(S)

Thirty-three patients had unilateral adnexectomy and 11 had cystectomy. Cystectomy was bilateral in 1 patient and was done in conjunction with contralateral adnexectomy in 5 patients.

MAIN OUTCOME MEASURE(S)

Tumor recurrence and pregnancy rates.

RESULT(S)

Tumor recurrence rates after radical surgery (hysterectomy with bilateral salpingo-oophorectomy), adnexectomy, and cystectomy were 5.7%, 15.1%, and 36.3%, respectively (P<.01). Among patients who initially received conservative treatment, tumors did not recur in the form of invasive carcinoma. Five patients who had recurrence underwent repeated conservative management; these patients are alive and free of disease. Seventeen pregnancies (of which 15 were spontaneous) occurred in 14 patients; 13 pregnancies occurred in patients with stage I disease and 4 occurred in patients with stage III disease.

CONCLUSION(S)

Conservative management of LMP tumor significantly increases the risk of recurrence but does not affect overall survival. Such management offers even patients with advanced disease the chance to have spontaneous pregnancy. Conservative management might be proposed in young patients who wish to preserve their fertility, but careful follow-up will be required to detect tumor recurrence.

Pilot study of the paclitaxel, oxaliplatin, and cisplatin combination in patients with advanced/recurrent ovarian cancer

To determine the feasibility of the paclitaxel, oxaliplatin, cisplatin combination in advanced ovarian cancer (AOC), 15 patients with AOC (8 chemonaive, and 7 second-line, disease-free interval > or = 12 months) received paclitaxel 135 mg/m2 at day 1, with oxaliplatin 100 mg/m2 and cisplatin 75 mg/m2 at day 2, every 3 weeks for 6 cycles. Pretreated patients received prophylactic granulocyte colony-stimulating factor (5 microg/kg/d, days 6-13). Seventy cycles were administered; median 5 (range: 2-6 cycles) in chemonaive, and 4 (range: 2-6) in pretreated patients. There were grades III to IV neutropenia in 77%, febrile neutropenia in 24%, and grades III to IV thrombocytopenia in 4% of the cycles. Besides neutropenia, cumulative neurosensory toxicity was also limiting although reversible, with National Cancer Institute Common Toxicity Criteria grades II to III observed in 13 patients. Three of the pretreated patients had complete responses (43%), three had partial responses, and one had disease stabilization. Six of the 8 chemonaive patients had complete responses (75%), 1 had disease stabilization, and 1 had disease progression. The median follow-up is 17 months (range: 9-20 months) in chemonaive and 41 months (range: 13-58 months) in pretreated patients, and time to progression has been consistently more than 12 months, with 6 patients (5 chemonaive) still progression free (range: 15+ to 22+ months). This active combination shows acceptable hematologic toxicity, and reversible cumulative neurosensory toxicity. Further clinical exploration of the present combination appears warranted.