Phase II prospective study of paclitaxel and carboplatin in older patients with newly diagnosed Müllerian tumors

Malignant mixed Müllerian tumor of the fallopian tube: Case report and literature review

Carcinosarcoma, also known as malignant mixed Müllerian tumor (MMMT), includes both malignant epithelial and mesenchymal elements. While the endometrium is the most frequent known site for carcinosarcomas, their development in the fallopian tube is rare condition, only accounting for 0.1 to 0.5% among all gynecological malignancies. Fallopian tube MMMT is associated with an aggressive progression. A total of 94 previous case reports were reviewed and divided, after applying the exclusion criteria, into 2 groups: No evidence of disease (NED) Group including 33 patients reported to be without any residual disease at the end of the follow-up period; death of disease (DOD) Group including 51 patients who died due to the progression of fallopian carcinosarcoma or its complications. The gathered data were statistically analyzed together with a case from our clinical experience: a 65-year-old postmenopausal patient with a final histological diagnosis of fallopian carcinosarcoma staged FIGO IC2, synchronous with a serous endometrial intraepithelial carcinoma. Patient age between 41 and 60 years, symptoms at presentation and computed tomography (CT)/magnetic resonance imaging (MRI) tumor evidence are prognostic factors (P<0.05). Omentectomy [odds ratio (OR)=0.3545] and pelvic lymphadenectomy (OR=0.3732) were found to be significant factors for survival (P<0.05). Fimbrial localization of the tumor is a negative prognosis factor (OR=4.263), as well as the heterologous type of tumor (OR=2.880). Chemotherapy was found to improve survival (OR=0.2679) while radiotherapy had no influence on patient prognosis. Reporting these rare cases could be essential for obtaining more precise information regarding the treatment and prognosis of patients with MMMT of the fallopian tube, in order to improve patient survival and quality of life.

Primary malignant mixed Müllerian tumors of the fallopian tube with cervix metastasis: A rare case report and literature review

RATIONALE

Primary malignant mixed mullerian tumors of the fallopian tube is very rare and has only 1 case in the current literature with cervix metastasis.

PATIENT CONCERNS

We reported a 49-year-old woman sufferring from primary malignant mixed mullerian tumors of the fallopian tube with cervix metastasis, and the imaging examination found a strip of solid mass in the right fallopian tube and a nodular mass in cervical canal, which were both hyperintense on T2 weighted image (T2WI) and diffusion weighted image (DWI) and continuous moderate enhancement on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI).

DIAGNOSES

The diagnosis was confirmed according to the specific anatomical location and pathological examination which was proved as primary malignant mixed mullerian tumors of the fallopian tube with cervix metastasis.

INTERVENTIONS

The patient underwent radical hysterctomy, bilateral adnexectomy, pelvic lymph node dissection, omentum majus excision and intravenous chemotherapy.

OUTCOMES

Her posttreatment condition was good.

LESSONS

Primary malignant mixed mullerian tumors of the fallopian tube can be located by magnetic resonance image examination, which may also offer several diagnostic tips according to changes in signal and enhancement. When combined with pathological findings, qualitative diagnosis can be determined. Surgery and adjuvant chemotherapy are considered as effective methods. Our paper discussed its epidemiology, clinical symptoms, pathologic characters, therapeutic method as well as magnetic resonance imaging findings suggesting the diagnosis and differential diagnosis, including precontrast scan, contrast scan and diffusion weighted image and provided magnetic resonance imaging characteristics of primary malignant mixed mullerian tumors of the fallopian tube described in other literatures.

Tolerance of weekly metronomic paclitaxel and carboplatin as neoadjuvant chemotherapy in advanced ovarian cancer patients who are unlikely to tolerate 3 weekly paclitaxel and carboplatin

OBJECTIVE

There are little data regarding safety and effectiveness of neoadjuvant chemotherapy (NACT) in patients who are considered unfit for receiving 3 weekly paclitaxel and carboplatin. The aim of this study was to examine the toxicity and response rates of weekly paclitaxel and carboplatin as NACT in such cohort of patients.

METHODS

Study population included advanced ovarian cancer patients who were unlikely to tolerate 3 weekly paclitaxel and carboplatin and hence received weekly paclitaxel (80 mg/m(2)) and carboplatin AUC-2 as NACT. The data regarding the baseline characteristics, chemotherapy tolerance, completion rates, toxicity (Common Terminology Criteria for Adverse Events version 4.02), and radiological response rates are presented. SPSS version 16 was used for analysis. Descriptive statistics is presented.

RESULTS

Eleven patients received this schedule. Nine patients completed nine cycles of NACT. Except one, all patients completed NACT with an average relative dose intensity of >0.8. There was no chemotherapy-related mortality. Grade 3-4 life-threatening complications were seen in two patients. The post NACT response rate was 100%.

CONCLUSIONS

Weekly paclitaxel and carboplatin chemotherapy is safe and efficacious in patients who are unsuitable for 3 weekly paclitaxel and carboplatin chemotherapy schedules.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Interval debulking surgery (IDS), following induction or neoadjuvant chemotherapy, may have a role in treating advanced epithelial ovarian cancer (stage III to IV) where primary debulking surgery is not an option.

OBJECTIVES

To assess the effectiveness and complications of IDS for women with advanced stage epithelial ovarian cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 6, MEDLINE and EMBASE for the original review in to June 2012. We updated the searches in June 2009, 2012 and 2015 for the review updates.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. We performed meta-analysis of overall and progression-free survival (PFS), using random-effects models.

MAIN RESULTS

Three RCTs randomising 853 women, of whom 781 were evaluated, met the inclusion criteria. Meta-analysis of three trials for overall survival (OS) found no statistically significant difference between IDS and chemotherapy alone (hazard ratio (HR) = 0.80, 95% confidence interval (CI) 0.61 to 1.06, I² = 58%). Subgroup analysis for OS in two trials, where the primary surgery was not performed by gynaecologic oncologists or was less extensive, showed a benefit of IDS (HR = 0.68, 95% CI 0.53 to 0.87, I² = 0%). Meta-analysis of two trials for PFS found no statistically significant difference between IDS and chemotherapy alone (HR = 0.88, 95% CI 0.57 to 1.33, I² = 83%). Rates of toxic reactions to chemotherapy were similar in both arms (risk ratio = 1.19, 95% CI 0.53 to 2.66, I² = 0%), but little information was available for other adverse events or quality or life (QoL).

AUTHORS' CONCLUSIONS

We found no conclusive evidence to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in women whose primary surgery was not performed by gynaecologic oncologists or was less extensive. Data on QoL and adverse events were inconclusive.

Considerations regarding the administration of systemic therapy for elderly patients with ovarian cancer

To improve the benefit and tolerability of cancer treatment, we must develop new geriatric-specific trials, better assessment tools, and encourage enrollment of older patients in clinical trials. Age is a strong predictor of survival in ovarian cancer and often influences the treatment plan. Elderly patients, broadly defined as older than age 65 years, are commonly not offered participation in clinical research or provided with substandard chemotherapy or surgical options. Because first-line, platinum-based chemotherapy with cytoreductive surgery is a potentially curative modality, all standard treatment options should be explored (intravenous, neoadjuvant, and/or intraperitoneal chemotherapy). However, one must balance the specific needs of the older patient and be aware of the increased risk of side effects. To be mindful and respectful, the oncologist should clearly define the goals (palliative vs. curative) and specific risks of treatment to patients and their families. As the field of geriatric oncology evolves and prospective trials tailored to older women with ovarian cancer are developed, specific guidelines will ultimately assist in these difficult decisions.

Is there an increase in the incidence of uterine carcinosarcoma in north-east Scotland? A 19 years population-based cohort study

Background and aims

The incidence of uterine carcinosarcoma and factors associated with its survival are little known and this study helps to address this question for women residing in north-east Scotland.

Methods and results

Data were collected from women diagnosed with carcinosarcoma of the uterus residing in north-east of Scotland from 1991 to 2009. Kaplan–Meier plots and Cox regression analysis were used for analysis. A total of 43 women were analysed during this period. The median survival was 25 months. The estimated five-year survival for stage I/II disease was 52.5% (95% CI: 30.5–74.5%). The 2-year survival rate for stage III/IV disease was 46% (95% CI: 16–75%). There was an increase in the incidence during this period. Improved survival was seen in early-stage disease (FIGO stages I and II) and in the absence of lymphovascular space invasion (LVSI; p = 0.015). A total of 26% of the women had a history of tamoxifen usage with no effect seen on survival. Multivariate analysis showed that when treatment modality and LVSI were adjusted for FIGO staging, there was no statistical significance in the survival outcomes.

Conclusion

The incidence of uterine carcinosarcomas is increasing parallel with endometrial carcinomas with no significant effect of tamoxifen on survival.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Interval debulking surgery (IDS), following induction or neoadjuvant chemotherapy, may have a role in treating advanced epithelial ovarian cancer (stage III to IV) where primary debulking surgery is not an option.

OBJECTIVES

To assess the effectiveness and complications of IDS for women with advanced stage epithelial ovarian cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group's Specialised Register to June 2012, the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 6, MEDLINE to June 2012 and EMBASE to June 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. We performed meta-analysis of overall and progression-free survival (PFS), using random-effects models.

MAIN RESULTS

Three RCTs randomising 853 women, of whom 781 were evaluated, met the inclusion criteria. Meta-analysis of three trials for overall survival (OS) found no statistically significant difference between IDS and chemotherapy alone (hazard ratio (HR) = 0.80, 95% confidence interval (CI) 0.61 to 1.06, I² = 58%). Subgroup analysis for OS in two trials, where the primary surgery was not performed by gynaecologic oncologists or was less extensive, showed a benefit of IDS (HR = 0.68, 95% CI 0.53 to 0.87, I² = 0%). Meta-analysis of two trials for PFS found no statistically significant difference between IDS and chemotherapy alone (HR = 0.88, 95% CI 0.57 to 1.33, I² = 83%). Rates of toxic reactions to chemotherapy were similar in both arms (risk ratio = 1.19, 95% CI 0.53 to 2.66, I² = 0%), but little information was available for other adverse events or quality or life (QoL).

AUTHORS' CONCLUSIONS

We found no conclusive evidence to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in women whose primary surgery was not performed by gynaecologic oncologists or was less extensive. Data on QoL and adverse events were inconclusive.

Does neoadjuvant chemotherapy decrease the risk of hospital readmission following debulking surgery?

OBJECTIVE

To compare primary debulking surgery (PDS) vs. neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) among elderly patients with ovarian/fallopian tube/primary peritoneal carcinoma.

METHODS

Medical records of patients ≥70 years old with epithelial ovarian/fallopian tube/primary peritoneal carcinoma between January 2000 and December 2010 were reviewed. Patients were separated by PDS or NACT-IDS. Preoperative characteristics, surgical procedures and postoperative and oncologic outcomes were compared. Surgical procedures were given a complexity score based on a previously published method.

RESULTS

Of 165 patients, 125 (75.8%) underwent PDS and 40 (24.2%) underwent NACT-IDS. Patients undergoing NACT-IDS were more likely to have a pleural effusion (without cytology) and stage 4 disease. Median CA-125 at diagnosis was greater for those undergoing NACT-IDS. The NACT-IDS group was associated with less intraoperative blood loss (250 vs. 400 mL, p=0.001), a greater chance of achieving no residual disease (40% vs. 16%, p=0.005) and a shorter hospital length of stay (LOS) (5 vs. 7 days, p<0.001). PFS (17 vs. 15 months, p=0.708) and OS (29 vs. 33 months, p=0.827) were similar between the two groups. Readmission rates within 30 days of surgery were greater in those undergoing PDS (17.6% vs. 2.5%, p=0.016). After readmission, the median hospital LOS was 6 days (range: 1-41).

CONCLUSIONS

Elderly patients undergoing PDS have similar oncologic outcomes when compared to patients undergoing NACT-IDS. The risk of readmission within 30 days of surgery is significantly greater among patients undergoing PDS.

The Feasibility and Effects of Acupuncture on Quality of Life Scores During Chemotherapy in Ovarian Cancer: Results from a Pilot, Randomized Sham-Controlled Trial

BACKGROUND

Within a pilot trial regarding chemotherapy-induced neutropenia, the secondary aim of the main study was explored. This involved measuring the effects-as shown on two key measurement scales reflecting quality of life (QoL)-of verum versus sham acupuncture on patients with ovarian cancer during chemotherapy.

OBJECTIVE

The aim of this substudy was to determine the feasibility of determining the effects of verum acupuncture versus sham acupuncture on QoL in patients with ovarian cancer during chemotherapy.

DESIGN

This was a randomized, sham-controlled trial.

SETTING

The trial was conducted at two cancer centers.

PATIENTS

Patients with ovarian cancer (N=21) who were receiving chemotherapy-primarily intravenous carboplatin and paclitaxel-participated in this substudy.

INTERVENTION

The participants were given either active or sham acupuncture 1 week prior to cycle 2 of chemotherapy. There were ten sessions of acupuncture, with manual and electro-stimulation over a 4-week period.

MAIN OUTCOME MEASURES

The European Organization for Research and Treatment of Cancer-Quality-of-Life Questionnaire-Core 30 Item (EORTC-QLQ-C30) and the Quality of Life Questionnaire-Ovarian Cancer Module-28 Item (QLQ-OV28) were administered to the patients at baseline and at the end of their acupuncture sessions.

RESULTS

Of the original 21, 15 patients (71%) completed the study, and 93% of them completed the questionnaires. The EORTC-QLQ-C30 subscores were improved in the acupuncture arm, including the mean scores of social function (SF), pain, and insomnia (p=0.05). However, after adjusting for baseline differences, only the SF score was significantly higher in the active acupuncture arm, compared with the sham acupuncture arm (p=0.03).

CONCLUSIONS

It appears feasible to conduct a randomized sham-controlled acupuncture trial measuring QoL for patients with ovarian cancer who are undergoing chemotherapy. Acupuncture may have a role in improving QoL during chemotherapy.

Neoadjuvant chemotherapy (NACT) is an effective way of managing elderly women with advanced stage ovarian cancer (FIGO Stage IIIC and IV)

BACKGROUND

To compare outcomes in women ≥ age 70 who receive neoadjuvant chemotherapy (NACT) for advanced epithelial ovarian cancer (EOC) followed by cytoreductive surgery with those undergoing upfront cytoreductive surgery followed by the same chemotherapy.

METHODS

A retrospective cohort study was performed for women ≥ age 70 with Stage IIIC or Stage IV EOC from 1996 to 2009.

RESULTS

Sixty-two patients who underwent upfront cytoreductive surgery and 42 patients who received NACT were eligible for analysis. Patients receiving NACT were significantly more likely to have Stage IV disease (P = 0.004). Cytoreduction to no macroscopic disease was achieved in 71.4% of women who received NACT and 28.1% of women undergoing upfront surgery (P < 0.001). NACT patients had significantly less blood loss at surgery (P = 0.01), required fewer small bowel resections (P = 0.009), had shorter ICU stays (P = 0.02) and fewer hospital days (P = 0.04). NACT patients experienced a trend toward an improved progression-free survival (P = 0.078); however, no statistically significant differences were found in either the progression-free or overall survival analyses.

CONCLUSION

NACT is associated with reduced perioperative morbidity in elderly patients with advanced stage ovarian cancer.

Management of the Elderly Patient With Gynecologic Cancer: Report of the 2011 Workshop in Geriatric Gynecologic Oncology

Abstract

Reflecting the worldwide aging trend and close association of aging with cancer, geriatric oncology is now growing beyond its pioneer years. Nevertheless, geriatric oncology in the gynecologic field is in the beginning stage; indeed, there is no geriatric specialist who is trained in this particular field of gynecologic oncology. Therefore, we held the first workshop in geriatric gynecologic oncology. In this review, we summarize what we discussed at the workshop and provide evidence-based recommendations for the diagnosis and treatment of gynecologic cancer in elderly individuals.

Prognosis and hormone receptor status in older and younger patients with advanced-stage papillary serous ovarian carcinoma

OBJECTIVE

Prior studies have suggested that patients diagnosed with ovarian cancer at an older age have worse outcomes. However, few studies have examined whether differing patterns of protein expression in tumors in older patients correlate with this poorer prognosis. We investigated the correlation of age with prognosis and the significance of hormone receptor status in younger versus older patients through construction of a clinically-annotated high-density tissue microarray (HTMA) composed of stage III and IV papillary serous ovarian cancer cases.

METHODS

Two cohorts of patients (age > or =65 and < or =55 at diagnosis) were identified retrospectively from ovarian carcinoma pathology cases reviewed at our institution between 1999 and 2005. An HTMA was constructed from 148 eligible cases, and clinical data were abstracted through chart and database review.

RESULTS

No difference in survival was observed between younger and older patients. Patients > or =70 years had decreased survival on univariate, but not multivariate, analysis. ER was significantly more likely (p=0.01) and PR significantly less likely (p=0.02) to be expressed in older patients. Neither ER nor PR independently correlated with survival in the overall study population.

CONCLUSIONS

Patients with advanced-stage papillary serous ovarian cancer > or =65 years of age at diagnosis have a similar survival as patients < or =55 years. Hormone receptor status differs significantly between the two age groups, and in the younger patient cohort, there is a trend towards longer overall survival for ER/PR positive tumors. These results suggest that ovarian cancer in younger patients differs biologically from that in older patients.