Assessing the risk of ovarian malignancy algorithm for the conservative management of women with a pelvic mass

OBJECTIVE

To evaluate the use of as an aid in the identification of women who can safely undergo conservative, non-surgical management.

METHODS

All patients referred to the Program in Women's Oncology for surgery with a pelvic mass are evaluated at a prospective multidisciplinary tumor board (TB) where ROMA and imaging are used for management recommendations. This study evaluated women presented to TB with a pelvic mass between 2009 and 2013 who had either surgical or conservative management.

RESULTS

Of the 498 patients assessed, 392 (79%) had benign disease, 22 (4%) had LMP tumors, 28 (6%) had stage I-II epithelial ovarian cancer (EOC), 36 (7%) had stage III-IV EOC and 20 (4%) had non-EOC. Using clinical assessment in conjunction with ROMA, the TB recommended observation in 188 (37.8%) women. All patients diagnosed with an invasive malignancy were recommended for surgery by the TB. In the 315 patients managed surgically, 212 were found to have benign disease and 84 women were diagnosed with an invasive malignancy. The sensitivity for the initial TB recommendations using ROMA in conjunction with clinical judgment for detecting malignancy was 100% with a specificity of 47.7% and a NPV of 100%. When including low malignant potential tumors the sensitivity was 99.1%. For stage I-IV EOC ROMA alone had a sensitivity of 95.3%.

CONCLUSIONS

ROMA in conjunction with clinical assessment can safely identify women for conservative management.

Predictive factors for the presence of malignant transformation of pelvic endometriosis

OBJECTIVES

To determine predictive factors for the presence of malignant transformation in ovarian endometriotic cysts.

STUDY DESIGN

This was an IRB approved, case control study analyzing patient data from 2004 to 2013. Pathology database records were searched to identify patients with benign endometrioma and ovarian carcinoma arising in the background of endometriosis. Inclusion criteria required each patient to have a preoperative diagnosis of adnexal mass and no other findings concerning for malignancy. Patient clinical records were queried for preoperative symptoms, serum CA125 levels and radiologic findings. Pathologic data were collected including histology, tumor grade and stage.

RESULTS

A total of 138 patients met inclusion criteria; 42 women with ovarian cancer arising in the background of endometriosis and 96 women with benign endometrioma. Women diagnosed with ovarian cancer were significantly older than women with endometriosis (53.6 vs. 39.2 years). There was no difference in presence of symptoms between the two groups. Women with malignant tumors were found to have significantly larger cysts (14 cm vs. 7.5 cm; p<0.0001) that were more often multilocular (45.7% vs. 12.2%; p<0.0001), and contained solid components (77.1% vs. 14.5%; p<0.0001). Among patients that were observed prior to surgery there was a significant difference in the change in size of the mass over time with 4.2 cm increase for cases vs. 1.0 cm increase for controls (p=0.02). Multiple logistic regression analysis indicated that for every 5 years increase in age there was an adjusted OR of 2.17 (p=0.003). An age of 49 years or greater had an 80.6% sensitivity (95% CI: 62.5-92.5%) and an 82.9% specificity (95% CI: 67.9-92.8%) for malignancy, and solid component on imaging had an adjusted OR of 23.7 (p<0.0001). Serum CA125 levels tended to be higher in patients with malignant tumors but did not reach statistical significance with a mean of 204.9 vs. 66.9 (p=0.1).

CONCLUSIONS

Significant predictors for malignant transformation of endometriosis include cyst characteristics and age. Women above the age of 49 with multilocular cysts and solid components are at high risk for malignant transformation of endometriosis. Serum CA125 level is not a significant predictor of malignant transformation.

Long-term follow-up of vulvar cancer patients evaluated with sentinel lymph node biopsy alone

OBJECTIVE

The objective of this study was to examine SLN evaluation alone in women with squamous cell carcinoma (SCC) of the vulva and evaluate the inguinal recurrence and complication rates.

METHODS

An IRB approved prospective study enrolled patients with SCC of the vulva. Peritumoral injection of Tc-99 sulfur colloid and blue dye was used to identify SLNs intraoperatively. Patients with negative SLN for metastasis were followed clinically without further treatment. Patients with metastasis to a SLN underwent full groin node dissection followed by standard treatment protocols.

RESULTS

A total of 73 women were enrolled onto protocol with 69 patients undergoing SLN dissection. Mean age was 66.9years (range: 29-91) with 47 stage I, 12 stage II, 9 stage III, 2 stage IV and 3 unstaged patients. SLN dissections were successful in 63 patients. Of the 111 groins evaluated with a SLN dissection 93% had a SLN identified with an average of 2 SLN per groin. There were 92 groins with negative SLN and 11 groins with positive SLN. 57 patients had negative SLN and underwent conservative management with the median follow-up of 58.3months. Three patients experienced groin recurrences (2 unilateral, 1 bilateral) for a recurrence rate of 5.2% (3/57). The complication rate for the inguinal incisions was 17.5% (1 cellulitis, 1 abscess, 2 lymphoceles, 5 lymphedema and leg pain).

CONCLUSIONS

Isolated SLN dissection alone has a low inguinal recurrence rate with decreased complications and should be considered as an option for women with SCC of the vulva.

Randomised controlled trial comparing hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors: a pilot study

OBJECTIVES

To compare the efficacy of hypnotherapy versus gabapentin for the treatment of hot flashes in breast cancer survivors, and to evaluate the feasibility of conducting a clinical trial comparing a drug with a complementary or alternative method (CAM).

DESIGN

Prospective randomised trial.

SETTING

Breast health centre of a tertiary care centre.

PARTICIPANTS

15 women with a personal history of breast cancer or an increased risk of breast cancer who reported at least one daily hot flash.

INTERVENTIONS

Gabapentin 900 mg daily in three divided doses (control) compared with standardised hypnotherapy. Participation lasted 8 weeks.

OUTCOME MEASURES

The primary endpoints were the number of daily hot flashes and hot flash severity score (HFSS). The secondary endpoint was the Hot Flash Related Daily Interference Scale (HFRDIS).

RESULTS

27 women were randomised and 15 (56%) were considered evaluable for the primary endpoint (n=8 gabapentin, n=7 hypnotherapy). The median number of daily hot flashes at enrolment was 4.5 in the gabapentin arm and 5 in the hypnotherapy arm. HFSS scores were 7.5 in the gabapentin arm and 10 in the hypnotherapy arm. After 8 weeks, the median number of daily hot flashes was reduced by 33.3% in the gabapentin arm and by 80% in the hypnotherapy arm. The median HFSS was reduced by 33.3% in the gabapentin arm and by 85% in the hypnotherapy arm. HFRDIS scores improved by 51.6% in the gabapentin group and by 55.2% in the hypnotherapy group. There were no statistically significant differences between groups.

CONCLUSIONS

Hypnotherapy and gabapentin demonstrate efficacy in improving hot flashes. A definitive trial evaluating traditional interventions against CAM methods is feasible, but not without challenges. Further studies aimed at defining evidence-based recommendations for CAM are necessary.

TRIAL REGISTRATION

clinicaltrials.gov (NCT00711529).

Comparison of hypnotherapy versus gabapentin in the treatment of hot flashes: A pilot study

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Background: The purpose of this study is to compare the efficacy of hypnotherapy versus gabapentin for the treatment of hot flashes in women with an increased risk or personal history of breast cancer.

Methods: In a prospective trial, eligible women were randomized to receive gabapentin (control arm) or hypnotherapy (experimental arm). Eligibility was defined by a personal history of breast cancer or an increased risk of developing breast cancer in women who reported at least one daily hot flash. The duration of participation was eight weeks, and women were asked to keep a daily journal of the number and severity of their hot flashes. The primary endpoints were number of daily hot flashes and hot flash severity score (HFSS). The secondary endpoint was quality of life, measured using the Hot Flash Related Daily Interference Score (HFRDIS).

Results: Twenty-seven women were enrolled (n=14 gabapentin, n=13 hypnotherapy) and 15 (56%) were considered evaluable for the primary endpoint (n=8 gabapentin, n=7 hypnotherapy). The median number of daily hot flashes at enrollment was 4.5 in the gabapentin arm, and 5 in the hypnotherapy arm. HFSS scores were 7.5 in the gabapentin arm and 10 in the hypnotherapy arm. After eight weeks, the median number of daily hot flashes was reduced by 33.3% among women in the gabapentin arm, and 80% in the hypnotherapy arm. The median HFSS was reduced by 33.3% in the gabapentin arm, and 85% in the hypnotherapy arm. HFRDIS scores improved by 51.6% in the gabapentin group and 55.2% in the hypnotherapy group.

Conclusions: Hypnotherapy and gabapentin both demonstrate efficacy in improving hot flashes in women with an increased risk or personal history of breast cancer. Complementary and alternative medicine (CAM) therapies are preferable to many women over hormone therapy due to the perceived risk of breast cancer, but objective data have been lacking comparing its use to conventional therapies. This pilot study provides evidence supporting the use of hypnotherapy for the treatment of hot flashes and emphasizes the need to perform further studies aimed at defining evidence-based recommendations for CAM.

Lower uterine segment involvement as a predictor for lymph node spread in endometrial carcinoma

OBJECTIVES

Several predictive factors for lymph node spread in endometrial cancer have been identified including tumor grade, depth of invasion, lymphatic or vascular-space invasion, and histologic subtype. Lower uterine segment involvement may also be predictive of lymph node spread. The objective of this study was to investigate the relationship between lower uterine segment involvement in endometrial carcinoma and lymph node spread.

METHODS

This was an IRB approved retrospective study. Data were collected for all patients diagnosed with endometrial cancer from June 1999 to December 2004. The primary end point was the presence of nodal involvement. Subset analysis was performed by histologic subtype. Univariate and multivariate nominal logistic regression was performed. Categorical variables were compared using Chi-square and Fischer's Exact Test.

RESULTS

Two-hundred and ninety-nine subjects were eligible for review. One-hundred seventy four (58%) had lower uterine segment involvement. Forty-four (25%) of those with lower uterine segment involvement had positive nodes compared to 10 (8%) of those without (p=0.0001). On univariate analysis, lower uterine segment involvement, lymphovascular-space invasion, and deep invasion predicted nodal disease. On multivariate analysis, lower uterine segment remained predictive of nodal spread for the endometrioid subset. For high-risk histologies, only lymphovascular-space invasion and deep myometrial invasion were predictive of nodal spread.

CONCLUSIONS

Lower uterine segment involvement in endometrial carcinoma is an important predictor of lymph node involvement for patients with endometrioid histologies. Tumor within the lower uterine segment may be an important factor to consider in intraoperative decision making regarding staging.

Oral thalidomide as palliative chemotherapy in women with advanced ovarian cancer

OBJECTIVE

We prospectively evaluated thalidomide, an oral agent with antiangiogenic and immunomodulatory properties, in patients with recurrent ovarian cancer, comparing the drug to standard intravenous chemotherapy and treatment holiday in terms of both progression-free interval and quality of life.

METHODS

Eligible patients had recurrent ovarian or primary peritoneal cancer and had received a minimum of two prior therapeutic regimens. Patients were offered one of three arms: (Arm A) any standard intravenous single-agent chemotherapy; (Arm B) oral thalidomide 200 mg daily; (Arm C) treatment holiday. Computed tomography (CT) scans were performed every two cycles until disease progression by Response Evaluation Criteria in Solid Tumors (RECIST) criteria. CA-125 was measured monthly as was quality of life using the Functional Assessment of Cancer Therapy (FACT-O) questionnaire.

RESULTS

Forty patients participated: 18 on Arm A; 18 on Arm B; and 4 on Arm C. The groups were comparable in terms of number of prior regimens and cycles of chemotherapy. The progression- free intervals were similar in Arm A and Arm B (3.7 versus 3.8 months). The PR/SD rate was 6.7%/60% for Arm A, and 7.7%/53.8% in Arm B. Of those treated with thalidomide, 53% had a drop in CA-125 greater than 50%, compared to 13% receiving intravenous chemotherapy. FACT-O scores at baseline and throughout treatment were equivalent.

CONCLUSION

The oral chemotherapeutic agent thalidomide appears to be comparable in response and quality of life, compared to single agent intravenous chemotherapy, in our population of heavily pretreated patients with ovarian cancer.

Does the platinum-free interval predict the incidence or severity of hypersensitivity reactions to carboplatin? The experience from Women and Infants' Hospital

OBJECTIVES

Carboplatin (C) is a standard treatment for gynecologic cancers, but its use in recurrence is associated with an increased risk of hypersensitivity reactions (HSR) in those previously treated with C. However, there is no way to predict those at risk for a C-HSR. We sought to evaluate whether the platinum-free interval (PFI) was predictive of incidence and severity of HSRs.

METHODS

Patients treated with C between 1/99 and 12/2005 were identified through our chemotherapy database. Records were reviewed in those receiving multiple C regimens or with C HSR. Severity was defined as mild or severe based on symptoms.

RESULTS

126 patients were identified who had multiple C regimens. 63 (50%) experienced C HSRs of which 36 (29%) were severe. The incidence of C HSR was 25.8% for PFI < 12 months and 56.5% if > or = 12 months (p=0.0023). The incidence of a severe C HSR significantly increased with time as well: 6.5% PFI < 12 months, 23.9% PFI 12-24 months and 47% PFI > or = 24 months (p=0.0091). Of those receiving a 3rd regimen of C, 8/8 had a HSR and these were severe in seven (88%). Of note, 60 patients received > 8 (range 9-19) cycles with the first C regimen, and none of the patients reacted after cycle 8.

CONCLUSIONS

A duration of greater than 12 months between C regimens is associated with an increased risk of both any--and severe--HSR. Our data also suggests that upfront treatment with C beyond eight cycles is not associated with an increased risk of HSR.

The prognostic significance of lower uterine segment involvement in surgically staged endometrial cancer patients with negative nodes

OBJECTIVES

Endometrial cancer is the most common female genital malignancy in the United States. Stage is the most important prognostic factor. Other factors include grade, lymph-vascular space invasion (LVI), and myometrial invasion. Tumor location in the lower uterine segment (LUS) may also be important. LUS involvement correlates with nodal involvement, and nodal involvement is an important prognostic indicator. This study investigates the importance of LUS involvement in patients with pathologically negative nodes.

METHODS

This was an IRB approved retrospective study. Data were collected for patients diagnosed with endometrial cancer from June 1999 to September 2004. Patients who underwent nodal evaluation with no evidence of nodal disease were eligible for analysis. The primary endpoint was progression-free survival. Secondary endpoints included recurrence rate and overall survival. Analysis was performed with the JMP5.1 statistical program.

RESULTS

285 patients were identified. 85 were excluded because they received postoperative care elsewhere. 3 charts were missing, and 15 pathology reports did not mention LUS. 147 of the remaining 182 subjects had negative nodes and formed the study population. 57% of these subjects had LUS involvement. Follow-up was similar for those with and without LUS involvement at 74 vs. 73 months respectively. PFS was similar at 70 and 63 months in those with and without LUS involvement (p=0.2). Recurrence correlated with LUS involvement on univariate analysis, however, not on multivariate analysis.

CONCLUSIONS

In endometrial cancer patients with negative nodes, disease within the lower uterine segment does not imply a worse prognosis. The previously described implications of LUS involvement are likely due to the strong association of LUS disease with lymph node spread.

Elevated body mass index does not increase the risk of palmar–plantar erythrodysesthesia in patients receiving pegylated liposomal doxorubicin

OBJECTIVES

The dose-limiting toxicity of pegylated liposomal doxorubicin (PLD) is palmar-plantar erythrodysesthesia (PPE). Some physicians are reluctant to use this drug in overweight patients, postulating that larger size increases the likelihood of PPE. We sought to determine whether a correlation exists between body mass index (BMI) and the frequency or severity of skin reactions during PLD chemotherapy.

METHODS

The records of all patients receiving PLD chemotherapy for gynecologic malignancy at our institution were reviewed for chemotherapy history, BMI at start of treatment, dose, infusion time, and adverse outcomes. Skin reaction sites, grade, and treatments were recorded. Possible predisposing factors were extracted, as well as the reason for drug discontinuation.

RESULTS

Over 7 years, 103 patients were treated with PLD for gynecologic malignancies. 429 cycles were given, and PPE occurred in 36% of patients treated. Of those with PPE, reactions were grades 1, 2, or 3 in 54%, 32%, and 14% of patients, respectively. The BMI of patients with PPE (29.0) was not significantly different from that of patients without PPE (28.8). Analysis using finer subsets of weight also revealed no association. Finally, logistic regression revealed no relationship between BMI and rash grade.

CONCLUSIONS

Elevated BMI does not appear to correlate with occurrence of PPE in our population. Of interest, among patients discontinuing PLD due to skin toxicity, 25% had clinical evidence of response. The identification of predisposing risk factors may help guide treatment decisions; however, elevated BMI does not appear to be such a risk factor.

Does the platinum-free interval predict the incidence or severity of hypersensitivity reactions to carboplatin? The experience from Women & Infants’ Hospital

5082

Background: Carboplatin (C) is a standard treatment for gynecologic cancers, but its use in recurrence is associated with an increased risk of hypersensitivity reactions (HSR) in those previously treated with C. However there is no way to predict those at risk for a C-HSR. We sought to evaluate whether the time between C was predictive of incidence and severity of HSRs. Methods: Patients treated with C between 1/1997 and 12/2005 were identified through our chemotherapy database. Records were reviewed for: dates and number of C regimens and cycles, age, drug allergies, cancer type, and date and symptoms of HSR. Severity was defined as mild if symptoms were rash, pruritis or severe for hypo/hypertension, vomiting, dyspnea, wheezing, chest pain, edema, rigors or generalized hives. Fisher’s exact test or Chi Square was used to compare categorized variables. Results: 126 patients were identified who had multiple C regimens. The median age was 60 (range, 40–90) and 89% were treated for ovarian cancer. 63 (50%) experienced C HSRs of which 36 (29%) were severe. The mean time between C regimens was 21 months for those with no HSRs and 24 months for those with HSRs (p = 0.1). The time between C regimens significantly predicted the incidence of HSRs (see table ). Of those receiving a 3rd regimen of C, 8/8 had a HSR and these were severe in seven (88%). Neither age nor presence of other drug allergies was associated with a risk of C HSR. Of interest, 60 patients received >8 (range 9–19) cycles with the first C regimen, and none of the patients reacted after cycle 8. Conclusions: A duration of greater than 12 months between C regimens is associated with an increased risk of both any- and severe- HSR. Our data also suggests that upfront treatment with C beyond eight cycles is not associated with an increased risk of HSR. Strategies for decreasing the risk of C HSR may be best focused on women receiving a repeat regimen after a platinum-free duration over 12 months or those receiving a 3rd regimen of C.

[Table: see text]

No significant financial relationships to disclose.

A novel multiple biomarker assay for the detection of ovarian carcinoma

5023

Background: Studies show that ovarian cancer patients operated on by gyn oncologists are more often adequately staged and debulked than those operated on by non-gyn oncologists. Many benign gynecologic conditions will elevate the CA125 tumor marker decreasing its specificity. An accurate test is needed to help triage patients with a pelvic mass to centers with expertise in treating ovarian cancer. This project examined several novel tumor markers to develop a multiple biomarker assay to predict the risk of ovarian cancer in patients with an ovarian cyst or pelvic mass. Methods: Data from two separate IRB approved prospective trials from two institutions were collected. After obtaining informed consent, serum samples were obtained preoperatively from women undergoing surgery for an adnexal mass and analyzed for levels of CA125, SMRP, HE4 and CA72–4. All pathology results were compared to the tumor markers. Sensitivities at set specificities of 90, 95 and 98% were determined using logistic regression for each marker individually and all combinations of 2, 3, & 4 markers. Results: 448 samples were analyzed. There were 267 benign cases and 181 ovarian cancers (27 stage I, 20 stage II, 115 stage III and 19 stage IV). Median values for HE4, SMRP, CA125 and CA72–4 all differed significantly between benign masses and cancer (p < 0.001). In the differentiation of benign masses and stage I malignancies, the addition of HE4 to CA125 increased the sensitivity by 22.2% at a specificity of 90%. The combination of HE4 and CA125 for all stages was superior to HE4 or CA125 alone (p ≤ 0.003). Conclusions: The improvement in sensitivity shown by the addition of HE4 to CA125 suggests that this biomarker combination can be used to provide an accurate risk assessment for the presence of ovarian cancer in patients with an ovarian cyst or mass. This multiple biomarker assay is now undergoing validation in a multicenter prospective study.

[Table: see text]

[Table: see text]

Utility of a novel serum tumor biomarker HE4 in patients with uterine cancer

5036

Background: Approximately 40,880 new cases of uterine cancer are diagnosed in the U.S. annually resulting in 7,310 deaths. Uterine cancer is surgically staged and 75% of patients present with stage I disease. Patients with stage I tumors with intermediate to high risk factors have a recurrence rate of 20 to 30%. Serum CA125 is elevated in 75% of patients with advanced stage disease and in only 17% of patients with early stage disease. The use of CA125 for the detection of recurrent disease is limited at best. Only 25% of patients with asymptomatic recurrent disease have an elevated CA125. A better marker indicating early recurrent disease is needed. The objective of this study was to examine the value of a novel serum tumor marker HE4 in endometrial cancer. Methods: Serum samples from two prospective IRB approved studies at two institutions were analyzed to compare HE4 with CA125 in patients who had surgical staging for uterine cancer. Normal controls were obtained from healthy patients. Informed consent was obtained from all patients and blood samples were drawn pre-operatively. HE4 and CA125 levels were determined using assays from Fujirebio Diagnostic Inc. ROC curves were constructed for each tumor marker and the sensitivity at a set specificity of 95% was determined. Results: Serum from 156 controls and 233 patients with surgically staged endometrial cancer; (151 stage I, 21 stage II, 47 stage III and 14 stage IV) were examined. The area under the ROC curves (ROC-AUC) for HE4 and CA125 were determined and compared ( Table1 ). At 95% specificity, the sensitivity for differentiation of controls versus all stages was 44.9% for HE4 compared to 25.2% for CA125 (p = 0.0001). For stage I cases, HE4 showed an improvement in the sensitivity of 20.5% compared to CA125 (37.1% vs 16.6%, p = 0.0001). Conclusions: HE4 is elevated in all stages of endometrial cancer and has a greater sensitivity for discrimination from normal controls compared to CA125. As well, HE4 is elevated in early stage endometrial cancer and should be investigated as a marker for early recurrent disease.

[Table: see text]

[Table: see text]

Inguinal sentinel node dissection versus standard inguinal node dissection in patients with vulvar cancer: A comparison of the size of metastasis detected in inguinal lymph nodes

OBJECTIVE

The emergence of sentinel lymph node (SLN) technology has provided the ability for an in depth pathologic evaluation for the detection of metastasis to lymph nodes through the use of ultra-staging. The SLN has been shown to be predictive of the metastatic status of its nodal basin. More recently, SLN dissections have been employed in the evaluation of the inguinal lymphatic basins in patients with vulvar malignancies. We hypothesize that the average size of metastasis detected in non-palpable inguinal lymph nodes is smaller when detected through the use of SLN dissection and ultra-staging versus complete inguinal node dissection (CND).

METHODS

This was an IRB approved retrospective study. The tumor registry database was searched to identify all patients diagnosed with a vulvar malignancy from 1990 to 2004. The records were reviewed to identify patients with inguinal lymph node metastasis. Only patients with non-palpable inguinal lymph nodes (metastasis 1 cm or less) were included in the analysis. All pathology slides were reviewed. The smallest metastatic foci of cells were measured from lymph nodes obtained through the traditional complete inguinal lymph node dissection (CND) and compared with the largest metastatic foci of cells detected in sentinel lymph node dissections. The mean size and standard deviation for each group was calculated and analyzed with a Mann-Whitney test.

RESULTS

There were 336 inguinal node dissections performed in patients identified with a vulvar malignancy. SLN dissections were performed in 52 groins and CND in 284 groins. Fifty-eight patients were found to have metastatic disease to the inguinal lymph nodes. Thirty of these patients had no evidence of lymph node metastasis on clinical exam or at the time of their EUA. There were 7 groins with metastasis detected through an SLN and 23 groins through a CND. The mean size of the metastatic foci detected in the SLN group was 2.52 mm (SD 1.55) and in the CND group was 4.35 mm (SD 2.63). This was not statistically significant (P = 0.109). However, when comparing the detection of micrometastasis in each set, there was a significant difference (P = 0.02) in the detection of the size of metastasis detected with smaller cluster of cells detected in the SLN group.

CONCLUSION

SLN dissection with ultra-staging allows for a more extensive pathologic examination of lymph nodes and may allow for the detection of smaller tumor foci than the traditional pathological examination of lymph nodes obtained from a CND. The clinical implication of the detection of these micrometastasis and smaller metastasis remains to be determined.

Pathologic evaluation of inguinal sentinel lymph nodes in vulvar cancer patients: a comparison of immunohistochemical staining versus ultrastaging with hematoxylin and eosin staining

OBJECTIVES

To evaluate the value of immunohistochemical (IHC) staining of inguinal sentinel lymph nodes (SLN) found to be negative for metastatic disease by ultrastaging with hematoxylin and eosin (H&E) staining.

METHODS

An IRB approved study identified 29 patients who had undergone an inguinal sentinel lymph node dissection for squamous cell carcinoma of the vulva. All sentinel lymph nodes found to be negative for metastatic disease based on ultrastaging with H&E staining were reevaluated with pancytokeratin antibody (AE1/AE3) immunohistochemical (IHC) staining to detect micrometastasis.

RESULTS

Twenty-nine patients with squamous cell carcinoma of the vulva underwent an inguinal sentinel node dissection. Nineteen patients had inguinal dissections negative for metastatic disease, 2 patients had bilateral inguinal metastasis, and 8 patients had unilateral inguinal metastasis. A total of 42 groin dissections with SLN biopsies were performed; 12 groins were positive for metastatic disease and 30 were negative based on ultrastaging with eosin and hematoxylin staining. A total of 107 sentinel lymph nodes (2.5 SLN per groin) were obtained, of which 18 SLN contained metastatic disease identified by ultrastaging and staining with H&E. Two SLN contained micrometastasis less than 0.3mm in size and 16 SLN contained metastasis greater than 2mm in size. Eighty-nine SLN found to be negative for metastasis by ultrastaging with H&E staining were also negative for micrometastasis on evaluation with pancytokeratin antibody AE1/AE3 IHC staining.

CONCLUSIONS

The addition of immunohistochemical staining to ultrastaging with H&E staining in the pathologic evaluation of inguinal sentinel lymph nodes does not increase the detection of micrometastasis in patients with primary squamous cell carcinoma of the vulva.

What matters matter? P values, H values, leadership, and us

Framed by the question "What matters matter?," this essay considers today's physicians' need for leadership, the principled road they embarked on, and the reasons to continue. Taken as a whole, the vast problems of health care seem unsolvable. Approached in small tangible steps, if not cure, could direction, even inspiration, appear? When people are sick, they look to physicians. By actually caring for patients, physicians have earned trust and learned, scientifically and artfully, about life in ways others cannot. Meaningful patient-centered care occurs at the junction of logical science and tenuous human needs: "p values" and "h values." Along with the privileged understanding gained from patients comes the responsibility to stand publicly for the rights of all patients to private moments. Standing up in these ways can never be easy; then again, it never was. It is the continued journey toward historic ideals. It is an imprecise place of struggle, where caring "leadership" has always been most needed, fulfilling and truly defining physicians. Despite today's seemingly insurmountable obstacles, in this place each physician can find ways to reenergize around what matters matter.

Caelyx/Doxil for the treatment of metastatic ovarian and breast cancer

Caelyx/Doxil is a novel pegylated liposomal formulation of the first-generation anthracycline, doxorubicin. The pharmacokinetics of this polyethylene-glycol-coated liposome are characterized by a reduced volume of distribution, a long intravascular circulating half-life and slow plasma clearance compared with free doxorubicin. This, coupled with a small vesicular size, uniquely promotes the localization of Caelyx/Doxil at tumor sites and explains its altered toxicity profile. The FDA and EMEA have approved its use for the treatment of AIDS-related Kaposi's sarcoma and, more recently, for recurrent epithelial ovarian cancer (EOC). Numerous investigations have focused on its use in the treatment of metastatic breast cancer, as well as recurrent squamous cell cervical carcinoma, soft tissue sarcoma, squamous head and neck cancers, prostate cancers and malignant gliomas. Ongoing clinical studies of combination regimens incorporating Caelyx/Doxil will further clarify its role in the treatment of advanced solid tumors.

Phase II study of liposomal doxorubicin in platinum- and paclitaxel-refractory epithelial ovarian cancer

PURPOSE

Stealth liposomal doxorubicin (Alzal Corp, Palo Alto, CA) has a slower clearance rate than free doxorubicin, resulting in sustained serum levels. Liposomal encapsulation also leads to increased concentration of drug in tumor tissue. Meta-analysis of previous studies has shown that doxorubicin has activity in epithelial ovarian cancer. The current study was developed to examine the activity of Stealth liposomal doxorubicin in platinum- and paclitaxel-refractory ovarian cancer.

PATIENTS AND METHODS

Patients had epithelial ovarian cancer that either progressed on or recurred within 6 months of completion of platinum and paclitaxel chemotherapy. All patients had measurable disease. Stealth liposomal doxorubicin was administered at 50 mg/m(2) every 4 weeks as a 1-hour infusion.

RESULTS

Eighty-nine patients were treated and included in an intent-to-treat analysis. There were 82 patients who were platinum and paclitaxel refractory and met all study criteria. There was one complete response and 14 partial responses, for a total response rate of 16.9% (95% confidence interval [CI], 9.1% to 24.6%). For platinum- and paclitaxel-refractory patients, the response rate was 18.3% (95% CI, 9.9% to 26.7%). Median time to progression was 19. 3 weeks for the entire population. Ten patients (11.2%) withdrew because of adverse events related to the drug (palmar-plantar erythrodysesthesia [PPE], n = 3; asthenia, n = 2; cardiac, n = 2; neutropenia, n = 1; stomatitis, n = 1; and edema, n = 1). There were no drug-related fatal events. There were only eight grade 4 adverse events attributable to the drug. Stomatitis, PPE, and skin lesions were managed with dose reductions and delays in most cases.

CONCLUSION

Stealth liposomal doxorubicin has activity in refractory epithelial ovarian cancer. PPE and stomatitis can usually be managed by dose adjustment. The ease of administration makes this an attractive agent.

Expectations about alternative therapies and women with gynecological cancer

Women with gynecological cancers are exploring and using 'alternative medicine(s)', as are other cancer patients and much of Western society. On behalf of their patients, physicians must understand something of its history, terms, types, who uses it and why and where to find answers, as well as being prepared to open and engage in dialogue about alternative medicine with their patients.

Absence of estrogen and progesterone receptors in glassy cell carcinoma of the cervix

OBJECTIVE

To evaluate the estrogen and progesterone receptor status of glassy cell carcinoma of the cervix to assess the possible implications of hormone replacement therapy in these patients.

METHODS

The estrogen and progesterone receptor status of 13 glassy cell carcinomas was evaluated by immunohistochemistry using commercial monoclonal antibodies and a streptavidin-biotin detection system.

RESULTS

No immunohistochemically detectable estrogen or progesterone receptor protein was present in tumor cells, although both receptors were identified in the adjacent normal cervical tissue.

CONCLUSION

The absence of estrogen and progesterone receptors in glassy cell carcinoma suggests that this tumor would not be hormonally responsive and that these patients can be safely treated with hormone replacement therapy. Further studies are indicated to confirm this observation.

S-Phase fraction, p53, and HER-2/neu status as predictors of nodal metastasis in early vulvar cancer

OBJECTIVE

Our aim was to determine the value of the S-phase fraction, p53, and HER-2/neu status as predictors of inguinal nodal metastasis in early vulvar cancer.

METHODS

The charts of 100 consecutive patients with invasive squamous cell cancer of the vulva were reviewed and a cohort of patients with clinical stage I or II disease treated primarily with radical surgery and inguinal node dissection was identified. Within this cohort, all node-positive patients were matched with node-negative controls by depth of invasion. Tumor from the 13 node-positive patients and 26 controls was then analyzed by flow cytometry and immunohistochemistry.

RESULTS

The median value of the S-phase fraction was higher in tumor from patients with inguinal nodal metastasis (median, 18.2; 25th-75th percentile: 13.9-28.3) than in node-negative patients (median, 8.9; 25th-75th percentile: 5.4-15.6) (P = 0.01). The presence of the HER-2/neu immunopositivity was also found to be associated with nodal metastasis (OR 4.05, 95% CI 1.0-16.6), but we found no evidence that DNA index or the presence of p53 immunopositivity was associated with nodal metastasis.

CONCLUSION

Early vulvar cancer patients with inguinal node metastasis have a significantly higher S-phase fraction and are more likely to have HER-2/neu immunopositivity when compared to those without nodal metastasis.

Prognostic value of clinical variables in ovarian cancer

OBJECTIVE

To test the hypothesis that clinical variables, including the patient's symptoms, symptom severity, and co-morbidity, affect the survival rate in patients with ovarian cancer.

METHODS

We reviewed the records of 137 cases of ovarian cancer diagnosed and treated between January 1987 and June 1992, and extracted data regarding patients' demographic characteristics, symptoms, medical co-morbidity, stage of disease, tumor histology and grade, treatment, and clinical course.

RESULTS

Once cases of borderline tumors were excluded, the overall 3-year and 4-year mortality rate were 38% and 49%, respectively. There was an decrease in 4-year survival with more advanced symptom type ranging from 85% in asymptomatic women to 38% in women with complex symptoms (log rank, p = 0.005). Medical co-morbidity was not found to affect survival in the cohort studied. We performed multivariable analysis using a Cox proportional hazards model and confirmed that the symptom stage was highly prognostic even after controlling for FIGO stage, age and co-morbidity (p = 0.004).

CONCLUSION

We found that clinical variables such as patient's symptoms, were associated with prognosis. Symptom classification is a necessary and important component in a system of prognostic stratification for ovarian cancer.

Synchronous endometrioid tumors of the ovary and endometrium. A clinicopathologic study of 22 cases

OBJECTIVE

To analyze a group of 22 patients with synchronous endometrioid tumors of the ovary and endometrium.

STUDY DESIGN

A retrospective chart review was undertaken and information collected on patient age, parity, tumor grade and stage, presence of coexisting endometriosis and survival. Flow cytometry was determined from archival samples of the endometrial and ovarian tumors.

RESULTS

The mean age at diagnosis was 52.8 years (range 36-71); mean parity was 1.05. With regard to the endometrial component, 68.2% were grade 1, 63.6% were stage I and, by flow cytometry, 62.5% were aneuploid. With regard to the ovarian lesions, 68.2% were grade 1, 68.2% were stage I, and 71.4% were aneuploid by flow cytometry. Twelve (54.5%) of 22 patients had pathologic evidence of coexisting endometriosis. Overall, three-year survival was 75%. All 11 patients with stage I disease at both sites were alive, without disease, at a mean follow-up of 34.9 months.

CONCLUSION

Patients with synchronous endometrioid tumors of the endometrium and ovary are generally younger than reported for either endometrial adenocarcinomas or ovarian epithelial adenocarcinomas. They tend to be low grade and early stage and are frequently associated with endometriosis. Our data suggest that the survival of patients with synchronous primaries correlates with the stage of the individual tumors and that a second, synchronous primary does not adversely affect prognosis.

Malignant mixed mesodermal tumors of the ovary

OBJECTIVE

To review the experience at Women & Infants Hospital and Hartford Hospital of patients with malignant mixed mesodermal tumors of the ovary, and to review the pertinent literature.

METHODS

Fourteen cases of malignant mixed mesodermal tumors of the ovary at the two hospitals over a 5-year period were identified through their tumor registries. Demographic data, pathology, treatment, and survival rates were reviewed.

RESULTS

The median survival of the patients in our series was 7 months, with 64% dead of disease in 1 year. A review of the pertinent literature indicated median survivals of 6-12 months, with more than 70% of the patients dead of disease at 1 year, despite treatment.

CONCLUSION

Further investigation is needed to determine the proper management for malignant mixed mesodermal tumors of the ovary. Meanwhile, current treatment strategies should recognize the present therapeutic limitations, so as not to diminish any further the quality of life for women with this malignancy.

Pelvic endometriosis mimicking advanced ovarian cancer: presentation with pleural effusion, ascites, and elevated serum CA 125 level

Two patients with clinical complications of endometriosis mimicking stage IV epithelial ovarian cancer are described. One had bilateral pleural effusions, ascites, and a serum CA 125 level of 440 U/ml. The other had a right-sided pleural effusion and a large abdominal mass.

The effects of a course in cadaver dissection on resident knowledge of pelvic anatomy: an experimental study

OBJECTIVE

To determine whether a course in cadaver dissection can significantly increase resident knowledge of pelvic anatomy beyond that of current educational practices.

METHODS

Thirteen first- and second-year residents were randomly assigned to a cadaver dissection course (seven) or a control group (six). The dissection group performed dissections with instruction, using a dissection guide designed specifically for the course. The control group received study references on pelvic anatomy and protected study time. Each participant took a practical and written examination at the beginning and end of the study.

RESULTS

The two groups did not differ statistically in their scores on the pre-test. Both groups improved on the post-test, but the dissection group scored nearly 50% higher on the test than did the controls. The two groups differed significantly on the post-test, adjusted for pre-test performance (P < .01). In their evaluation of the course, participants from the dissection group emphasized its educational value and urged that it be offered to residents as a regular part of their training.

CONCLUSION

Dissection of a human cadaver provides a valuable experience, allowing participants to gain a greater understanding of surgical anatomy and surgical procedures in a no-risk, unhurried setting. Residents who participated in a cadaver dissection course designed specifically for their needs showed a statistically significant increase in knowledge compared with those without this experience. Both objectively and subjectively, a cadaver dissection course is an excellent tool for instructing gynecology residents.

Tumor angiogenesis as a prognostic factor in cervical carcinoma

Angiogenesis, the induction of new capillaries and venules, has been associated with tumor growth. Increased tumor size and new vessel growth may further the opportunity for tumor cells to enter the circulation and potentiate metastatic disease. To investigate if tumor angiogenesis could serve as a prognostic factor in cervical carcinoma, we counted microvessels (capillaries and venules) in 29 patients with squamous cell carcinoma of the cervix. Surgical specimens were stained for endothelial cells specifically with Factor VIII to identify all vessels. The microvessels were counted by light microscopy (per 200 x field) in tumor sections with the highest population of microvessels. This was performed by two investigators without knowledge of patient outcome or extent of disease. Microvessel counts in patients with squamous cell carcinoma were significantly different from those of control subjects: 56 +/- 28.9 and 16.3 +/- 3.3 (P = 0.013). There was no correlation between microvessel count and node status, parametrial involvement, depth of invasion, or gross disease. Microvessel count was significantly correlated with vascular space involvement (P = 0.017). Four patients who developed recurrent disease within 1 year had high microvessel counts and yet were node negative and VSI negative at surgery. As shown by Folkman in breast cancer, angiogenesis may also be an independent predictor for recurrent disease in squamous cell carcinoma of the cervix. Microvessel counts could be of prognostic value in patients who do not have other risk factors for disease recurrence.

Endometriosis with myxoid change. A case simulating pseudomyxoma peritonei

After a diagnosis of endocervical adenocarcinoma was made on examination of a curettage specimen, a 46-year-old woman underwent laparotomy for the purpose of radical hysterectomy. After frozen section of a biopsy specimen obtained from a nodule 2 cm in diameter on the posterior surface of the cervix was interpreted as adenocarcinoma, consistent with pseudomyxoma peritonei, the planned hysterectomy was abandoned; only biopsies of the pelvic and para-aortic lymph nodes and a bilateral salpingo-oophorectomy were performed. Permanent sections of the nodule revealed pools of almost acellular mucin, myxoid fibrous tissue, and typical endometriotic glands and stroma. Similar findings were associated with endometriotic foci in the serosa of a fallopian tube and adjacent to a pelvic lymph node. There was no evidence of adenocarcinoma in any of the specimens. A radical hysterectomy was performed subsequently, and pathological examination of the uterus revealed a superficially invasive adenocarcinoma of the cervix without evidence of extrauterine spread. The diagnosis of endometriosis associated with myxoid change was confirmed in residual cul-de-sac tissue. The patient was alive with no clinical evidence of tumor 6.5 years later. This case illustrates that rare cases of endometriosis can be associated with striking degrees of myxoid change, a finding that should not be confused with mucinous adenocarcinoma on microscopic examination.

Persistence of gestational trophoblastic disease for longer than 1 year following evacuation of hydatidiform mole

BACKGROUND

A spontaneous fall in the radioimmunoassay for the beta subunit of hCG to less than 2 mIU/mL documents regression of hydatidiform mole following evacuation of a molar pregnancy. Continued negative hCG levels for the year after evacuation indicates the absence of risk for persistent gestational trophoblastic disease. This report describes an unusual case of recurrent nonmetastatic gestational trophoblastic disease 16 months after initial evacuation.

CASE

A 29-year-old woman presented at 19 weeks' gestation with severe preeclampsia and vaginal bleeding. Pelvic ultrasonography demonstrated a molar pregnancy. Pathology following uterine evacuation confirmed a hydatidiform mole. Serial hCG levels fell progressively to less than 2 mIU/mL over the following 25 weeks. She remained compliant with oral contraceptive pills despite having no sexual activity. Sixteen months after uterine evacuation, recurrence of gestational trophoblastic disease was documented by a rising beta-hCG, negative pelvic ultrasound, normal liver function tests, and normal computed tomography of the head. Endometrial curettage showed no chorionic villi or molar tissue. She was treated with five courses of actinomycin D and has remained disease-free for the following 5 years.

CONCLUSION

This late recurrence of gestational trophoblastic disease suggests that those with a molar pregnancy may benefit from surveillance beyond 1 year after uterine evacuation.

Lower limb ischemic venous thrombosis in patients with advanced ovarian carcinoma

Three cases of lower limb, deep venous thrombosis that progressed to ischemia in patients with advanced ovarian cancer are reported. One patient developed frank gangrene of the extremity. Venous stasis, secondary to venous compression from metastatic disease, was the predisposing factor in all cases. Heparin therapy was uniformly unsuccessful in halting progression of thrombosis. Ischemic thrombosis originating from extrinsic venous compression is unlikely to respond to conventional therapy alone. Local external radiation to metastatic sites, given early and possibly in conjunction with conventional treatment methods, may achieve a clinical response by causing a reduction in tumor size and thus relief of venous compression.

An ectopic pregnancy in the upper retroperitoneum following in vitro fertilization and embryo transfer

Thirty-seven days after successful embryo transfer, a chorionic vesicle was recovered from the upper abdominal retroperitoneal space in a patient presenting with an acute life-threatening hemorrhage. This is the first case report of a retroperitoneal ectopic pregnancy which, although uncommon, is a potentially fatal complication of in vitro fertilization-embryo transfer.

Leiomyosarcoma of the small intestine presenting as a pelvic mass: four cases

Four patients with leiomyosarcoma of the small intestine who presented with a pelvic mass are reviewed. The tumors had clinical and radiographic features resembling ovarian neoplasms. These patients develop sizable tumors and, yet, have relatively few symptoms which would necessarily direct the physician to the intestine as the site of origin. The clinicopathologic features and management of these tumors are reviewed.

Use of the omental J flap for better delivery of radiotherapy to the pelvis

The surgically created omental J flap (or synthetic equivalents) can facilitate radiation therapy, particularly brachytherapy, in which adhesions of the pelvis would otherwise limit its value. The J flap used in this role has an occasional place in the management of patients with carcinoma and exemplifies how surgical procedures and irradiation can be combined for more effective treatment of carcinomas.

Ultrasound for diagnosing and preventing malplacement of intrauterine tandems

Postoperative B-mode ultrasound was used to evaluate final tandem position in 50 consecutive placements (28 patients). In 34% (17 of 50), the tandem was found to be suboptimally positioned; in 24% (12 of 50), it penetrated the myometrium; and in 10% (five of 50), it frankly perforated the uterus. The uterine fundus was the region most commonly perforated, and the anterior myometrium was the site most frequently penetrated. In all cases in which postoperative ultrasound showed malpositioning, the clinical and radiographic assessment indicated proper intracavitary placement. Ultrasound affected clinical management in 42% (21 of 50) of the placements involving 61% (17 of 28) of the patients. To improve tandem placement, we used intraoperative real-time ultrasound to guide 73 consecutive surgical insertions. Ultrasound clearly visualized the procedure, allowing tandems to be positioned with confidence even in the most difficult cases. The immediate feedback from intraoperative ultrasound eliminated malplacements and thus the need for a second anesthesia to reposition the tandem.

Intraoperative real-time ultrasonography during intrauterine tandem placement

Real-time ultrasound is used in the operating room as an aid in the placement of the intrauterine tandem. This method provides excellent imaging of the ongoing procedure, facilitating final tandem placement in the endometrial cavity even in the most difficult case.

The value of endocervical curettage as part of the standard colposcopic evaluation

Whether to perform endocervical curettage (ECC) as part of a routine colposcopic examination in patients with an abnormal Papanicolaou smear remains controversial. Some studies consider ECC an essential part of a colposcopic examination regardless of the level of the squamocolumnar junction (SCJ); others consider it superfluous in cases where the SCJ can be visualized. Between January 1980 and December 1982, 278 new patients with abnormal Papanicolaou smears underwent colposcopy. Directed biopsies established the degree of cervical intraepithelial neoplasia (CIN) and ruled out invasive disease. ECC was done on every patient. A total of 51 patients (18%) had a positive ECC. Seven patients could not be evaluated because their records were incomplete. Of the 44 evaluable patients, 32 (73%) had satisfactory colposcopy. In the remaining 12 (27%) the upper limit of the transformation zone could not be seen clearly; in that group the degrees of CIN on colposcopic biopsy and ECC were in agreement in two cases; ECC revealed the degree to be less severe in four cases and more severe in six (50%). In the group with satisfactory examinations, 15 had the same degree of CIN on colposcopic biopsy and ECC; ten had less severe and seven (22%), more severe degrees of CIN on ECC. Of greatest clinical importance was that, overall, 11.5% had a positive ECC despite a satisfactory colposcopic examination. This study indicated that ECC provides unique and important information, justifying its inclusion as part of the standard evaluation of every patient undergoing colposcopy for abnormal cervical cytology.