Cyclin-dependent kinase 4/6 inhibitors in the treatment of advanced or metastatic breast cancer

OBJECTIVE

Despite the relatively high cure rates in early-stage breast cancer, advanced and metastatic breast cancer cases are associated with more inauspicious patient outcomes. Fortunately, with the advent of cyclin-dependent kinase (CDK)4/6 inhibitors (e.g. palbociclib, ribociclib, and abemaciclib) with endocrine therapy, survival in advanced and metastatic breast cancer has appreciably improved. In the current review, we discuss these distinctions and the concomitant implications associated with the individual CDK4/6 inhibitors.

DATA SOURCES

We conducted an extensive PubMed search comprising several review articles on the topic of advanced or metastatic breast cancer treatment, with specific terms that included CDK4/6 inhibitors, treatment, and breast cancer.

DATA SUMMARY

Palbociclib, ribociclib, and abemaciclib have exhibited superior progression-free survival differences compared to endocrine therapy alone. However, there are differences among the various CDK4/6 inhibitors with regard to overall survival, tolerability and quality of life.

CONCLUSIONS

Ribociclib may be indicated for pre/perimenopausal patients, whereas abemaciclib is potentially recommended to address endocrine-resistant or visceral disease. Alternatively, palbociclib is associated with lower discontinuation rates than abemaciclib and unlike ribociclib, QTc prolongation is not observed with palbociclib.

Current analysis of the survival implications for minimally invasive surgery in the treatment of early-stage cervix cancer

Early-stage cervical cancer (ESCC) is managed with radical hysterectomy, a procedure that can be performed either via open surgery or minimally invasive surgery (MIS), the latter of which is accomplished via traditional laparoscopy or robotic-assisted surgery. Previously, MIS was routinely incorporated into the management of ESCC due to the approach's reduced operative morbidity and truncated hospital stay duration, but more recent clinical evidence has since impugned the efficacy of MIS because of the reportedly inferior disease-free survival and overall survival outcomes compared to open surgery. However, additional studies have documented equivalent outcomes among the various surgical modalities, suggesting further exploration of clinical factors as we endeavor to conclusively determine the standard of care for patients diagnosed with ESCC.

A phase II, open-label, non-randomized, prospective study assessing paclitaxel, carboplatin and metformin in the treatment of advanced stage ovarian carcinoma

OBJECTIVE

The purpose of this study was to assess the efficacy and tolerability of a paclitaxel, carboplatin and metformin regimen in the first-line treatment of advanced-stage ovarian, fallopian tube, and primary peritoneal carcinoma.

METHODS

Eligible subjects underwent surgery and 6 cycles of neoadjuvant or adjuvant dose-dense intravenous paclitaxel (80 mg/m²), carboplatin (area under the curve 5 or 6 on Day 1), and oral metformin (850 mg daily). Study participants who completed their primary therapy and attained a clinically defined complete or partial response (PR) were treated with a planned 12 cycles of paclitaxel (135 mg/m² every 21 days) and metformin (850 mg twice daily) maintenance therapy.

RESULTS

Thirty subjects received a median of 6 cycles (range, 5-6) of primary induction chemotherapy and were eligible for response evaluation; twenty-three patients exhibited a complete response, while 3 study patients obtained a PR (an overall response rate of 86.7%). Grade 3-4 hematological toxicity included neutropenia (43.3%), thrombocytopenia (10%) and anemia (36.7%). There was no incidence of grade 3-4 neuropathy although 15 patients (50%) developed grade ≤2 neurotoxicity. Additionally, we observed grade ≤2 diarrhea in 20 (66.7%) subjects. The median progression-free survival was 21 months (range, 3-52) and overall median survival was 35 months (range, 15-61). The subjects also received an aggregate 103 cycles (median, 12; range, 6-12) of maintenance chemotherapy.

CONCLUSION

The study results suggest that the combination of paclitaxel, carboplatin and metformin is associated with moderate efficacy and a reasonable toxicity profile.

Prolonged endocrine therapy in the management of hormone receptor-positive early-stage breast cancer: What is the appropriate duration?

AIM

The clinical benefits associated with 5 years of endocrine therapy in the treatment of hormone receptor-positive, early-stage breast cancer (ESBC) have been well-substantiated. However, numerous studies have reported on the results of extended (i.e., >5 years) endocrine therapy to further effectuate a clinical benefit, with varying outcomes. Hence, the purpose of this study is to review these prolonged investigations and endeavor to clarify their corresponding treatment implications.

METHODS

We reviewed the study findings from several randomized controlled trials and meta-analyses, which incorporated clinical outcomes from pre-and postmenopausal, hormone receptor-positive, ESBC patients.

RESULTS

Hormone receptor-positive, ESBC patients treated with 5 years of endocrine therapy, who are node-negative with tumors <2 cm, will unlikely benefit from five additional years of treatment. Conversely, in women with larger tumors and node-positive disease, 7-8 total years of endocrine therapy may be indicated. Ultimately, clinicians should also consider the attendant side effects from endocrine therapy, namely bone fractures, namely cardiovascular symptoms, and vasomotor symptoms, when considering the appropriate treatment regimen.

CONCLUSIONS

While increased duration of endocrine therapy may selectively accord significant clinical benefits, prior to determining the patient's treatment interval, physicians should also assess the cumulative side effects from endocrine therapy when endeavoring to maintain treatment compliance and bolster quality of life.

Talc powder and ovarian cancer: what is the evidence?

Talc is a desiccant that has been historically used as baby powder by numerous women to enhance their feminine hygiene. Talc has been identified in proximity to asbestos; accordingly, retrospective and case-control studies have implicated the role of talc use in the development of ovarian cancer, whereas prospective evaluations have not documented concordant findings. Moreover, the positive associations derived from case-control studies have been remote and the putative causal factors remain inconclusive. Consequently, one should be circumspect regarding the assertion that genital talc powder application induces ovarian cancer development.

Hormone Therapy and Risk of Breast Cancer: Where Are We Now?

Several studies have examined the clinical benefits of hormone replacement therapy (HRT). However, because long-term use of HRT has been implicated as a risk factor for the development of breast cancer, some women remain skeptical when considering this therapy to address their vasomotor symptoms. Hence, physicians and nurses should actively engage in constructive discourse with their patients regarding HRT while specifically reviewing the potential risks of its extended use as well as provide the available medical alternatives the patients could potentially use.

Robotic-Assisted Surgery for the Treatment of Breast and Cervical Cancers

Background:

Robotic-assisted surgery facilitates the performance of numerous, complex procedures, namely conferring precision, flexibility, and control that is otherwise unavailable with conventional laparoscopy; and compared to open surgery, robotic-assisted surgery is ostensibly associated with fewer complications, reduced intraoperative complications, and shorter hospital stay duration. Nevertheless, the American College of Obstetricians and Gynecologists and the Food and Drug Administration have criticized the pervasive acceptance of robotic-assisted surgery, given the absence of randomized clinical trial data compared to traditional laparoscopy and open procedures, not to mention the increased surgical cost.

Conclusions:

While the research data continue to be borne out, surgeons should exercise considerable discretion in selecting the surgical approach from which their patients would derive the greatest clinical benefit.

A retrospective study comparing the efficacy of dose-dense chemotherapy, intraperitoneal chemotherapy and dose-dense chemotherapy with hyperthermic intraperitoneal chemotherapy in the treatment of advanced stage ovarian carcinoma

OBJECTIVES

Hyperthermic intraperitoneal chemotherapy (HIPEC), intraperitoneal chemotherapy (IP) and dose-dense (DD) chemotherapy have been employed with varying success in the treatment of advanced stage ovarian carcinoma. Despite the clinical benefits associated with these specific forms of chemotherapy administration, they have not been comparatively analyzed, vis-à-vis their efficacy.

STUDY DESIGN

Advanced stage ovarian cancer patients who were treated with platinum/taxane chemotherapy via a DD regimen (n = 100), IP approach (n = 81) or a DD regimen in conjunction with HIPEC (n = 64) were retrospectively evaluated. The clinical variables of interest were patient age, body mass index, surgery and pathology data, chemotherapy regimen, inclusion of maintenance therapy, and progression free/overall survival.

RESULTS

Progression free survival (PFS) was significantly more pronounced in the HIPEC (34.9 months) and IP (34.0 months) patients, compared to the DD group (27.6 months) (P = 0.005). A cox-proportional hazards regression model indicated that there was a decreased risk of disease progression accorded to the patients who were treated with IP chemo or HIPEC and DD chemotherapy (HR, 0.43; 95 % CI: 0.21-0.88; P = 0.022) and the subjects who underwent optimal cytoreductive surgery (HR, 2.42; 95 % CI: 1.22-4.80; P = 0.011). Positive BRCA status (HR, 0.434; 95 % CI: 1.59-3.44; P = 0.001) and number of chemotherapy regimens (HR, 1.36; 95 % CI: 1.159-1.61; P = 0.001) were significantly correlated with improved OS although we did not discern a survival benefit associated with any of the chemotherapy treatments (P = 0.136).

CONCLUSION

We observed PFS advantages conferred to the ovarian cancer patients treated with HIPEC and IP chemotherapy compared to DD chemotherapy. However, an overall survival advantage related to the chemotherapy regimens was not borne out, possibly due to the retrospective nature of the study or differing time periods wherein the specific patient cohorts underwent treatment.

A Prospective, Observational Trial Assessing the Efficacy of Abdominal Compression in Reducing Laparoscopic-Induced Shoulder Pain

INTRODUCTION

Postoperative shoulder pain is a condition associated with laparoscopic surgery and presumably attributed to residual carbon dioxide (CO₂) in the abdomen. The intent of the current prospective, observational study was to assess the efficacy of abdominal compression in mitigating this painful complication.

METHODS

We recruited 30 patients who were treated with laparoscopic surgery for the management of gynecologic disease. All study participants underwent abdominal compression to evacuate the CO₂ associated with their pneumoperitoneum. Postoperatively, the subjects' pain intensity was measured via the visual analogue scale at 12, 24, and 48 hours.

RESULTS

The patients' mean postoperative visual analogue scale pain scores were the highest during the initial 12 hours (1.93), and thereafter, steadily declined at 24 hours (0.73) and 48 hours (0.70) ( P = .045). Furthermore, toxicity was reasonable, with only 20% of subjects who reported grade ≤2 nausea and vomiting.

CONCLUSION

Abdominal compression is a relatively safe procedure that appears to sufficently evacuate residual CO₂, thereby reducing the severity of laparoscopic surgery induced shoulder pain.

Consolidation hyperthermic intraperitoneal chemotherapy for the treatment of advanced stage ovarian carcinoma: a 3 year experience

PURPOSE

Hyperthermic intraperitoneal chemotherapy (HIPEC) potentially confers significant survival benefits in the management of ovarian cancer although the long-term data remain scant. We sought to compare the survival rates of advanced stage ovarian cancer patients who were treated with primary induction therapy alone or in conjunction with consolidation HIPEC.

METHODS

69 ovarian cancer patients who underwent surgery and completed their primary induction chemotherapy were treated with consolidation carboplatin (AUC 10) based HIPEC and compared to a historical cohort that received surgery and primary chemotherapy alone (n = 69). The demographic and clinical characteristics on which we were primarily focused, included patient age, body mass index, surgery and pathology data, chemotherapy regimen, toxicity, and progression free/overall survival.

RESULTS

The two patient groups' demographic and clinical characteristics were similar (P > 0.05). Progression-free survival was significantly more pronounced in the HIPEC (25.1 months) patients compared to the control group (20 months) (P = 0.024) and there was a decreased risk of disease progression accorded to the patients treated with HIPEC (HR 2.1028; 95% CI 1.2941-3.4167; P = 0.0027). However, we did not discern any HIPEC related overall survival advantages (P = 0.29).

CONCLUSIONS

The results from our ovarian cancer study suggest that adjunctive HIPEC proffers a significant progression-free survival advantage and a decreased risk for disease progression. There was, however, no overall survival advantage discerned by the HIPEC group. We also recognize that HIPEC remains controversial, and thus randomized studies evaluating HIPEC compared to standard chemotherapy in the management of ovarian cancer are warranted.

Individual Physician Experience With Laparoscopic Supracervical Hysterectomy in a Single Outpatient Setting

The authors report the surgical experience of a single physician operating at 1 outpatient surgery center using laparoscopic supracervical hysterectomy for the treatment of 100 patients with benign gynecologic disease. Operative status was evaluated in terms of patient morbidity, length of surgery, blood loss, and duration of hospital stay. The mean operative time was 2.6 hours, and the mean anesthesia time was 3.2 hours. The mean estimated blood loss was 116.6 mL, and the mean patient hospital stay was 16.5 hours. There were no reported intraoperative or postoperative complications. Laparoscopic supracervical hysterectomy was not feasible and was converted to laparotomy and total abdominal hysterectomy in 4 patients. The authors present one of the first individual physician experiences at a single outpatient surgery center using laparoscopic supracervical hysterectomy for benign gynecologic conditions. Optimal patient postoperative stay and a minimal complication rate suggest that this procedure performed at a single outpatient surgery center is feasible.

A comparison of open surgery, robotic-assisted surgery and conventional laparoscopic surgery in the treatment of morbidly obese endometrial cancer patients

Background and Objectives:

The intent of this retrospective study was to assess the operative outcomes of morbidly obese endometrial cancer patients who were treated with either open surgery (OS) or a minimally invasive procedure.

Methods:

Morbidly obese (body mass index [BMI] > 40 kg/m²) patients with endometrial cancer who underwent OS, robotic-assisted laparoscopic surgery (RS), or conventional laparoscopic surgery (LS) were eligible. We sought to discern any outcome differences with regard to operative time, perioperative complications, and hospital stay.

Results:

Sixteen patients were treated with LS (BMI = 47.9 kg/m²), 13 were managed via RS (BMI = 51.2 kg/m²), and 24 underwent OS (BMI = 53.7 kg/m²). The OS (1.35 hours) patients had a significantly shorter operative duration than the LS (1.82 hours) and RS (2.78 hours) patients (P < .001); blood loss was greater in the OS (250 mL) group in comparison with the RS (100 mL) and LS (175 mL) patients (P = .002). Moreover, the OS (4 days) subjects had a significantly longer hospital stay than the LS (2 days) and RS (2 days) patients (P = .002).

Conclusion:

In the present study, we ascertained that minimally invasive surgery was associated with longer operative times but lower rates of blood loss and shorter hospital stay duration compared with treatment comprising an open procedure.

The feasibility of administering varying high-dose consolidation hyperthermic intraperitoneal chemotherapy with carboplatin in the treatment of ovarian carcinoma

OBJECTIVES

Hyperthermic intraperitoneal chemotherapy (HIPEC) is an intriguing method of delivery wherein the cytotoxic agent is continuously heated and circulated throughout the peritoneum in an attempt to bolster drug efficacy. Despite HIPEC's potential, ascertaining the optimal dose without compromising patient tolerability remains indeterminate.

METHODS

We retrospectively evaluated 52 advanced stage ovarian cancer patients who were treated with consolidation HIPEC with carboplatin at varying doses (e.g., AUC 6, 8 or 10) subsequent to optimal debulking surgery and the attainment of a clinical complete response to their primary chemotherapy regimen. The following patient and operative characteristics were abstracted: demographics, surgery and pathology data, chemotherapy regimen, intraoperative results, toxicity, postoperative complications, length of hospital stay and survival data.

RESULTS

Twelve patients received HIPEC carboplatin at an AUC 6, 15 subjects were treated with carboplatin at an AUC 8 and 25 underwent carboplatin at an AUC 10. There were no intraoperative complications during the administration of HIPEC; mean estimated blood loss was 50 mL and length of hospital stay was 1.65 days. In the overall study population, 5 patients developed grade 3/4 anemia and 33 subjects exhibited grade ≤2 thrombocytopenia and neutropenia. Thirteen patients also developed grade ≤2 nausea on postoperative day 1, which was successfully addressed with anti-emetic therapy; there were no hospital readmissions.

CONCLUSIONS

The results from the current evaluation suggest that consolidation hyperthermic intraperitoneal chemotherapy with carboplatin is both feasible and reasonably tolerated, even at an AUC of 10. However, additional, randomized study of this procedure incorporating chemotherapy dose escalation with a more extensive patient population is warranted.

The retreatment of carboplatin via high-dose intraperitoneal chemotherapy in patients with a history of a hypersensitivity reaction

A hypersensitivity reaction attributed to platinum-based chemotherapy is a relatively common occurrence. Hyperthermic intraperitoneal chemotherapy potentially facilitates the safe retreatment of platinum therapy following this complication. We describe 3 ovarian cancer patients who were successfully retreated with carboplatin via hyperthermic intraperitoneal chemotherapy following hypersensitivity reaction.

Robotic-assisted surgery for the treatment of pelvic masses in pregnant patients: a series of four cases and literature review

The purpose of this study was to assess the safety and feasibility of robotic-assisted surgery for the treatment of a pelvic mass in gravid patients. We retrospectively reviewed the charts of all pregnant women who were diagnosed with a pelvic mass by individual obstetric physicians and referred to our gynecologic oncology service from January 2009 until March 2012; four patients were identified and treated with robotic-assisted surgery by the same group of gynecologic oncologists. The following patient data were collected: age, disease origin, histology, tumor size, gravid status at surgery, surgical procedure, intra- and postoperative surgical complications, and both maternal and fetal outcomes. The gynecologic lesions comprised an immature teratoma, a mucinous cystadenoma, a hemorrhagic cyst and an ovarian endometrioma; in each case, blood loss was minimal and no maternal or fetal intra-operative complications were encountered. All patients had normal, spontaneous vaginal deliveries at term. Robotic-assisted surgery for the treatment of pelvic masses in pregnant patients is ostensibly feasible and associated with favorable outcomes for both the patient and fetus.

A rare case of primary retroperitoneal mucinous adenocarcinoma: a case report

BACKGROUND

Primary retroperitoneal mucinous adenocarcinomas are very rare tumors that resemble ovarian mucinous cystadenocarcinomas.

CASE

A 39-year-old woman presented with a 20-cm cystic lesion. Following surgery final pathology revealed mucinous adenocarcinoma consistent with a primary retroperitoneal process. The patient responded favorably to 6 cycles of paclitaxel and carboplatin chemotherapy and currently has no evidence of disease.

CONCLUSION

During surgical resection of a primary retroperitoneal mucinous adenocarcinoma, ensuring that the lesion remains intact has clinically significant implications.

Sequential chemotherapy and radiotherapy as sandwich therapy for the treatment of high risk endometrial cancer

Objective

The purpose of this retrospective study was to assess the tolerability and efficacy of sequential chemotherapy and radiotherapy for the treatment of high risk endometrial cancer.

Methods

We conducted a retrospective study of previously untreated high risk endometrial cancer patients who received sequential chemotherapy and radiotherapy in accordance with the sandwich approach from June 2008 until June 2011. High risk endometrial cancer patients underwent complete surgical staging followed by adjuvant therapy encompassing sequential chemotherapy, radiation therapy and consolidation chemotherapy.

Results

The study analysis comprised 32 endometrial cancer patients. All subjects were treated with carboplatin and paclitaxel chemotherapy; currently, 186 cycles have been administered and 94% of patients have completed the planned number of cycles. Grade 3 neutropenia developed in 1 (3.1%) patient; there was no incidence of grade 4 neutropenia. Moreover, we observed grade 3 anemia in four (12.5%) patients and grade 4 anemia in one (3.1%) patient. One (3.1%) patient developed grade 3 thrombocytopenia; grade 4 thrombocytopenia was not observed. Five patients exhibited progressive disease, three of whom have since expired; mean progression free survival and follow-up were 17.4 months and 18.9 months, respectively.

Conclusion

The preliminary results from our study suggest that the sandwich approach to treating high risk endometrial cancer patients is feasible. Hematologic toxicity was well tolerated and non-hematologic toxicity was mild and easily managed. Further study of this novel regimen in a larger patient population with extended follow-up is necessary.

Improved overall survival with 12 cycles of single-agent paclitaxel maintenance therapy following a complete response to induction chemotherapy in advanced ovarian carcinoma

OBJECTIVES

Previously reported studies have suggested that maintenance therapy in the treatment of ovarian cancer may provide progression-free survival (PFS) benefits, although they have not discerned a similar impact on patient overall survival (OS).

METHODS

We examined the long-term PFS and OS of a previous study population consecutively treated with either 3 cycles (group A; n = 13 patients) or 12 cycles (group B; n = 13) of paclitaxel (135 mg/m(2); Q21 days) maintenance therapy. Eligible patients received maintenance chemotherapy following a complete response to 6 cycles of primary induction chemotherapy, comprising 6 cycles of carboplatin (AUC = 5), paclitaxel (175 mg/m(2)), and gemcitabine (800 mg/m(2)) per protocol.

RESULTS

There were statistically significant PFS differences between group A (12 months) and group B (24 months) (p = 0.016). Moreover, the OS in group A was 38 months and 80 months for group B (p = 0.012). Current follow-up for this patient population exceeds 58 months.

CONCLUSIONS

In the present investigation, 12 cycles of single agent paclitaxel maintenance therapy were associated with improved patient PFS and OS benefits. Despite contradictory reports, paclitaxel-based maintenance therapy may favorably impact both PFS and OS in advanced ovarian cancer patients who obtain a complete response to primary induction chemotherapy.

A retrospective review of the GelPort system in single-port access pelvic surgery

STUDY OBJECTIVE

Since the advent of single-port access surgery, novel instruments have been developed to facilitate this laparoscopic approach. The GelPort system is an innovative sealing device that permits abdominal access and frequent instrument exchange during surgery while preserving the pneumoperitoneum. The GelPort system has been previously reported in gastric, colorectal, and urologic single-port access procedures but has yet to be described during pelvic surgery.

DESIGN

A retrospective pilot study reviewing 19 single-port access pelvic surgeries that involved the GelPort system was undertaken. Patient and operative statistics, including diagnosis, surgery and anesthesia times, complications and length of hospital stay were evaluated (Canadian Task Force Classification II-2).

RESULTS

Operative time exhibited a direct association with anesthesia time (p=.001). Additionally, patient blood loss (p=.043) and anesthesia time (p=.003) were significant prognostic indicators for length of hospital stay. There were no significant patient complications or subsequent port site hernias.

CONCLUSIONS

The GelPort system appears to contribute favorably to single-port access surgery because the device permits circumferential access and retraction during instrumentation. Furthermore, the specialized design augments a surgeon's versatility and access to complicated anatomic regions without compromising the peritoneum.

Borderline ovarian tumors and extended patient follow-up: an individual institution's experience

INTRODUCTION

Borderline tumors of the ovary (BOT) comprise nearly 20% of all ovarian malignancies and are associated with a favorable prognosis. However, since these lesions can present with malignant features and recur, a further evaluation of appropriate patient management and long-term follow-up is warranted.

METHODS

We report a physician group's retrospective experience treating BOT patients at a single institution. Patient demographics, disease pathology, treatment type (surgery, chemotherapy), and patient surveillance (e.g., disease-free survival (DFS), overall survival, follow-up via CA-125/radiology/physical exam) data were reviewed in all cases.

RESULTS

In the present study, 78 BOT patients treated from April 2001 until February 2009 were identified and confirmed via pathologic diagnosis. The majority (87%) underwent surgery, although nearly 13% of patients also received adjuvant chemotherapy. In the study population, 12% of the patients developed progressive disease, which was primarily detected via CA-125 and physical exam/disease symptomatology. DFS for these patients was 38 months. Recurrent disease was significantly related to the administration of chemotherapy (P = 0.0024) and prolonged time since initial treatment (P < 0.001).

DISCUSSION

Since BOT can be aggressive and eventually recur, continued (i.e., long-term) surveillance with CA-125 evaluation and physical examination should be considered for optimal patient follow-up.

The Minailo knot: a time-saving and cost-saving technique

Endoscopic knot tying during minimally invasive surgery can be complicated, time consuming, and associated with a protracted learning curve. The Minailo knot seems to be a reasonable option because the technique does not require any specialized instrumentation or skill to perform. In particular, vaginal closure is obtained with the placement of a single intra-corporeal knot. Our initial and successful experience with this knot-tying technique during robotic hysterectomy for treatment of gynecologic disease suggests that the method is safe and feasible.

Bevacizumab, paclitaxel and carboplatin for advanced ovarian cancer: low risk of gastrointestinal and cardiovascular toxicity

The purpose of this preliminary study was to retrospectively assess the incidence of bowel perforation and hypertension in two separate advanced ovarian cancer patient populations following first-line therapy, comprising paclitaxel, carboplatin and bevacizumab. The first 20 patients were treated with six cycles of paclitaxel (175 mg/m2), carboplatin (AUC of 5 i.v.), and bevacizumab (15 mg/kg of body weight); q21 days per an independent protocol. The subsequent patients (n = 12) were administered weekly paclitaxel (80 mg/m2), carboplatin (AUC of 5 i.v.) every four weeks, and bevacizumab (10 mg/kg of body weight) every two weeks for six cycles according to a separate, independent protocol. Bevacizumab was not added to either chemotherapy regimen until cycle 2. In both groups patients who achieved a complete response, partial response or stable disease at the conclusion of induction therapy received bevacizumab (10 mg/kg) and paclitaxel (135 mg/m2) q21 days as maintenance therapy. A total of 170 cycles (median = 6; range 3-6) of primary induction chemotherapy, 140 of which contained bevacizumab, were administered. Moreover, 206 cycles (median = 9; range 1-12) of maintenance chemotherapy have been delivered to 28 patients thus far. There was no incidence of GI perforation and only two patients demonstrated clinically significant hypertension. Previous studies involving bevacizumab have raised concerns regarding bowel perforations and hypertension. However, we did not encounter difficulties with either of these complications. While we recognize that the risk for bowel perforation remains in the 5-11% range, the study's preliminary results suggest that first-line treatment of advanced stage ovarian carcinoma with bevacizumab can be safely administered.

Chemotherapy and patient co-morbidity in ventral site hernia development

OBJECTIVE

The risk factors associated with early ventral site hernia development following cancer surgery are ill defined and associated with an undetermined incidence.

METHODS

We analyzed 1,391 gynecologic cancer patient charts to identify the number of post-operative ventral site hernias over a nearly 6 year period. The following study variables were noted for evaluation: patient demographics, disease co-morbidity (hypertension, cardiovascular disease, diabetes), body mass index (BMI), treatment (e.g., chemotherapy regimen), intra-operative (e.g., bleeding) and postoperative (e.g., infection) complications, time to hernia development and length of hospital stay.

RESULTS

Twenty-six gynecologic cancer patients who developed a post-operative ventral hernia and subsequently underwent herniorrhaphy by our gynecologic oncology service were identified. The patient group's overall time to initial hernia development was 11.23 months. Following a multiple regression analysis, we found that treatment (e.g., bevacizumab, liposomal doxorubicin or radiotherapy associated with compromised wound healing [p=0.0186] and disease co-morbidity [0.0432]) were significant prognostic indicators for an accelerated time to hernia development. Moreover, five patients underwent treatment associated with compromised wound healing and also had disease co-morbidity. In this sub-group, post-operative hernia development occurred more rapidly (3.8 months) than the overall group of patients. BMI and age did not impact time to hernia development (p>0.05).

CONCLUSION

In the present gynecologic cancer patient series, a tendency for early post-operative hernia development appeared to coincide with treatment associated with compromised wound healing and disease co-morbidity. Gynecologic cancer surgeons should anticipate this potential complication and consider employing prophylactic intra-operative mesh to potentially prevent this condition.

Perivascular epithelioid cell neoplasms: a systematic review of prognostic factors

Perivascular epithelioid cell tumors (PEComas) are rare, soft tissue tumors characterized by epithelioid cells with clear or eosinophilic cytoplasm and a perivascular disbursement. We compiled the treatment and follow-up results from an extensive collection of reported gynecologic PEComa cases and statistically analyzed their respective therapy modalities and corresponding patient outcomes. In the group of patients with PEComa who received surgical management alone, there was a tendency for them to exhibit a lower disease recurrence rate. Conversely, patients with PEComa who initially received surgery and chemotherapy or radiation therapy were associated with a higher disease recurrence rate (P =.024). Metastatic involvement was related to higher patient mortality rates (P =.0001), although this finding was unrelated to treatment type. Surgical management alone may suffice for nonaggressive lesions, but chemotherapy and radiotherapy appear necessary for patients who present with high-risk histologic condition or metastatic disease. Because PEComas exhibit varying biologic behavior and an ill-defined presentation, the treatment for these lesions necessitates further evaluation.

Clinical utility of CA-125 for maintenance therapy in the treatment of advanced stage ovarian carcinoma

Maintenance therapy has been extensively studied to discern any prospective therapeutic advantage in the treatment of advanced stage ovarian carcinoma. The CA-125 assay may have prognostic benefit in determining whether this treatment regimen is appropriate for ovarian carcinoma patients who achieve a complete response to first-line therapy. We retrospectively documented the CA-125 levels of 2 advanced ovarian cancer patient groups who exhibited a clinically defined complete response to their primary induction therapy. Patients were then treated with a paclitaxel-based maintenance therapy regimen. The first group (group A; n = 13 patients) received 3 cycles of single-agent paclitaxel maintenance therapy, and the second group (group B; n = 13 patients) received 12 cycles of single-agent paclitaxel maintenance therapy. The premaintenance therapy CA-125 serum levels (<10 or > or =10 U/mL) of the 2 treatment groups were then retrospectively evaluated in an intragroup analysis to discern any relationship with progression-free survival (PFS) and overall survival. There was a statistically significantly relationship between the CA-125 levels (<10 U/mL) premaintenance therapy and PFS. The patients who had the lowest CA-125 levels exhibited the most favorable PFS results. Despite the limited sample size and nonrandomized nature of this study, these results are provocative and suggest that advanced ovarian cancer patients who achieve an excellent response to primary platinum-based chemotherapy with a CA-125 serum level less than 10 U/mL may be more amenable to the benefits of paclitaxel maintenance therapy.

New perspectives in clinical research: the Women's Cancer Research Foundation's experience

The number of physicians involved in clinical research continues to decline. Financial and administrative barriers appear to be primarily responsible, although inadequate community-based infrastructure has also contributed significantly to this troubling phenomenon. Therefore, novel physician-friendly research models amenable to conducting efficient clinical research are necessary. The physicians from the Women's Cancer Research Foundation have developed such a paradigm over the past 23 years, which has proven to increase research productivity above and beyond the traditional academic model.

Laparoscopic supracervical hysterectomy for benign gynecologic conditions

Recent results from metaanalyses and observational studies have suggested that total abdominal hysterectomy (TAH) is superior to laparoscopic supracervical hysterectomy (LSH) for the treatment of benign gynecologic conditions. However, because LSH is associated with fewer intraoperative complications, shorter operative time, and preserves patient anatomy and sexual function in comparison with TAH, clinicians should reconsider the benefits of LSH.

Realhand high dexterity instruments for the treatment of stage I uterine malignancy

BACKGROUND

The purpose of this pilot study was to evaluate the impact of RealHand instruments on laparoscopic-assisted vaginal hysterectomy (LAVH) for the treatment of stage I uterine cancer.

METHODS

This was a single-center, nonrandomized, consecutive patient pilot study. Patient status was evaluated in terms of operative morbidity, length of surgery, anesthesia time, body mass index (BMI), estimated blood loss, uterine weight, and hospital stay.

RESULTS

In the group of 10 patients, mean operative time was 1.7 hours, and anesthesia time was 2.3 hours. Mean estimated blood loss was 70mL, and patient hospital stay was 31.8 hours. No intra- or postoperative complications occurred. Blood loss, anesthesia time, BMI, and uterine weight were significant predictors of operative time. In one patient, LAVH using the RealHand instruments was canceled because of deep pelvic visualization difficulties, resulting in a conversion to laparotomy.

CONCLUSION

We present the first reported individual physician LAVH experience using RealHand instruments for the treatment of clinical stage I uterine cancer. The reported operative time, reasonable patient complication rates, and acceptable postoperative stay suggest that these innovative surgical instruments may have significant promise in the treatment of patients diagnosed with this gynecologic disease.

Ovarian cancer and late onset paraneoplastic cerebellar degeneration

Paraneoplastic cerebellar syndrome (PCD) is a rare, neurological disorder that primarily emerges before the detection of malignancy. We present a case involving a 52-year-old woman who was diagnosed and treated for primary ovarian cancer in 2005. In 2007, the patient exhibited ataxia, dysarthria and peripheral neuropathy. Following neurological assessment and immunologic testing, the diagnosis of PCD was made. The disease typically precedes the detection of malignancy by a year or more and has been documented in only a few cases following the treatment for ovarian cancer.

Rapid manifestation of CNS metastatic disease in a cervical carcinoma patient: a case report

OBJECTIVES

Brain metastases originating from primary cervical carcinoma are very rare. Despite surgery and adjuvant therapy, patient prognosis is extremely unfavorable. Prior studies have reported that the median time from the primary disease's diagnosis to development of CNS metastases is approximately 18 months.

CASE REPORT

A 60-year-old woman was initially diagnosed and treated for FIGO clinical stage IB2 cervical carcinoma in March 2007. She underwent a radical hysterectomy, bilateral salpingo-oophorectomy and peri-aortic lymphadenectomy. Two weeks later, the patient presented with dysmetria and homonymous hemianopsia, which was related to a large right occipital CNS metastasis. The patient had surgery to resect the brain tumor and then received Gamma Knife stereotactic radiosurgery and chemotherapy. The neurological deficits were resolved and the patient's disease status has since remained stable, with five months of follow-up.

CONCLUSION

The incidence of brain metastases originating from primary cervical carcinoma is very rare. Furthermore, the occurrence of CNS metastatic disease manifesting itself within a couple weeks following diagnosis of the primary disease is even more unusual. Since the presenting symptoms of CNS metastatic disease are not well characterized and patient prognosis is very poor, oncology physicians should anticipate the presence of this condition in order to provide prompt and comprehensive treatment.

Recurrent vulvar lymphangitis cured with vulvectomy in a cervical carcinoma patient: a case report

BACKGROUND

Recurrent vulvar lymphangitis secondary to pelvic lymphadenectomy and radiation therapy can be a vexing clinical dilemma.

CASE

A 55-year-old woman was initially treated with radical hysterectomy and 1 postoperative radiotherapy for cervical carcinoma in 1984. In 1987 she developed persistent vulvar, leg, and ankle edema; chronic vulvar pain; and recurrent vulvar cellulitis, which were ultimately attributed to group B Streptococcus. Despite long-term antibiotic therapy and compression stockings, the cellulitis was intractable. In June 2006 the patient underwent a bilateral simple vulvectomy with preservation of the clitoris and insertion of bilateral subcutaneous Jackson-Pratt drains. Her postoperative culture results revealed normal vaginal flora.

CONCLUSION

The patient's wounds healed very well, and she has had no further episodes of vulvitis or lymphangitis. The management of recurrent infections involving lymphedema can be difficult and cause complicated clinical issues.

Malignant pericardial effusion secondary to ovarian adenocarcinoma: a case report

BACKGROUND

The treatment for ovarian cancer has continued to improve, resulting in disease recurrence associated with previously unusual locations. However, there are still very few documented cases involving treatment for ovarian cancer metastatic to the pericardium.

CASE

A 46-year-old woman was diagnosed with and treated for primary ovarian cancer in 1999. She underwent optimal cytoreductive surgery and received adjuvant chemotherapy. In 2003 she developed ovarian cancer metastatic to the breast and was treated with additional chemotherapy. In 2005 she presented with a malignant pericardial and pleural effusions, which were treated with a thoracotomy and pericardial window. The pericardial effusion recurred and was then successfully treated with intrapericardial mitoxantrone.

CONCLUSION

There are a limited number of reported cases involving malignant pericardial effusions originating in an ovarian primary. Consequently, there is even less information documenting successful management of this disease. Thoracotomy, pericardial window and intrapericardial mitoxantrone instillation appear to constitute effective treatment.

A phase II study of outpatient first-line paclitaxel, carboplatin, and bevacizumab for advanced-stage epithelial ovarian, peritoneal, and fallopian tube cancer

The purpose of this study was to assess the response rate and toxicity of paclitaxel, carboplatin, and bevacizumab (PCB) primary induction therapy for the treatment of advanced-stage ovarian carcinoma. Twenty patients were treated with paclitaxel (175 mg/m(2)), carboplatin (AUC of 5 IV), and bevacizumab (15 mg/kg) of body weight; q21 days for six cycles. Bevacizumab was administered at cycles two through six. Patients received 116 cycles of PCB chemotherapy (median = 6, range 2-6) and were evaluable for toxicity assessment. Grade 3 and 4 neutropenia developed in 23.3% and 25% of cycles, with no incidence of grades 3/4 thrombocytopenia or anemia. Prior to cycle six, one patient was removed from the study due to grade 3 neuropathy and another patient was excluded due to clinical deterioration. There was no incidence of gastrointestinal perforations, and only two patients demonstrated grade 3 hypertension (HTN). No grade 4 HTN was observed. Eighteen patients were evaluated for response following induction therapy. Six demonstrated a complete response (30%) and ten exhibited a partial response (50%), resulting in a total response rate of 80%. One patient exhibited stable disease (5%), and one demonstrated disease progression (5%). The lack of bowel perforations and wound complications should mitigate some concerns regarding these side effects. This study suggests that first-line treatment with PCB can be safely administered to previously untreated advanced-stage ovarian carcinoma patients. The favorable toxicity results and reasonable response rate warrant additional study in a larger patient population.

Pilot study assessing robotic laparoscopic hysterectomy and patient outcomes

STUDY OBJECTIVE

To examine the operative variables and complications associated with robotic-assisted total laparoscopic hysterectomy.

DESIGN

Canadian Task Force classification II-1.

SETTING

Gynecology service affiliated with a major cancer center in Southern California.

PATIENTS

Twenty women with a benign gynecologic condition.

INTERVENTION

Robotic-assisted total laparoscopic hysterectomy. Patient status was evaluated in terms of operative morbidity, length of surgery, anesthesia time, estimated blood loss, and hospital stay.

MEASUREMENTS AND MAIN RESULTS

Mean operative time was 3.2 hours, and anesthesia time was 4 hours. Mean estimated blood loss was 81 mL, and patient postoperative hospital stay was 2 days. The complication rate in this study was low. The surgical procedure was converted to a laparotomy and abdominal hysterectomy in two patients because of poor visualization during robotic-assisted surgery.

CONCLUSIONS

While the number of patients and nonrandomized nature of this single-institution experience are insufficient to draw any definitive conclusions regarding potential treatment efficacy, the patient postoperative stay and low complication rates suggest that this procedure is feasible and promising. Additional study comparing the efficacy and cost of robotic laparoscopic hysterectomy with standard laparoscopic hysterectomy with a larger patient population is warranted.

Improved Survival with Single-Agent Paclitaxel Consolidation/Maintenance Therapy in Advanced Ovarian Carcinoma

OBJECTIVES

Consolidation/maintenance therapy in the standard management of ovarian cancer remains controversial, primarily due to the unknown impact of this strategy on overall survival.

METHODS

We examined the survival of a previously reported patient population consecutively treated with either 3 cycles (group A; n = 13 patients) or 12 cycles (group B; n = 13) of single-agent paclitaxel consolidation following 6 cycles of primary induction chemotherapy comprising 6 cycles of carboplatin (AUC = 5), paclitaxel (175 mg/m(2)) and gemcitabine (800 mg/m(2)).

RESULTS

There were no differences in the 2 patient populations regarding known relevant prognostic factors (age, stage, tumor grade). The median progression-free survival was 11 months for group A and 24 months for group B (p = 0.0062). The median overall survival in group A was 38 months and was not reached in group B (p = 0.0019). Current follow-up for these 2 patient groups exceeds 43 months.

CONCLUSION

We recognize the important limitations of this study, particularly its sample size and nonrandomized nature. However, these data provide support for the conclusion that paclitaxel 'maintenance/consolidation' therapy may favorably impact overall and progression-free survival in advanced ovarian cancer patients who achieve an excellent response to primary platinum-based chemotherapy.