Primary cytoreductive surgery with rectosigmoid colon resection for patients with advanced epithelial ovarian carcinoma

BACKGROUND

The impact of radical bowel resection with multiple organ resection on the survival if patients with advanced ovarian carcinoma has not been well defined. The authors investigated whether primary cytoreductive surgery including rectosigmoid colon resection would affect the recurrence free interval and survival of these patients.

METHODS

Between April 1990 and April 1997, 66 previously untreated Stage IIIC-IV ovarian carcinoma patients with macroscopic involvement of the rectosigmoid colon were enrolled. All patients underwent cytoreductive surgery with rectosigmoid colon resection to remove residual tumor less than 2 cm in greatest dimension and received 6 cycles of cisplatin-based postoperative chemotherapy.

RESULTS

The median follow-up was 26 months (range, 7-104 months). In multivariate analysis, residual disease and depth of tumor infiltration of the bowel wall were independently associated with overall survival and recurrence free interval. Disease stage was independently associated only with overall survival. Residual tumor was the most strongly predictive factor for recurrence or death. The 2-year estimated survival rates according to the amount of residual tumor were 100% for 24 patients with no macroscopic residual disease and 77.3% for 28 patients with residual disease less than 1 cm. None of the 14 patients with residual disease larger than 1 cm were alive 2-years after operation. Overall, 48 patients (72.7%) developed disease recurrence: 43 (65.1%) in the abdomen, 19 (29.8%) in the liver, and 3 (4.5%) in the pelvis.

CONCLUSIONS

The current findings suggest that cytoreductive surgery with rectosigmoid colon resection should be considered for ovarian carcinoma patients with bulky pelvic disease to help ensure that they are left with no residual disease after debulking surgery.

Primary cytoreductive surgery with rectosigmoid colon resection for patients with advanced epithelial ovarian carcinoma

BACKGROUND

The impact of radical bowel resection with multiple organ resection on the survival if patients with advanced ovarian carcinoma has not been well defined. The authors investigated whether primary cytoreductive surgery including rectosigmoid colon resection would affect the recurrence free interval and survival of these patients.

METHODS

Between April 1990 and April 1997, 66 previously untreated Stage IIIC-IV ovarian carcinoma patients with macroscopic involvement of the rectosigmoid colon were enrolled. All patients underwent cytoreductive surgery with rectosigmoid colon resection to remove residual tumor less than 2 cm in greatest dimension and received 6 cycles of cisplatin-based postoperative chemotherapy.

RESULTS

The median follow-up was 26 months (range, 7-104 months). In multivariate analysis, residual disease and depth of tumor infiltration of the bowel wall were independently associated with overall survival and recurrence free interval. Disease stage was independently associated only with overall survival. Residual tumor was the most strongly predictive factor for recurrence or death. The 2-year estimated survival rates according to the amount of residual tumor were 100% for 24 patients with no macroscopic residual disease and 77.3% for 28 patients with residual disease less than 1 cm. None of the 14 patients with residual disease larger than 1 cm were alive 2-years after operation. Overall, 48 patients (72.7%) developed disease recurrence: 43 (65.1%) in the abdomen, 19 (29.8%) in the liver, and 3 (4.5%) in the pelvis.

CONCLUSIONS

The current findings suggest that cytoreductive surgery with rectosigmoid colon resection should be considered for ovarian carcinoma patients with bulky pelvic disease to help ensure that they are left with no residual disease after debulking surgery.

Systematic pelvic and para-aortic lymphadenectomy in advanced ovarian cancer patients with no residual intraperitoneal disease

A comparative non-randomized study was carried out to evaluate the role of systematic pelvic and para-aortic lymphadenectomy (SL) on patients with no residual intraperitoneal disease (NRID) of advanced ovarian cancer (stage IIIC-IV). A total of 142 optimally cytoreduced patients (macroscopic disease absent on peritoneal surface) were divided into two groups: Group A, consisting of 98 patients (53 previously untreated and 45 pretreated at other Institutions), who underwent SL; Group B, consisting of 44 patients (21 previously untreated and 23 pretreated at other Institutions), who did not undergo SL. Each group had statistically equivalent histology, grading, performance status and variety of cytoreductive operations performed. Group A pretreated patients had a greater number of stage III than Group B (P = 0.03). Systematic pelvic and para-aortic lymphadenectomy could be carried out with an acceptable morbidity and no mortality. All 142 patients received post-operative chemotherapy including carboplatin. The number of chemotherapy sessions did not differ between the two groups. Comparison of survival revealed that SL significantly improved the survival of previously untreated patients (P = 0.02). The survival was significantly different with nodal status (P = 0.006). Cox's proportional hazard analysis showed that only systematic lymphadenectomy was a significant covariate. The survival was not significantly different in Group A vs Group B pretreated patients; however, it was significantly different with respect to nodal status (P<0.001). Cox's proportional hazard analysis showed that only the initial stage of disease was a significant covariate. The results of the present study shows that aggressive surgical cytoreduction with SL could be therapeutic in previously untreated patients with NRID. Currently, an international prospective randomized study is ongoing to clarify definitively the clinical role of SL.

Loss of heterozygosity at the 5,10-methylenetetrahydrofolate reductase locus in human ovarian carcinomas

The high-affinity folate-binding protein (FBP) is primarily involved in the uptake of the 5-methyltetrahydrofolate, and its expression may be physiologically regulated by the intracellular folate content. The overexpression of FBP on the cell surface of ovarian carcinoma cells may be responsible for an increased folate uptake. We tested the hypothesis of the existence of a defect in the 5, 10-methylenetetrahydrofolate reductase (MTHFR) in ovarian tumours that could cause reduced intracellular regeneration of the 5-methyltetrahydrofolate and induce increased FBP expression. No sequence mutations were found in the MTHFR gene, but allelic deletions of this gene were frequently detected in ovarian tumours (59%). Chromosomal losses appeared to be confined to the 1p36.3 region to which the MTHFR gene maps. Although it cannot be stated that MTHFR is the target gene of the chromosomal loss involving the 1p36.3 region, a correlation between loss of heterozygosity at this locus and decrease in MTHFR activity was shown, suggesting a role of these allelic deletions in generating a biochemical defect in folate metabolism. Further studies are needed to assess further the relationship between MTHFR and FBP overexpression, but the demonstration of the alteration of a key metabolic enzyme of the folate cycle in a subset of human ovarian tumours is in accordance with the hypothesis of an altered folate metabolism in these neoplasias and might be exploited for therapeutic purposes.

Diagnostic and biological determinants in undifferentiated and poorly differentiated ovarian carcinomas

Six ovarian undifferentiated carcinomas (UCs) and 19 poorly differentiated serous (14 cases) and endometrioid (5 cases) carcinomas with areas of solid diffuse carcinomas have been considered for the study. Pathological findings were analyzed in conjunction with molecular analysis concerning the structure and expression of nm23-H1 gene. Differences in the frequency of loss of heterozigosity (LOH) of this gene have been observed between the two groups, UCs displaying lower percentage of LOH (1/5) as compared to poorly differentiated tumors (17/17). The remaining 3 cases (1 UC and 2 poorly differentiated carcinomas) were homozygotes, i.e., noninformative. UCs might occur as a consequence of cellular dedifferentiation, being at the end of the differentiation spectrum of epithelial ovarian tumors. Nevertheless, this study suggests that, in a fraction of cases, UCs could represent a distinct entity not involved in the malignant progression, associated with peculiar DNA anomalies, one possibly being that of the nm23-H1 deletion. In other words, a noticeable subset of UCs, not harboring nm23-H1 alterations, may be histologically uncommitted "ab initio". Moreover, nm23-H1 LOHs could be considered early events in the ovarian carcinogenesis, because similar molecular patterns were found both in primary and metastatic sites of the same tumor.

Multimodal treatment with neoadjuvant intraarterial chemotherapy and radical surgery in patients with stage IIIB-IVA cervical cancer. A preliminary study

BACKGROUND

The purpose of this study was to determine the role of neoadjuvant intraarterial chemotherapy (NIC) in patients with advanced cervical cancer.

METHODS

From June 1989 to December 1993, 36 consecutive patients with International Federation of Gynecology and Obstetrics Stage IIIB-IVA cervical cancer were admitted to the study. Treatment consisted of a bilateral infusion in the internal iliac artery of bleomycin (2.5 mg), doxorubicin (10 mg), and cisplatin (20 mg) for five courses after a 4-day rest period.

RESULTS

Twenty-nine (80.5%) patients received 100% of the programmed chemotherapeutic dose. The major toxic effects, according to World Health Organization criteria, were hematologic (19.4%, Grade 3 or 4), renal (2.8%, Grade 2), and gastrointestinal (61.1%, Grade 1 or 2). Only four patients (11.1%) had scanty bleeding around the site of catheter insertion. Neoadjuvant intraarterial chemotherapy induced responses in 33 of the 36 patients (5 complete, 28 partial; overall response rate, 91.7%), thus permitting radical surgery in all of these cases. Pretreatment characteristics were analyzed for response to NIC. None of the clinical parameters studied were related to chemoresponsiveness. A lower than expected incidence of lymph node metastases was detected (33.3%). Ten (30.3%) of the 33 patients who underwent surgery had disease recurrence. Lymph node status and pathologic parametrial involvement were significant prognostic factors for recurrence. The 5-year estimated survival for patients with a complete response, partial response, and stable disease was 100%, 36.2%, and 0%, respectively (P < 0.001). Clinical stage (P = 0.003) and response to NIC (P < 0.001) were significant prognostic factors in the overall estimated survival. The 5-year actuarial survival for patients with Stage IIIB and IVA disease was 66.7% and 0%, respectively.

CONCLUSION

These results suggest that NIC should be considered as a means of achieving prompt local control before surgery and/or radiotherapy.

Suppressive role of the metastasis-related nm23-H1 gene in human ovarian carcinomas: association of high messenger RNA expression with lack of lymph node metastasis

The nm23-H1 gene has been proposed as a metastasis suppressor gene. It is located on the long arm of chromosome 17, which is frequently deleted in ovarian cancer, and shows altered expression and structure in some advanced neoplasms. To evaluate the role of nm23-H1 in ovarian carcinogenesis, we have analyzed this gene in 66 primary human ovarian carcinomas at both the DNA and RNA levels. Despite the high frequency (76%) of nm23-H1 loss of heterozygosity (LOH), the complete absence of gene mutations in the coding portions of the retained allele clearly indicated that, in ovarian carcinomas, this gene does not function in the same way as do classic oncosuppressor genes. The relationship of clinicopathological parameters with nm23-H1 gene deletions and expression levels was also investigated. LOHs were more common in the serous and endometrioid histotypes (85 and 93%, respectively), and the highest LOH frequency was detected in poorly differentiated tumors (89%). A significant relationship between nm23-H1 mRNA expression and lymph node metastasis was observed in high-grade tumors, which are intrinsically more invasive than are low-grade tumors. In particular, among the poorly differentiated tumors showing areas of undifferentiated solid carcinoma (classified as G3/G4), lymph node-negative tumors displayed expression levels that were significantly higher than those of lymph node-positive tumors (P < 0.001). In conclusion, our data suggest that the nm23-H1 gene product may exert an inhibitory effect on the lymphatic dissemination of human ovarian tumors. However, several other factors, biological or time and patient dependent, influence the complex metastatic progression of ovarian tumors and may cooperate with nm23-H1 in the promotion or inhibition of this process.

[Second surgery in the management of ovarian cancer]

The aim of this study was to evaluate the value of second surgery in the combined and multidisciplinary treatment of mullerian ovarian cancer. A retrospective study was carried out in 86 consecutive patients with advances stages of mullerian ovarian cancer (stage 3-4) referred to the Division of Gynecological Surgical Oncology of the Oncological Reference Centre at Aviano for continuation of treatment following initial surgery and chemotherapy performed in various peripheral institutions. Second surgery only revealed 11.6% of complete endocelomatic pathological responses (10 patients) to earlier treatments; among the 76 patients with persistent disease it was possible to achieve optimal redebulking in 50 (65.8%) (31 R0 and 19 R1 after second surgery), whereas it was not possible to perform adequate second surgery in 26 (34.2%). The impact of second surgery on the probability of survival (mean survival rate) was highly significant in the 50 patients in whom it was possible to perform adequate second surgery compared to the non-operated group (14.34 months versus 6.10, chi square = 12.671, p = 0.0004). The authors underline both the prognostic value of lymph node status with increased mortality among patients with positive retro-peritoneal lymph nodes (LN+), and the value of retroperitoneal re-evaluation in predicting endo-peritoneal recidivation in patients with free abdomen who subsequently relapsed.

Chromosomal localisation of two putative 11p oncosuppressor genes involved in human ovarian tumours

In this study, 44 primary or metastatic human ovarian tumours were tested for allelic deletions on the short arm of chromosome 11. Analysis of 12 polymorphic loci by Southern blotting evidenced loss of heterozygosity (LOH) in at least one locus in 41% of cases. Moreover, two hot spots of deletions were tentatively mapped on 11p13 and 11p15.5. Our results demonstrated that LOH at 11p is a common event in ovarian carcinomas and were indicative of the possible existence in 11p of two oncosuppressor genes involved in ovarian carcinogenesis. The similarity observed with 11p allelic losses in Wilms tumours, clustered in 11p13 and 11p15.5 too, suggests that deletion and possibly inactivation of the same growth regulatory genes (WT genes) could also contribute to development of the malignant phenotype in ovarian carcinomas. Finally, a statistically significant association (P = 0.005) between 11p deletions and hepatic involvement was suggested by the analysis of distribution of 11p LOH relative to different clinical and pathological parameters of the tumour patients.

[CA-125 serum levels in the diagnostic and clinical approach to ovarian cancer]

The CA 124 serum level is a useful marker in monitoring epithelial ovarian carcinoma. More elevated serum levels when compared to the conventional cut-off (ie 35 U/ml), after the first surgical and/or chemotherapeutic approach, give evidence for the presence of an endocelomic and/or retroperitoneal tumour or are indicative of relapses. Also, they are well correlated with the endoperitoneal cytology pattern. Good correlation exists between the serological amount of CA 125 and tumoral mass before surgical removal whereas its efficacy in the differential diagnosis between primary ovarian tumours and metastatic disease ad well as its diagnostic specificity towards pelvic bulks, before removing them, is limited. Higher specificity seems to be obtained on increasing the cut-off threshold over 70 U/ml.

[Bilateral hydrothorax with hydromediastinum after cannulation of the left internal jugular vein]

A rare case of combined bilateral hydrothorax and hydromediastinum was encountered during Total Parenteral Nutrition (TPN) via incannulation of the left internal jugular vein in a patient with advanced cancer of the portio. The possible anatomical and technical causes of this very serious complication were investigated in order to assess the importance of specific manual technique and to supply appropriate instrumental back-up that could prevent the recurrence of this sometimes fatal complication of TPN.