Radiotherapy Versus Inguinofemoral Lymphadenectomy as Treatment for Vulvar Cancer Patients With Micrometastases in the Sentinel Node: Results of GROINSS-V II

PURPOSE

The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN).

METHODS

GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences.

RESULTS

From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL (P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL.

CONCLUSION

Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

Beyond Sedlis-A novel histology-specific nomogram for predicting cervical cancer recurrence risk: An NRG/GOG ancillary analysis

PURPOSE

The Sedlis criteria define risk factors for recurrence warranting post-hysterectomy radiation for early-stage cervical cancer; however, these factors were defined for squamous cell carcinoma (SCC) at an estimated recurrence risk of ≥30%. Our study evaluates and compares risk factors for recurrence for cervical SCC compared with adenocarcinoma (AC) and develops histology-specific nomograms to estimate risk of recurrence and guide adjuvant treatment.

METHODS

We performed an ancillary analysis of GOG 49, 92, and 141, and included stage I patients who were surgically managed and received no neoadjuvant/adjuvant therapy. Multivariable Cox proportional hazards models were used to evaluate independent risk factors for recurrence by histology and to generate prognostic histology-specific nomograms for 3-year recurrence risk.

RESULTS

We identified 715 patients with SCC and 105 with AC; 20% with SCC and 17% with AC recurred. For SCC, lymphvascular space invasion (LVSI: HR 1.58, CI 1.12-2.22), tumor size (TS ≥4 cm: HR 2.67, CI 1.67-4.29), and depth of invasion (DOI; middle 1/3, HR 4.31, CI 1.81-10.26; deep 1/3, HR 7.05, CI 2.99-16.64) were associated with recurrence. For AC, only TS ≥4 cm, was associated with recurrence (HR 4.69, CI 1.25-17.63). For both histologies, there was an interaction effect between TS and LVSI. For those with SCC, DOI was most associated with recurrence (16% risk); for AC, TS conferred a 15% risk with negative LVSI versus a 25% risk with positive LVSI.

CONCLUSIONS

Current treatment standards are based on the Sedlis criteria, specifically derived from data on SCC. However, risk factors for recurrence differ for squamous cell and adenocarcinoma of the cervix. Histology-specific nomograms accurately and linearly represent risk of recurrence for both SCC and AC tumors and may provide a more contemporary and tailored tool for clinicians to base adjuvant treatment recommendations to their patients with cervical cancer.

Beyond Sedlis: A novel, histology-based nomogram for predicting recurrence risk and need for adjuvant radiation in cervical cancer—A NRG/GOG ancillary analysis

6019

Background: In GOG 49, factors associated with a 3-year, 30% recurrence risk in squamous cell carcinoma of the cervix (SCC) after surgery alone were defined. These "intermediate" risk factors [tumor size (TS), depth of tumor invasion (DOI), and lymphvascular space invasion (LVSI)] were then studied in GOG 92, which demonstrated the utility of treating patients (pts) with ≥2 intermediate risk factors with adjuvant radiation (RT), Sedlis Criteria. However, pts with < 30% recurrence risk were not eligible and few pts with adenocarcinoma (AC) were included. Our study purpose was 1) to evaluate recurrence risk factors for AC vs SCC, and 2) to define contemporary nomograms for adjuvant treatment in pts with both histologies. Methods: We performed an ancillary analysis of GOG 49, 92, and 141, and included Stage I pts who received no neoadjuvant/adjuvant therapy. Multivariable Cox proportional hazards models were created separately for AC and SCC to evaluate independent risk factors for recurrence. Model accuracy was tested with ROC curves. Prognostic nomograms were generated for 2-year recurrence risk for AC and SCC. Results: We identified 715 with SCC and 105 pts with AC; 142 with SCC (19.9%) and 18 with AC 17.1%) recurred. For SCC, factors associated independently with recurrence were: LVSI [HR 1.58 (CI 1.12-2.22)], DOI [middle 1/3, HR 4.31 (CI 1.81-10.26); deep 1/3, HR 7.05 (CI 2.99-16.64)] and TS [≥4cm HR 2.67 (CI 1.67-4.29)]. In contrast, for AC, only TS ≥4cm was independently associated with recurrence [HR 4.69 (CI 1.25-17.63)]. At 3 years, ROC curves for these models predicted recurrence with 76% and 75% accuracy for SCC and AC, respectively. Utilizing a nomogram generated from these models, for SCC, DOI had the greatest impact on recurrence, with mid 1/3 conferring an 18% risk and deep 1/3 a 32% risk, while LVSI and TS increased risk by 4-10%, respectively. In contrast, for AC, TS alone had the greatest impact on recurrence risk with TS 2-4cm conferring a 20% risk over 3 years and TS ≥4cm, a 28% risk. Conclusions: Our nomogram differs from the Sedlis Criteria in demonstrating that single, as well as a combination of risk factors predict substantial 3-year recurrence rates in Stage I cervical cancer. Furthermore, these factors differ by AC and SCC subtypes, suggesting that distinct, histology-specific nomograms may have greater utility in identifying pts who will most benefit from adjuvant therapy.

A randomized phase 3 trial of paclitaxel (P) plus carboplatin (C) versus paclitaxel plus ifosfamide (I) in chemotherapy-naive patients with stage I-IV, persistent or recurrent carcinosarcoma of the uterus or ovary: An NRG Oncology trial

5500

Background: Gynecologic carcinosarcomas (CS) are rare yet aggressive epithelial malignancies for which optimal therapy is debated. PI was shown to be superior to I. PC demonstrated compelling phase 2 activity with improved safety and convenience. Methods: Main inclusion: ≥18 y; chemotherapy naïve stage I-IVB or recurrent uterine (U) or ovarian (O) CS. Treatment randomised 1:1 to PC (P 175mg/m2 with C: AUC 6 or 5 if prior RT on D1) or PI (P: 135 mg/m2; I 1.6 g/m2 D1-3; G-CSF support with dose escalation & de-escalation based on nadir counts) q21days for 6-10 cycles. Quality of life (QOL) (FACT-En TOI) and neurotoxicity (FACT/GOG-Ntx subscale) administered at 4 timepoints. A stratified log-rank test compared primary endpoint of overall survival (OS) from entry between treatment groups for non-inferiority (NI) of PC to PI. With 264 events, power was 80% for a null hazard ratio of 1.2 against a 13% greater death rate on PI when type I error is limited to 5% for a one-tail test. NCT00954174. Results: 637 pts accrued with a median follow-up of 61 months. The primary (U, n = 536) and secondary (O, n = 101) cohorts are analyzed separately and included 449 and 90 pts eligible pts, respectively. For the U cohort:PC and PI were randomly assigned to 228 and 221 eligible pts. Stage distribution: I (40%), II (6%), III (31%), IV (15%) and recurrent (8%). The study met its primary objective withPC not inferior to PI (intention-to-treat analysis;Median OS 37 vs. 29 mo, HR = 0.87; 90% CI = 0.70 to 1.075; p < 0.01 for NI, p > 0.1 for superiority (S)).PFS (median on PC 16mo vs PI 12mo; HR = 0.73; p = < 0.01 for NI, p < 0.01 for S). Toxicity (grade 1/2/3/4/5: PC 1/8/40/48/2%; PI 1/32/39/25/1%). Most of increase toxicity for PC was hematologic with G-CSF rarely used (N = 6). Confusion and genitourinary hemorrhage were significantly worse with PI. Both groups had decline in QOL and neurotoxicity scores. Similar trends were noted for the O cohort (OS: PC 30mo vs PI 25mo; and PFS: 15 mo vs 10 respectively). Conclusions: PC was not inferior to PI for OS with longer PFS and similar QOL and neurotoxicity. These results establish a new standard regimen for women with CS. Clinical trial information: NCT00954174.

A randomized phase III trial of cisplatin and tumor volume directed irradiation followed by carboplatin and paclitaxel vs. carboplatin and paclitaxel for optimally debulked, advanced endometrial carcinoma

5505

Background: Patients with stage III/IVA uterine cancer (UC) carry high risk of systemic and local recurrence. Chemotherapy was shown to reduce systemic recurrence, however the risk of local failure remains high. Methods: The primary endpoint of this open label, randomized phase III trial was to determine if treatment with cisplatin and volume-directed radiation followed by carboplatin and paclitaxel for 4 cycles (C-RT, experimental arm) reduces the rate of recurrence or death (i.e., increases recurrence-free survival, RFS) when compared to carboplatin and paclitaxel for 6 cycles (CT, control arm) in patients with stages III-IVA (<2 cm residual disease) or FIGO 2009 stage I/II serous or clear cell UC and positive cytology. Secondary objectives were assessment of overall survival (OS), acute and late toxicities, and quality of life. A 28.5% reduction in the rate of recurrence or death was considered significant. Treatment randomization and analysis were stratified by gross residual tumor and age. Results: Between 6/2009 and 7/2014, 813 patients were enrolled and randomized (407 C-RT and 406-CT). Of those, 733 were eligible (344 C-RT and 360 CT), and 680 received the trial intervention (333 C-RT and 347 CT). Median follow up is 47 months. Patients characteristics were balanced between arms. There were 201 (58%) > grd 3 toxicity events in the C-RT arm and 227 (63%) in the CT arm. The most common > grd 3 events were myelosupression (40% vs. 52%), gastrointestinal (13% vs. 4%), metabolic (15% vs. 19%), neurological (7% vs. 6%), infectious (4% vs. 5%). Treatment hazard ratio for RFS was 0.9 (C-RT vs. CT; CI 0.74 to 1.10). C-RT reduced the incidence of vaginal (3% vs. 7%, HR = 0.36, CI 0.16 to 0.82), pelvic and paraaortic recurrences (10% vs. 21%, HR=0.43, CI 02.8 to 0.66) compared to CT, but distant recurrences were more common with C-RT vs. CT (28% vs. 21%, HR 1.36, CI 1 to 1.86). The analysis is premature for OS comparison. Conclusions: Although C-RT reduced the rate of local recurrence compared to CT; the combined modality regimen did not increase RFS in optimally debulked, stage III/IVA UC. Clinical trial information: NCT00942357.

Phase III randomized trial of weekly cisplatin and irradiation versus cisplatin and tirapazamine and irradiation in stages IB2, IIA, IIB, IIIB, and IVA cervical carcinoma limited to the pelvis: a Gynecologic Oncology Group study

PURPOSE

This prospective, randomized phase III intergroup trial of the Gynecologic Oncology Group and National Cancer Institute of Canada Clinical Trials Group was designed to test the effectiveness and safety of adding the hypoxic cell sensitizer tirapazamine (TPZ) to standard cisplatin (CIS) chemoradiotherapy in locally advanced cervix cancer.

PATIENTS AND METHODS

Patients with locally advanced cervix cancer were randomly assigned to CIS chemoradiotherapy versus CIS/TPZ chemoradiotherapy. Primary end point was progression-free survival (PFS). Secondary end points included overall survival (OS) and tolerability.

RESULTS

PFS was evaluable in 387 of 402 patients randomly assigned over 36 months, with enrollment ending in September 2009. Because of the lack of TPZ supply, the study did not reach its original target accrual goal. At median follow-up of 28.3 months, PFS and OS were similar in both arms. Three-year PFS for the TPZ/CIS/RT and CIS/RT arms were 63.0% and 64.4%, respectively (log-rank P = .7869). Three-year OS for the TPZ/CIS/RT and CIS/RT arms were 70.5% and 70.6%, respectively (log-rank P = .8333). A scheduled interim safety analysis led to a reduction in the starting dose for the TPZ/CIS arm, with resulting tolerance in both treatment arms.

CONCLUSION

TPZ/CIS chemoradiotherapy was not superior to CIS chemoradiotherapy in either PFS or OS, although definitive commentary was limited by an inadequate number of events (progression or death). TPZ/CIS chemoradiotherapy was tolerable at a modified starting dose.

Tumor heterogeneity in ovarian cancer as demonstrated by in vitro chemoresistance assays

OBJECTIVE

Tumor heterogeneity has been demonstrated in solid tumors. In vitro assays were developed in an effort to predict in vivo tumor response to therapy. We compare the in vitro assay results from multiple synchronous tumor samples in primary and recurrent ovarian cancers.

METHODS

38 patients underwent surgery for primary (18) or recurrent (20) ovarian cancer. Two (22) or three (16) samples were obtained per patient and tested using the EDR assay (Oncotech, Inc.). The percentage of Extreme (E), Intermediate (I) and Low (L) drug resistance for each chemotherapy was compared between synchronous specimens.

RESULTS

A total of 92 samples were collected and 787 drug assays were performed. Tumor heterogeneity was seen in 22.4% of all cases, including 18.6% primary and 26.1% recurrent diseases (p=0.01). Two category differences (L vs. E) were seen in 4.1% primary and 11.3% recurrent cases (7.8% of all cases). Overall, an increased frequency in EDR was seen in recurrent disease as compared to primary for all agents tested (22.9% primary vs. 31.6% recurrent, p=0.006). Marked heterogeneity of the drug resistance profiles was seen with paclitaxel as compared with cisplatin/gemcitabine (p=0.03), taxotere (p=0.04) or topotecan (p=0.04). No association was demonstrated between assay results and clinicopathologic parameters collected in this cohort.

CONCLUSIONS

Treatment failure is often attributed to the development of chemoresistance. These results suggest that tumor heterogeneity may play an equally important role in treatment failure. Recurrent lesions exhibit greater heterogeneity and more frequent EDR. These data can influence therapeutic strategy i.e., multiple samples, sequential, or consolidation therapy.

Regional blood flow occlusion during extensive pelvic procedures for ovarian cancer: a randomized trial

The objective of this study was to determine the effects of intraoperative aortic occlusion on blood loss and operative time when used during en bloc resection of internal reproductive organs, pelvic peritoneum, and rectosigmoid colon [modified posterior exenteration (MPE)] for primary cytoreduction of ovarian cancer. Patients undergoing MPE, without palpable distal aortic plaque or calcification, were randomized to: (a) complete distal aortic occlusion (</=60 min, with heparin and protamine reversal) with a vascular clamp immediately before MPE, (b) bilateral hypogastric artery occlusion, or (c) no regional blood flow occlusion. Outcomes were compared with respect to blood loss, operative time, and the transfusion rate (anova analysis of variance). Fifty-six patients were accrued. Groups were equivalent with respect to age, disease severity, extent of upper abdominal surgery done, and cytoreductive outcomes. Aortic occlusion significantly reduced the total operative time (P = 0.02), estimated blood loss (P = 0.01), transfusion rate (P = 0.02), hospital stay (P = 0.05), and both operative time (P </= 0.001) and blood loss (P </= 0.001) specifically associated with MPE. There were no immediate or delayed complications due to aortic clamping. Aortic occlusion significantly reduces the blood loss and operative time for patients requiring MPE in the context of primary cytoreductive operations.

Radiation fields in gynecologic oncology: correlation of soft tissue (surgical) to radiologic landmarks

OBJECTIVES

(1). To determine if radiation fields defined by bony structure landmarks correlate to anatomic boundaries of lymph node dissection marked intraoperatively; and (2). to determine if a patient's body mass index (BMI) correlates with these anatomic or radiographic boundaries.

METHODS

One hundred patients undergoing exploratory laparotomy with pelvic and paraaortic lymph node dissection had three medium hemoclips placed at vascular junctions considered of clinical significance to lymph node dissection: insertion of the left ovarian vein into the renal vein, insertion of the right ovarian vein into the vena cava, inferior mesenteric artery (IMA), bifurcation of the aorta, bifurcation of the common iliacs (bilateral), and the insertion of the deep circumflex vein (DCV) in to the external iliac vein (bilateral). Postoperatively, an abdominal X-ray was obtained. Comparisons were made between these eight major vascular landmarks and radiographic bony landmarks that are used to define radiation field boundaries. The percentage of vascular landmarks that were encompassed or fell outside of traditional radiation fields was determined with a 1-cm margin considered an adequate boundary for radiation. These measurements were also compared to patient BMIs.

RESULTS

Radiation fields defined by traditional bony landmarks would adequately encompass the paraaortic lymph nodes in the majority of patients (91%). For pelvic radiation fields, there was a significant "miss" (39%) of common iliac lymph nodes. Approximately one quarter (26%) of patients would receive inadequate coverage of one or both of the lateral boundaries of pelvic radiation. There was no apparent correlation of BMI to vascular or bony landmarks.

CONCLUSIONS

Radiation fields determined by traditional bony landmarks do not adequately reflect the anatomic (surgical) landmarks associated with the lymphatic drainage of the female reproductive organs. Although the majority of tertiary care centers now use advanced imaging techniques (e.g. computed tomography) to plan their radiation treatments, the historical guidelines of radiographic landmarks are still used in smaller institutions and continue to be referenced in Gynecologic Oncology Group protocols. For centers still using radiographic landmarks, the application of hemoclips with X-ray identification is a low-cost modality that is easily reproducible and may be clinically useful in guiding treatment.

The relative importance of surgical training and laboratory research in a gynecologic oncology fellowship

The objective was to determine trends of surgical skill acquisition during fellowships, and the consensus amongst gynecologic oncologists about the relative importance of surgical training and laboratory research in fellowships. A survey addressing surgical capability at the time of fellowship completion, and relative priorities that should be given to surgical training and laboratory research was mailed to gynecologic oncologists and fellows in the Society of Gynecologic Oncologists directory. Of 820 surveyed, 454 (55.4%) of provided utilizable data, of whom 56 (12.5%) were fellows, and 398 (87.5%) in practice (49.5% university-based and 50.5% community hospital-based). Relative to past graduates, recent ones report and current fellows anticipate a lower probability of being able to independently perform some procedures applicable to cervical and ovarian cancer, as well as others necessary to manage complications at the time of fellowship completion. 69.8% of all respondents think that greater emphasis should be placed on surgical training at the expense of doing less laboratory research. There is wide variation of opinion among respondents concerning the value of and most appropriate length of time that should be dedicated to laboratory research in a fellowship. There is an indication of a trend for more recent fellows to graduate having acquired less surgical skill and a prevalent opinion that surgical training should be more heavily emphasized in fellowships.

Radical trachelectomy and pelvic lymphadenectomy with uterine preservation in the treatment of cervical cancer

OBJECTIVE

The purpose of this study was to determine whether radical trachelectomy, combined with pelvic lymphadenectomy, can be a feasible method for the treatment of early-stage cervical carcinoma in women who want to preserve their fertility.

STUDY DESIGN

From January 1, 1995, through December 31, 1999, 12 women with stage I carcinoma of the cervix were scheduled to undergo radical trachelectomy and pelvic lymphadenectomy of the intact uterus as treatment. The procedure was abandoned in 2 women because of endometrial extension of the cancer. Surgical margins were clear in all other women. No lymph node metastases were encountered. The proximal cervical remnant was reinforced in 10 women.

RESULTS

Hospitalization ranged from 2 to 8 days (mean, 3.2 days). Estimated blood loss averaged 203 mL (range, 50-600 mL). Complications included 2 intraoperative cystotomies and 1 pelvic hematoma. Four pregnancies have occurred, with 2 third-trimester deliveries and 2 preterm losses at 24 and 26 weeks of gestation, respectively. The follow-up period has ranged from 28 to 84 months (mean, 47.6 months).

CONCLUSION

Radical trachelectomy, combined with pelvic lymphadenectomy, can be a feasible method of treatment for early-stage cervical carcinoma in women who want to preserve their fertility.

Surgical chores and approach in the management of endometrial cancer

Carcinoma of the uterine corpus is the most common malignancy in the female pelvis. Surgical resection and staging are now the accepted approach to therapy, with excellent survival compared with other gynecologic malignancies. Several controversies exist, however, regarding optimal surgical management. Some of these controversies are addressed in this article, with a review of their recent and historic literature.

Laparoscopic retroperitoneal lymphadenectomy followed by immediate laparotomy in women with cervical cancer: a gynecologic oncology group study

OBJECTIVES

From May 1993 until June 1997, the Gynecologic Oncology Group undertook a study of women with cancer of the cervix (Stage IA, IB, and IIA) who were about to undergo radical abdominal hysterectomy, pelvic lymphadenectomy, and aortic lymph node sampling. Immediately before this surgery, laparoscopy was performed and removal of the lymph nodes was attempted. There were two objectives: (1) to obtain information on the adverse effects and difficulties associated with laparoscopic lymph node removal and (2) to determine the adequacy of the lymph node removal.

METHODS

Four methods determined the adequacy of the lymph node removal: (1) the surgeon's opinion during laparoscopy, (2) a photographic record reviewed by two independent observers, (3) inspection of the surgical sites at laparotomy, and (4) lymph node count.

RESULTS

Seventy-three women were entered onto the study. Four patients were judged ineligible; 2 did not undergo laparoscopy and 17 women did not complete laparoscopic surgery because of metastatic lymph nodes judged unresectable or complications. Ten women were inevaluable. The remaining 40 women were completely evaluable for protocol objectives. All cases of bilateral laparoscopic aortic lymph node sampling were judged adequate by all four methods of evaluation. For laparoscopic pelvic lymphadenectomy 6 were judged incomplete at laparotomy, 3 of which were judged incomplete by independent reviewers. The mean number of right pelvic nodes removed was 16.6; left pelvic nodes 15.5; right aortic nodes 6.2; and left aortic nodes 5.9.

CONCLUSIONS

Laparoscopic bilateral aortic lymph node sampling appeared to be reasonably safe and feasible. Laparoscopic therapeutic bilateral pelvic lymphadenectomy, although having a reasonable complication rate, demonstrated problems regarding adequacy, which are probably correctable.

Procedures required to accomplish complete cytoreduction of ovarian cancer: is there a correlation with "biological aggressiveness" and survival?

OBJECTIVE

The aim of this study was to determine if the necessity of using specific procedures to attain complete cytoreduction in ovarian cancer correlates with innate biologic aggressiveness and independently influences survival.

METHODS

Between 1990 and 2000, 213 patients with Stage IIIC epithelial ovarian cancer underwent complete cytoreduction before initiation of systemic platinum-based combination chemotherapy. Survival was stratified and analyzed (log rank and Cox regression) on the basis of whether extrapelvic bowel resection, diaphragm stripping, full-thickness diaphragm resection, modified posterior pelvic exenteration, peritoneal implant ablation and/or aspiration, and excision of grossly involved retroperitoneal lymph nodes were necessary to attain a visibly disease-free cytoreductive outcome.

RESULTS

The median and estimated 5-year survival for the cohort were 75.8 months and 54%, respectively. Survival was influenced (log rank) by the requirement of diaphragm stripping (required, median 42 months vs not required, median 79 months; P = 0.03) and the extent of mesenteric and serosal implants that required removal (none, median not reached, vs 1-50 implants, median not reached, vs >50 implants, median 40 months; P = 0.002). Survival was independently influenced (Cox regression) only by the extent of peritoneal metastatic implants that required removal (P = 0.01). The other investigated procedures and type of chemotherapy used did not influence survival.

CONCLUSIONS

The need to remove a large number of peritoneal implants correlates with biological aggressiveness and diminished survival, but not significantly enough to preclude long-term survival or justify abbreviation of the operative effort. The need to use the other investigated procedures had minimal or no observed influence on survival.

What are the current surgical objectives, strategies, and technical capabilities of gynecologic oncologists treating advanced epithelial ovarian cancer?

OBJECTIVE

The purpose of this survey was to determine the range of surgical objectives, strategies, and outcomes of primary cytoreductive operations performed by gynecologic oncologists.

METHODS

A survey addressing the definition of "optimal" cytoreduction, the use of neoadjuvant chemotherapy, disease sites precluding optimal cytoreduction, reasons optimal cytoreduction or cytoreduction to a visibly disease-free outcome is or is not accomplished, the use of 15 specific operative procedures, and attitude toward postfellowship training in the surgical management of advanced stage epithelial ovarian cancer was mailed to candidate and full members of the Society of Gynecologic Oncologists. Analysis of discrete and binomial data utilized the chi(2) and independent samples t tests. Logistic regression confirmed relationships between responses and both the definition of optimal cytoreduction and the attitudes toward postfellowship training.

RESULTS

Three hundred ninety-three (61.4%) of 640 physicians provided utilizable data. A median of 95% of patients were reported to be operated on primarily and 5% were treated with neoadjuvant chemotherapy (P < 0.0001). A median of 9 (range 0-15) of the surveyed procedures were utilized. Forty-seven (12.0%) respondents defined optimal cytoreduction as no residual disease, 54 (13.7%) used a 5-mm threshold, 239 (60.8%) used a 1-cm threshold, and 48 (12.6%) utilized a 1.5- to 2.0-cm threshold. Small dimensions of residual disease (0-5 mm versus 1-2 cm) defined optimal cytoreduction for physicians indicating that fewer disease sites precluded optimal cytoreduction (P = 0.02), using a larger number of the surveyed procedures (P = 0.04), and in practice longer (P = 0.001). Three hundred seventeen (83.9%) of 378 respondents favored development of postfellowship training in cytoreductive surgery. Physicians against postfellowship training used fewer of the surveyed procedures because of concerns about efficacy (P = 0.01). More recent fellowship graduates favored postfellowship training (P = 0.01).

CONCLUSIONS

A range of surgical objectives, strategies, procedures used, and outcomes exists among gynecologic oncologists. Confirmation of the efficacy of cytoreductive surgery may cultivate a consensus about the most appropriate therapeutic objective and strategy for advanced ovarian cancer. Cooperative efforts should be undertaken to offer postfellowship training.

The clinical significance of occult macroscopically positive retroperitoneal nodes in patients with epithelial ovarian cancer

OBJECTIVE

The goal of this study was to determine the time during primary cytoreduction when retroperitoneal lymph nodes that are involved with macroscopic disease are recognized to be involved with tumor, the dimensions of intranodal disease present, and the possible clinical significance of macroscopically positive nodes that are recognized at different phases of the operation.

METHODS

One hundred consecutive patients with stage IIIC and IV epithelial ovarian cancer underwent a retroperitoneal lymph node dissection during primary cytoreductive surgery. The phase of the operation in which nodes were recognized to be macroscopically involved with tumor was noted. Nodes were classified to be positive by palpation if recognized to be macroscopically involved by transperitoneal palpation, positive by inspection if recognized to be macroscopically involved by palpation after opening the retroperitoneal area, and positive by dissection if recognized to be macroscopically involved anytime after starting the actual process of lymph node dissection. The largest dimension of the intranodal disease in macroscopically positive nodes was measured. Log rank analysis determined whether nodal status or the time at which the nodes were recognized to be macroscopically positive influenced the probability of survival.

RESULTS

Of the 100 patients, 66 had positive lymph nodes. Five were microscopically positive and 61 were macroscopically positive, of which 19 (31.1%) were positive by palpation, 16 (26.2%) were positive by inspection, 26 (42.6%) were positive by dissection. Of the 39 patients with negative and microscopically positive nodes 15 (38.5%) were clinically suspicious. Compared with patients with negative and microscopically positive lymph nodes, survival was not significantly different for patients who required excision of macroscopically positive nodal tissue. Survival was not influenced by the specific phase of surgery in which macroscopically positive nodes were recognized.

CONCLUSIONS

A significant percentage of patients had retroperitoneal nodes recognized to be involved with macroscopic disease only after a lymph node dissection was in progress. The decision not to perform a lymph node dissection for optimally and completely cytoreduced patients may result in unrecognized macroscopic residual disease that is larger than what would otherwise be documented.

Second-look laparotomy after modified posterior exenteration: patterns of persistence and recurrence in patients with stage III and stage IV ovarian cancer

OBJECTIVE

The purpose of this study was to determine patterns of persistence and recurrence in patients with advanced ovarian cancer (stage IIIC and stage IV) after modified posterior exenteration.

STUDY DESIGN

Retrospective chart review was used to determine patterns of persistence and recurrence of disease in patients undergoing modified posterior exenteration. From January 1, 1987, to September 15, 1998, 151 of 212 (71.2%) patients undergoing modified posterior exenteration in addition to other cytoreductive surgical procedures for stage IIIC and stage IV ovarian cancer underwent second-look laparotomy. The average age of the patients was 60.3 years (range, 20.3-86.3). A total of 207 of the 212 (97.6%) had grade 2 or 3 disease. Papillary serous carcinoma (113/212; 53.3%) and adenocarcinoma (75/212; 35.4%) were the most frequent cell types encountered. After initial cytoreductive surgery, minimal disease (<5 mm) was present in 206 of the 212 (96.2%) patients with 153 of 212 (72.2%) having no visible residual disease. There were 4 (1.9%) postoperative deaths. In 13 patients (6.1%) progressive disease was noted. Second-look laparotomy was not undertaken in 61 of the 212 (28%) patients. Fluid for cytologic testing was obtained from all four intra-abdominal quadrants, and biopsies of previously noted sites of disease were performed, in addition to random biopsies of diaphragmatic peritoneum, colonic gutters, and pelvic peritoneum. If present, the retroperitoneal lymph nodes were resected; biopsy specimens of these sites were obtained if there was no evidence of intraperitoneal disease.

RESULTS

Findings at second-look laparotomy were negative for cancer in 85 of 151 (56.3%) and positive for cancer in 66 of 151 (43.7%). Only 8 of 151 (5.3%) patients had persistent disease in the pelvis. In the remainder (58/151; 38.4%) disease was found either in the upper abdomen or in the bowel mesentery. Recurrence was documented in the upper abdomen only (71/212; 33.5%), upper abdomen and pelvis (18/212; 8.5%), multiple sites excluding the pelvis (22/212; 10.4%), pelvis only (2/212; 0. 9%), chest alone (5/212; 2.4%), head alone (4/212; 1.9%), or groin alone (2/212; 0.9%). Median survival in the overall group was 51.1 months, with estimated 5- and 10-year survival rates of 44.2% and 32. 9%, respectively.

CONCLUSIONS

Modified posterior exenteration is an effective surgical means of eliminating pelvic disease in patients with advanced ovarian cancer. Results of second-look laparotomy confirmed that only 8 of 151 (5.3%) had persistent disease in the pelvis.

The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian carcinoma

BACKGROUND

This study examined the impact of secondary cytoreductive surgery on survival of patients with recurrent epithelial ovarian carcinoma.

METHODS

One hundred six patients with a disease free interval (DFI) > 6 months after primary treatment underwent secondary cytoreductive surgery. Multivariate analysis determined which variables influenced the cytoreductive outcome and survival.

RESULTS

Eighty-seven patients (82.1%) underwent removal of all visible tumor. The median and estimated 5-year survival for the entire cohort after recurrence was 35.9 months and 28%, respectively. The probability of complete cytoreduction was influenced by the largest size of recurrent tumor (< 10 cm ¿90.0% vs. > 10 cm ¿66.7%; P = 0.003), use of salvage chemotherapy before secondary surgery (chemotherapy given ¿64.3% vs. chemotherapy not given ¿93.8%; P = 0.001), and preoperative Gynecologic Oncology Group performance status (0 ¿100%, 1 ¿91.4%, 2 ¿82.4%, and 3 ¿47.4%; P = 0.001). Survival was influenced by the DFI after primary treatment (6-12 months ¿median, 25.0 months vs. 13-36 months ¿median, 44.4 months vs. > 36 months ¿median, 56.8 months; P = 0.005), the completeness of cytoreduction (visibly disease free ¿median, 44.4 months vs. any residual disease ¿median, 19.3 months; P = 0.007), the use of salvage chemotherapy before secondary surgery (chemotherapy given ¿median, 24.9 months vs. chemotherapy not given ¿median, 48.4 months; P = 0.005), and the largest size of recurrent tumor (< 10 cm ¿median, 37.3 months vs. > 10 cm ¿median, 35.6 months; P = 0.04).

CONCLUSIONS

Complete cytoreduction is possible for the majority of patients with recurrent epithelial ovarian carcinoma and maximizes survival if undertaken before salvage chemotherapy. The authors believe a randomized trial should be initiated to confirm these findings.

The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian carcinoma

BACKGROUND

This study examined the impact of secondary cytoreductive surgery on survival of patients with recurrent epithelial ovarian carcinoma.

METHODS

One hundred six patients with a disease free interval (DFI) > 6 months after primary treatment underwent secondary cytoreductive surgery. Multivariate analysis determined which variables influenced the cytoreductive outcome and survival.

RESULTS

Eighty-seven patients (82.1%) underwent removal of all visible tumor. The median and estimated 5-year survival for the entire cohort after recurrence was 35.9 months and 28%, respectively. The probability of complete cytoreduction was influenced by the largest size of recurrent tumor (< 10 cm ¿90.0% vs. > 10 cm ¿66.7%; P = 0.003), use of salvage chemotherapy before secondary surgery (chemotherapy given ¿64.3% vs. chemotherapy not given ¿93.8%; P = 0.001), and preoperative Gynecologic Oncology Group performance status (0 ¿100%, 1 ¿91.4%, 2 ¿82.4%, and 3 ¿47.4%; P = 0.001). Survival was influenced by the DFI after primary treatment (6-12 months ¿median, 25.0 months vs. 13-36 months ¿median, 44.4 months vs. > 36 months ¿median, 56.8 months; P = 0.005), the completeness of cytoreduction (visibly disease free ¿median, 44.4 months vs. any residual disease ¿median, 19.3 months; P = 0.007), the use of salvage chemotherapy before secondary surgery (chemotherapy given ¿median, 24.9 months vs. chemotherapy not given ¿median, 48.4 months; P = 0.005), and the largest size of recurrent tumor (< 10 cm ¿median, 37.3 months vs. > 10 cm ¿median, 35.6 months; P = 0.04).

CONCLUSIONS

Complete cytoreduction is possible for the majority of patients with recurrent epithelial ovarian carcinoma and maximizes survival if undertaken before salvage chemotherapy. The authors believe a randomized trial should be initiated to confirm these findings.

The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian carcinoma

BACKGROUND

This study examined the impact of secondary cytoreductive surgery on survival of patients with recurrent epithelial ovarian carcinoma.

METHODS

One hundred six patients with a disease free interval (DFI) > 6 months after primary treatment underwent secondary cytoreductive surgery. Multivariate analysis determined which variables influenced the cytoreductive outcome and survival.

RESULTS

Eighty-seven patients (82.1%) underwent removal of all visible tumor. The median and estimated 5-year survival for the entire cohort after recurrence was 35.9 months and 28%, respectively. The probability of complete cytoreduction was influenced by the largest size of recurrent tumor (< 10 cm ¿90.0% vs. > 10 cm ¿66.7%; P = 0.003), use of salvage chemotherapy before secondary surgery (chemotherapy given ¿64.3% vs. chemotherapy not given ¿93.8%; P = 0.001), and preoperative Gynecologic Oncology Group performance status (0 ¿100%, 1 ¿91.4%, 2 ¿82.4%, and 3 ¿47.4%; P = 0.001). Survival was influenced by the DFI after primary treatment (6-12 months ¿median, 25.0 months vs. 13-36 months ¿median, 44.4 months vs. > 36 months ¿median, 56.8 months; P = 0.005), the completeness of cytoreduction (visibly disease free ¿median, 44.4 months vs. any residual disease ¿median, 19.3 months; P = 0.007), the use of salvage chemotherapy before secondary surgery (chemotherapy given ¿median, 24.9 months vs. chemotherapy not given ¿median, 48.4 months; P = 0.005), and the largest size of recurrent tumor (< 10 cm ¿median, 37.3 months vs. > 10 cm ¿median, 35.6 months; P = 0.04).

CONCLUSIONS

Complete cytoreduction is possible for the majority of patients with recurrent epithelial ovarian carcinoma and maximizes survival if undertaken before salvage chemotherapy. The authors believe a randomized trial should be initiated to confirm these findings.

Phase II trial of intraperitoneal paclitaxel in carcinoma of the ovary, tube, and peritoneum: a Gynecologic Oncology Group Study

PURPOSE

To determine the response rate of intraperitoneal (i.p.) paclitaxel in patients with small-volume residual carcinomas of the ovary, fallopian tube, or peritoneum.

PATIENTS AND METHODS

Eligibility criteria included patients with one of the cancers noted above, with the largest residual disease 0.5 cm or less in maximum diameter at the end of second-look surgery, and prior treatment with systemic paclitaxel was permitted. The treatment plan was paclitaxel 60 mg/m2 i.p. weekly for 16 weeks, followed by surgical evaluation in patients without evidence of disease progression.

RESULTS

Of 80 patients entered onto the study, 76 were eligible, of whom 86% were considered to be potentially cisplatin-sensitive. Although five patients (7%) did not complete the first course of therapy because of catheter leakage or blockade, 53 patients (70%) received all 16 planned courses. Only 14 patients (18%) received fewer than 11 courses. Treatment was well tolerated, which included only moderate abdominal pain (grade 2, 12 patients; grade 3, one patient) and minimal neutropenia (grade 2, three patients; grade 3, one patient). Of 28 assessable patients with microscopic disease at the start of i.p. therapy, 17 patients (61%) achieved a surgically defined complete response (CR). Only one of 31 patients (3%) with any macroscopic disease achieved a CR. Of the eligible patients, 18 of 76 (24%) achieved a CR.

CONCLUSION

Salvage i.p. paclitaxel is tolerable and active in patients with microscopic residual disease. The impact of this treatment strategy on survival remains to be assessed in a phase III trial.

Flow cytometric analysis of lymph node metastases in advanced ovarian cancer: clinical and biologic significance

OBJECTIVE

This study was undertaken to evaluate the deoxyribonucleic acid content and S-phase fraction in advanced epithelial ovarian carcinomas to determine whether lymph node metastases are biologically distinct from peritoneal sites of metastases.

STUDY DESIGN

Thirty-five patients with stage III or IV epithelial ovarian cancer who had undergone complete pelvic and paraaortic lymphadenectomy had representative samples from the primary ovarian tumor, peritoneal metastases, and lymph node metastases analyzed by flow cytometry for deoxyribonucleic acid nuclear content and S-phase fraction.

RESULTS

Diploid cell lines are found in metastatic lymph nodes (52%) significantly more frequently than in peritoneal metastases (25%, p < 0.02) or in primary ovarian tumors (26%, p < 0.001). The ploidy category frequency distribution of peritoneal metastases mirrors that found in the primary tumor, and both are significantly different from the ploidy category frequency distribution found in metastatic lymph nodes. Heterogeneity among sites is common, being identified in 54% of patients. Peritoneal metastases are more likely to be concordant with the primary tumor (69%) than are lymph node metastases (39%, p < 0.001). Mean S-phase fraction did not differ overall by site but was significantly different between diploid and aneuploid samples by site. Diploid lymph node metastases were found to have the lowest mean S-phase fraction (7.2% +/- 3.3%), and aneuploid lymph node metastases had the highest mean S-phase fraction (22.3% +/- 10.2%). Diploidy of the primary tumor is a positive predictor of long-term survival. Tumoral heterogeneity and lymph node metastases are not related to survival in this group of patients who underwent therapeutic pelvic and aortic lymphadenectomy.

CONCLUSIONS

A high proportion of tumor deposits found in metastatic lymph nodes are diploid with a low S-phase fraction. Therapeutic pelvic and aortic lymph node dissection removes disease that, on the basis of flow cytometric characteristics, may be predicted to be resistant to chemotherapy and radiation therapy.

Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy

OBJECTIVE

The purpose of this study was to incorporate a wide range of operative laparoscopic techniques to complete a type III radical hysterectomy with aortic and pelvic lymphadenectomy.

STUDY DESIGN

A type III radical hysterectomy with bilateral aortic and pelvic lymph node dissection was separated into eight component parts: (1) right and left aortic lymphadenectomy, (2) right and left pelvic lymphadenectomy, (3) development of the paravesical and pararectal spaces, (4) ureteral dissection, (5) ligation and dissection of the uterine artery, (6) development of the vesicouterine and rectovaginal spaces, (7) resection of the parametria, and (8) resection of the upper vagina. The adequacy of the component parts was determined and documented on video.

RESULTS

Complete aortic and pelvic lymphadenectomy and a type III radical hysterectomy were performed by operative laparoscopy. Argon beam coagulation and countertraction facilitated pelvic and aortic lymph node dissection, including removal of nodal tissue lateral to the iliac vessels. Ureteral dissection with resection of the cervicovesical fascia ("the tunnel") was completed with right-angle dissectors, vascular clips, and argon-beam coagulation. Resection of the cardinal and ureterosacral ligaments was successful by use of Endo-GIA stapling instruments (United States Surgical Corporation, Norwalk, Ct.).

CONCLUSION

A complete pelvic and aortic lymphadenectomy and type III radical hysterectomy were performed laparoscopically. This approach could potentially decrease morbidity historically associated with radical hysterectomy and lymphadenectomy performed either abdominally or vaginally. Only prospective randomized trails will allow for the evaluation of potential benefits associated with this surgical technique.

Cost and quality-of-life analyses of surgery for early endometrial cancer: laparotomy versus laparoscopy

OBJECTIVE

The purpose of this study was to determine whether the cost or quality of life associated with surgical treatment of presumed early-stage endometrial cancer differed on the basis of the surgical approach.

STUDY DESIGN

A retrospective analysis was performed on a consecutive series of women with presumed early-stage endometrial cancer treated at the Women's Cancer Center of Northern California. The senior author was the surgeon, cosurgeon, or assistant on all cases. The women comprise two groups with different surgical approaches. The first group of 17 women underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and aortic lymphadenectomy. The second group of 13 women underwent the same surgery by laparoscopy. The two groups were compared with a two-tailed Student t test. Variables analyzed included age, height, weight, Quetelet index, and predisposing medical problems. Lymph node counts were compiled. Hospital costs were broken down into four cost categories: (1) operating room, (2) hospital bed, (3) pharmacy, and (4) anesthesia. A two-tailed Student t test was also used in this analysis. Issues examined regarding quality of life included (1) average hospital stay, (2) complications, and (3) time to return to normal activity.

RESULTS

The patient population differed significantly (p < 0.05) with regard to weight and Quetelet index. The laparotomy group required significantly longer hospitalization than the laparoscopy group (6.3 vs 2.4 days, p < 0.001), resulting in higher overall hospital costs ($19,158 vs $13,988, p < 0.05). Similarly, patients undergoing laparotomy took longer to return to normal activity (5.3 weeks vs 2.4 weeks, p < 0.0001).

CONCLUSION

Laparoscopic management of endometrial cancer may result in significant cost savings and improved quality of life as demonstrated by shortened hospital stays and an earlier return to normal activity.

Chemotherapy, early surgical reassessment, and hyperfractionated abdominal radiotherapy in stage III ovarian cancer: results of a gynecologic oncology group study

PURPOSE

To determine outcomes and treatment toxicities in patients with optimal (< or = 1 cm residual) Stage III ovarian carcinoma treated with three courses of cisplatin-cyclophosphamide, surgical reassessment (SRA), and hyperfractionated whole abdominal irradiation (WAI).

METHODS AND MATERIALS

Forty-two eligible patients entered this prospective Phase II study conducted by the Gynecologic Oncology Group (GOG). Disease characteristics were as follows: age range, 32-76 years (median 58); Stage IIIA (n = 1, 2%), IIIB (n = 2, 5%), IIIC (n = 39, 93%); histology-serous papillary (n = 21, 50%); other (n = 21, 50%); Grade 1 (n = 1, 2%); 2 (n = 14, 33%); 3 (n = 27, 54%); residual disease after initial surgery (present: n = 23, 55%; absent: n = 19, 45%). Five patients progressed while on chemotherapy, could not be effectively cytoreduced, and were not eligible for WAI. Of the remaining 37 patients, 35 received WAI. Surgical reassessment was not performed in five patients.

RESULTS

Of 37 patients with known SRA status after chemotherapy, 21 (57%) were grossly positive, 4 (11%) were microscopically positive, and 12 (32%) were negative. Based on measurements recorded following initial laparotomy and surgical reassessment, progression during chemotherapy was noted in 40%, stage disease in 37%, and objective response in 23%. Toxicity during hyperfractionated WAI was limited and reversible. No patient beginning WAI failed to complete or required a significant treatment break. Following WAI, six patients underwent laparotomies for abdominal symptoms; five had recurrent disease. Five additional patients were managed conservatively for small bowel obstruction (SBO) or malabsorption, of whom three subsequently developed recurrence. Twenty-two patients having pelvic boosts were significantly more likely to require management for gastrointestinal morbidity (p = 0.0021). Considering all eligible patients, median disease-free and overall survivals were 18.5 and 39 months, respectively. Considering patients completing chemotherapy and WAI, median disease-free and overall survivals were 24 and 46 months, respectively.

CONCLUSIONS

(a) Disease progression occurred within three cycles of cisplatin and cyclophosphamide chemotherapy in 40% of patients with optimal (< or = 1 cm residual) Stage III ovarian carcinoma. (b) Following limited chemotherapy, hyper-fractionated WAI was acutely well tolerated. (c) Late radiation-related toxicity was observed in only three patients (8.6%) in the absence of recurrent disease. Late gastrointestinal morbidity was significantly associated with the administration of a pelvic radiotherapy (RT) boost. (d) Short duration chemotherapy followed by SRA and hyperfractionated WAI without a pelvic boost is a promising management option for patients with optimal Stage III ovarian cancer. A Phase III trial will be necessary to determine how this treatment strategy compares with chemotherapy or RT alone in this patient population.

Laparoscopic bilateral pelvic and paraaortic lymph node sampling: an evolving technique

OBJECTIVE

Reports describing laparoscopic lymph node sampling in patients with gynecologic malignancies have yet to describe a method to sample left-sided aortic lymph nodes that has been successful in a large series of patients. We submit our experience with evolving techniques that allow for excellent visualization and resection of both left and right aortic and pelvic lymph nodes.

STUDY DESIGN

Forty patients with gynecologic malignancies underwent laparoscopy for surgical staging. Thirty-five of the patients were completely staged laparoscopically with minimal blood loss. The average number of lymph nodes sampled was 27.7 (range 14 to 35).

RESULTS

Five patients required laparotomy, two to control bleeding, two to remove unsuspected intraabdominal disease, and one because of equipment failure. Four patients were rehospitalized within 30 days of surgery, two with small bowel obstructions resulting from herniation of the intestine through 12 mm trocar sites and two others with deep vein thromboses.

CONCLUSION

These preliminary results demonstrate an ability to complete surgical staging in patients with gynecologic malignancies by means of specific endoscopic techniques. However, there remains a need for continued evaluation of these techniques and the associated morbidities.

Incisional bowel herniations after operative laparoscopy: a series of nineteen cases and review of the literature

OBJECTIVES

The objectives of this report were (1) to identify all cases of incisional bowel herniations noted after operative laparoscopy in 11 participating institutions and (2) to report the clinical details of such patients.

STUDY DESIGN

A retrospective case review was performed.

RESULTS

Nineteen cases of incisional bowel herniation were identified. The average age of the patients was 50.5 years. Initial laparoscopic procedures varied and included laparoscopically assisted vaginal hysterectomy (six patients), laparoscopically assisted vaginal hysterectomy with lymphadenectomy (five patients), oophorectomy (two patients), adhesiolysis (two patients), myomectomy (two patients), lymphadenectomy alone (one patient), and ovarian cystectomy (one patient). The average time to reoperation was 8.5 days.

CONCLUSIONS

Incisional bowel herniation is a serious complication of operative laparoscopy. Herniations occur through ports > or = mm in size at both umbilical and extraumbilical sites. New techniques are needed to avoid this serious complication.

Cytoreductive surgery in advanced epithelial cancer of the ovary: the impact of aortic and pelvic lymphadenectomy

Beginning in July 1988, a planned program was undertaken to assess the role of aortic and pelvic lymphadenectomy in patients with advanced epithelial cancer of the ovary (Stages IIIa-IVa) undergoing cytoreductive surgery. Our intent was to perform a complete aortic and pelvic lymphadenectomy in all patients in whom we could surgically remove all intra- or retroperitoneal disease measuring 1 cm or greater. Accordingly, 56/77 patients (73%) underwent complete aortic and pelvic lymphadenectomy. The remaining 21/77 patients (27%) did not, either because the lymphadenectomy would not have impacted on the patient's cytoreductive status or because intraoperative conditions precluded it. Positive lymph nodes were found in 36/56 patients (64%). Of these, 23/36 (64%) were macroscopically positive, and if left in situ would have affected the patient's cytoreductive status. Thirteen of 36 (36%) were positive microscopically. Reassessment laparotomy was performed in 44/56 (79%) of the patients having had a lymphadenectomy and is correlated to disease status. Median follow-up is 30 months (range 2-64 months). Survival analysis reveals: 10/20 patients (50%) with negative lymph nodes; 6/13 patients (46%) with microscopically positive lymph nodes; 10/23 patients (43%) with macroscopically positive, but surgically removed lymph nodes; and only 2/21 patients (10%) with residual disease measuring at least 1 cm in diameter are alive without evidence of disease. These preliminary findings suggest that the removal of macroscopically negative lymph nodes offers little benefit to the patient with advanced epithelial cancer and minimal residual (less than 1 cm) disease. However, the concept of cytoreductive surgery, whether it be intra- or retroperitoneal, appears to be validated by the fact that the patients undergoing removal of macroscopically positive lymph nodes have approximately the same chance of survival as those with microscopically positive and/or negative lymph nodes.

Laparoscopic staging of the patient with incompletely staged early adenocarcinoma of the endometrium

OBJECTIVE

To determine the feasibility of laparoscopic staging in patients with presumed early stage but incompletely surgically staged adenocarcinoma of the endometrium.

METHODS

Thirteen patients with incompletely staged adenocarcinoma of the endometrium underwent laparoscopic staging. The women ranged in age from 36-74 years (mean age 64) and weighed 132-201 lb (mean 147.5). The interval between hysterectomy and laparoscopic staging ranged from 14-63 days, for an average of 47. All patients underwent inspection of the entire intraperitoneal cavity, procurement of pelvic washings, and/or pelvic or para-aortic lymphadenectomy, and two patients had remaining ovaries removed.

RESULTS

Extrauterine disease was found in three patients: One had intraperitoneal washings positive for adenocarcinoma, and two had pelvic lymph nodes positive for microscopic carcinoma. The average number of lymph nodes removed was 17.5. There were no intraoperative complications. Estimated blood loss averaged less than 50 mL, and the mean hospital stay was 1.5 days.

CONCLUSION

Our initial experience indicates that this is a safe, effective procedure that offers a short hospital stay. We consider laparoscopic staging an attractive option for some patients with incompletely staged early adenocarcinoma of the endometrium.

The impact of subspecialty training on the management of advanced ovarian cancer

A retrospective study was conducted to determine the influence of subspecialty training in gynecologic oncology as well as several other covariates on the feasibility, operative mortality, and survival benefits of cytoreductive surgery for 263 patients with stages IIIC and IVA epithelial ovarian cancer. Covariates most predictive of an optimal (< or = 1 cm) cytoreductive outcome were the diameter of the largest metastases before cytoreduction (< or = 10 cm vs > 10 cm, P < 0.001) and the specialty training of the physicians present at surgery (gynecologic oncologists vs other, P < 0.001). Age influenced operative mortality most (< 60 vs > or = 60, P < 0.001). Covariates found to most significantly influence survival time include the specialty training of the physicians present at surgery (gynecologic oncologists vs other, P < 0.0001), cytoreductive outcome (complete vs optimal, P = 0.001, optimal vs suboptimal, P < 0.0001), grade of tumor (grade 1 vs grades 2 and 3, P = 0.01), and pelvic disease status (frozen pelvis vs mobile primary tumor, P = 0.03). We conclude that patients with advanced epithelial ovarian cancer should undergo aggressive cytoreductive surgery by gynecologic oncologists, with the objective to remove all macroscopic disease. Subsequent treatment with platinum-based chemotherapy offers the best chance for long-term survival or cure.

Critical reassessment of second-look exploratory laparotomy for epithelial ovarian carcinoma. Minimal diagnostic and therapeutic value in patients with persistent cancer

From 1979 to 1984, 88 women with epithelial ovarian cancer were treated with surgery and chemotherapy, achieved a clinical complete response, and then had "second-look" exploratory laparotomy to assess the pathologic status of their disease. Persistent cancer was found in 50 (57%) patients: 34 of 50 (68%) had gross tumor, which was larger than 2 cm in 12 (24%) and smaller than 2 cm in 22 (44%), and 16 (32%) had microscopic disease. Salvage therapy was as follows for these patients: whole abdominal irradiation, 29 (58%); chemotherapy, 17 (34%); intraperitoneal chromic phosphate, 1 (2%); and no further therapy, 3 (6%). With a follow-up time of 4 to 8 years, 7 (14%) patients are alive without evidence of cancer, 7 (14%) are alive with disease, 35 (70%) are dead of disease, and 1 (2%) has died of treatment complications. At 5 years, the relapse-free rate was 18% and the survival rate was 25%. Seventy-two parameters of suspected prognostic significance and 64 potential sites of tumor involvement were correlated with survival in a univariate analysis. The factors favorably affecting survival included the following: lower grade; microscopic tumor versus gross disease at second-look laparotomy; removal of the uterus; removal of the omentum; pelvic and paraaortic lymph node biopsy; negative results of a right diaphragm biopsy; and radiation therapy at Stanford University Medical Center, Stanford, California. There was no survival advantage for whole abdomen irradiation compared with chemotherapy or for the patients who had their disease successfully debulked at second-look laparotomy. The above factors and others were evaluated by multivariate regression. The best model (P = 0.000004) for predicting survival included largest tumor mass (P = 0.0002), operative blood loss (P = 0.002), perioperative blood transfusion (P = 0.003), and grade (P = 0.004). The detection of persistent ovarian cancer by second-look exploratory laparotomy should identify a subgroup of patients whose conditions can be salvaged by a second-line therapy. Unfortunately, that subgroup is small (8%) and an effective salvage therapy remains to be identified.

Sarcoid-like lesions associated with epithelial ovarian adenocarcinoma

A woman with poorly differentiated endometrioid adenocarcinoma of the ovary had sarcoid-like lesions in the bone marrow. Sarcoid-like lesions may be misinterpreted as metastatic disease, resulting in inappropriate modification of therapy.

The clinical significance of blood transfusion at the time of radical hysterectomy

A retrospective review was conducted to evaluate the clinical implications of perioperative blood transfusion in the surgical management of stage IB cervical cancer. The investigation focused on 126 patients treated with radical hysterectomy and retroperitoneal lymph node dissection who were found to have clear surgical margins, negative retroperitoneal lymph nodes, and no lymph-vascular space involvement in the hysterectomy specimen, and who had no perioperative radiation therapy, no history of immunosuppression with medication, and at least 18 months of follow-up. The distributions of age, weight, operative time, nodal yields, mean lesion diameters, median depths of invasion, and histologic subtypes were not statistically different between the transfused and untransfused groups. The average estimated blood loss among the transfused patients was 1104 mL, compared with 764 mL among the untransfused patients (P = .015). Among the 68 who received blood perioperatively, there were ten recurrences (14.7%), compared with two (3.4%) among the 58 patients who did not receive blood (P = .035). In this select population of patients, in which perioperative transfusion was isolated as a variable, transfusion adversely affected the outcome of surgical therapy.

Prospective randomized trial of topical alpha-interferon (alpha-interferon gels) for the treatment of vulvar intraepithelial neoplasia III

Twenty-one patients were prospectively randomized into a blinded double-armed crossover study comparing alpha-interferon (alpha-IFN, 10(6) IU in a 3.5% aqueous methylcellulose base) with and without 1% nonoxynol-9. Nine and twelve patients were randomized to arms with (+N) and without (-N) 1% nonoxynol-9, respectively. Patients applied the gel to affected areas every 8 hr and were evaluated biweekly. Including those crossed over, 14 patients were treated with -N. Six of fourteen (43%) achieved complete responses: biopsy proven with at least 1 year follow-up (CR). One patient achieved a partial response with at least a 50% reduction in the total surface area of all lesions present (PR). Similarly, 13 patients were treated with +N. Two patients in this group were found to have invasive cancer and one to have HIV and thus were eliminated from statistical analysis. Of the remaining 10 patients, 3 had CRs (30%), 5 had PRs (50%), and 2 failed to respond. There was no significant difference in responses between the two groups. Overall, 14 of 18 (67%) patients demonstrated some response to alpha-IFN applied topically. These data support the conclusion that alpha-IFN is an active agent in the treatment of vulvar intraepithelial neoplasia III.

Radiation therapy for primary squamous cell carcinoma of the vagina: Stanford University experience

A retrospective analysis of 38 patients with primary squamous cell carcinoma of the vagina seen at Stanford University Medical Center from 1958 to 1984 was undertaken. Patients were analyzed with regard to symptoms, stage, treatment techniques, survival, patterns of failure, and complications. Eighteen patients were classified as FIGO Stage I, 5 as Stage II, 10 as Stage III, and 5 as Stage IV. The 5-year disease-free survival was 94% in Stage I, 80% in Stage II, 50% in Stage III, and 0% in Stage IV. Five patients (13%) had eight major complications secondary to treatment. Only 2 of 23 patients with Stage I or Stage II disease developed a recurrence. There was a significant correlation between dose and response in patients treated with radiotherapy.

Needle catheter jejunostomy: a controlled, prospective, randomized trial in patients with gynecologic malignancy

Sixty patients with gynecologic cancer entered a prospective, randomized study of immediate postoperative feeding. Thirty-three women in the study group received an elemental diet (Vivonex HN) delivered through a needle catheter jejunostomy. Twenty-seven patients in the control group were given standard 5% dextrose and electrolyte solutions. Patients in both groups were stratified according to nutritional status as determined by anthropometric evaluation and levels of serum albumin, total protein, and transferrin. These parameters also were measured at intervals throughout the study. Only one catheter-related complication occurred. Patients in the study group received significantly more calories (p = 0.01) and were better able to maintain serum levels of transferrin (p = 0.05) than those in the control group. An elemental diet administered through the needle catheter jejunostomy effectively maintains postoperative nutrition and is associated with few complications.

Efficacy and safety of single-dose ceftizoxime vs. multiple-dose cefoxitin in preventing infection after vaginal hysterectomy

The efficacy, safety and effect of a single, 1-g dose of ceftizoxime on the return of vaginal flora were compared to those of the standard regimen of three 2-g doses of cefoxitin for prophylaxis in 99 randomized women undergoing vaginal hysterectomy. Thirty-four were studied in Dallas and 65 in Los Angeles. Surgical procedures were comparable for all the antibiotic groups, although proportionately more simple hysterectomies were performed in Dallas. The patients received a povidone-iodine vaginal preparation immediately before surgery; vaginal packs, when used, contained no antimicrobial agents. Primary prophylactic failure (operative site infection) occurred in 1 of 52 (1.9%) and 4 of 47 (8.5%) of the ceftizoxime- and cefoxitin-treated patients, respectively, for a nonsignificant difference. All five primary prophylactic failures occurred in the Los Angeles patients. One patient in each antibiotic group developed a urinary tract infection and was classified as a secondary prophylactic failure. Febrile morbidity, length of hospital stay and incidence of adverse effects did not differ by antibiotic. The enterococcus was commonly found in the postoperative vaginal flora and was of no value in predicting operative-site infection. Enterobacter species and Pseudomonas aeruginosa were isolated more commonly in patients who received cefoxitin. Diphtheroids, Staphylococcus epidermidis and Peptostreptococcus species were isolated more commonly in patients treated with ceftizoxime.(ABSTRACT TRUNCATED AT 250 WORDS)

A critical evaluation of the endocervical curettage

A prospective study was undertaken to critically evaluate the endocervical curettage. The study group consisted of 261 patients with colposcopically identifiable cervical lesions that had not been previously biopsied and were not macroscopically suspicious for invasive cancer. In 210 patients, the entire lesion, transformation zone, and squamocolumnar junction were visible (satisfactory colposcopy), and in 51 patients, the full extent of the lesion was not visualized colposcopically (unsatisfactory colposcopy). We used a method of examination not previously described. Colposcopy was performed before and after the endocervical curettage, but before the ectocervical biopsy. This method of examination allowed us to identify potentially contaminated endocervical curettages and to test the null hypothesis that a positive endocervical curettage in patients with satisfactory colposcopy is not the result of contamination. Twenty of 210 endocervical curettages in patients with satisfactory colposcopy were potentially contaminated, as suggested by an ectocervical lesion disrupted by the endocervical curettage. No patient with a positive endocervical curettage had an intact ectocervical lesion. Therefore, the null hypothesis was rejected (P less than .005). Of the 51 patients with unsatisfactory colposcopy, 39 (76%) underwent cone biopsy. Invasive cancer was diagnosed by cone biopsy in two patients when both ectocervical biopsy and endocervical curettage demonstrated only dysplasia. We also confirmed that patients with unsatisfactory colposcopy occasionally benefit from having an endocervical curettage. However, basing the treatment plan for any lesion short of invasive cancer solely on the results of colposcopy, ectocervical biopsy, and/or endocervical curettage could lead to significant undertreatment of some patients.

The use of vascular clips to minimize blood loss in colpourethropexy

A serious intraoperative and postoperative complication associated with colpourethropexy as described by Burch and Tanagho and others is hemorrhage. We performed the Tanagho modification of the Burch procedure in 13 patients, as the sole procedure in the treatment of genuine stress incontinence. Vascular clips were used to circumscribe the fat overlying the anterior part of the vaginal wall, thereby allowing en bloc resection of the vascular fat pad. Suspensory sutures of 1-0 Vicryl (polyglactin 910) were placed; no retroperitoneal drains were used. The blood loss was estimated to be less than 50 milliliters in ten instances and less than 75 milliliters in three. The average hospital stay was 4.2 days. All of the patients were given antibiotic prophylaxis and were discharged home with suprapubic drainage of the bladder. There were no intraoperative or postoperative complications. Thus, one of the serious complications of colpourethropexy can be avoided by using vascular clips to facilitate the removal of the periurethral and paravesical fat from the anterior part of the vaginal wall.

Resumption of ovulation after ectopic pregnancy

Forty-four patients with ectopic pregnancies were followed with serial serum progesterone determinations for up to 40 days after surgery. Seven patients (16%) failed to show luteal function during the study. Thirty-seven (84%) demonstrated luteal activity (serum progesterone at least 3 ng/mL): in six patients by days 17-19, in 50% by day 24, and in 72% by day 30. Because hormonal contraception delayed until the first postoperative office visit would miss the onset of folliculogenesis in approximately three-quarters of ectopic pregnancies, contraception should be begun immediately after surgery.