Can We Improve the Quality of Care Delivered to Cervical Cancer Patients? Development of Quality Metrics and Quality Improvement Program at a Single Institution

PURPOSE/OBJECTIVE(S)

Cervical cancer patients often face significant barriers to receiving high quality, multi-disciplinary standard of care therapy due to socio-economic factors and failures in the health care system. Other cancers, such as rectal cancer, requiring complex multi-disciplinary care, have shown improved outcomes with the use of standardized quality metrics. We hypothesized that developing evidence-based quality metrics for cervical cancer and tracking adherence in a large tertiary care medical system would allow identification of systemic issues that can then be addressed to improve quality of care and patient outcomes. We also implemented a weekly cervical cancer huddle in September 2021 attended by a physician, nurse practitioner, social workers, and other caregivers to discuss all newly diagnosed patients prior to treatment with a focus on improving quality in real time. Here we report our initial results.

MATERIALS/METHODS

AnIRB-approved retrospective review of cervical cancer patients treated at our institution from January 2019 to December 2022 was performed using a data collection web application. We assessed quality metrics in newly diagnosed patients including: tumor board presentation, outside pathology review, receipt of PET-CT/MRI prior to treatment start, use of radiology and pathology synoptic reports, receipt of external beam radiation and brachytherapy, completion of chemotherapy and radiation within 56 days, receipt of post-treatment PET-CT, referral to social work, and laparotomy for radical hysterectomy. In addition, we tracked the impact of the "huddle" on pre-treatment quality metrics before and after implementation.

RESULTS

One hundred seventy-three patients were identified with newly diagnosed cervical cancer; most were squamous cell carcinoma (61%). 44% were stage I, 39% stage II or III, and 16% stage IV. Over the entire study period, 65% of patients completed imaging prior to treatment start, 73% had a radiology synoptic report on MRI, 71% of hysterectomy patients had pathology synoptic reports, 90% of eligible patients had receipt of both external beam radiation and brachytherapy, 91% of eligible patients had completion of chemotherapy and radiation within 56 days, and 96% had a post-treatment PET-CT within 3-6 months. The impact of the huddle on pre-treatment quality metrics was evident: tumor board presentation increased from 38% to 73%, social work referral increased from 42% to 59%, outside pathology review increased from 64% to 83%, and use of laparotomy increased from 67% to 81%.

CONCLUSION

Definingquality metrics in cervical cancer and tracking adherence can help identify areas of improvement in the continuum of care in a large healthcare system. A dedicated weekly huddle can help reduce barriers to diagnosis and initiation of treatment with earlier and increased referral to social work and increased multi-disciplinary review and discussion that can affect patient treatment and subsequent outcomes. Future work will focus on implementation of systemic processes to improve adherence to metrics.

Hyperthermic Intra-Thoracic Chemotherapy (HITeC) for the management of recurrent ovarian cancer involving the pleural cavity

•Intra-thoracic chemotherapy is an option for heavily pre-treated patients with recurrent ovarian cancer.•HITeC is technically feasible and well tolerated.

Self-efficacy, quality of life, and weight loss in overweight/obese endometrial cancer survivors (SUCCEED): a randomized controlled trial

OBJECTIVE

More patient-centered programming is essential for endometrial cancer (EC) survivors needing to lose weight to reduce cardiovascular disease risk (CVD). The purpose of this study was to improve self-efficacy (SE) and quality of life (QOL) using a lifestyle intervention program designed for weight loss.

METHODS

Overweight and obese early-stage EC survivors, n = 75, were randomized into two groups: 1) Survivors of Uterine Cancer Empowered by Exercise and Healthy Diet (SUCCEED), a six-month lifestyle intervention or 2) a usual care group (UC). Participants completed the Weight Efficacy Lifestyle Questionnaire (WEL) to assess SE and the Functional Assessment of Cancer Therapy-General (FACT-G) to measure QOL, and their body mass index (BMI) was calculated at baseline, 3, 6, and 12 months. Mixed, repeated-measures ANCOVA models with baseline covariates were employed using SPSS 20.0.

RESULTS

Positive effects in every WEL domain, including the total score, were statistically significant in the SUCCEED group versus the UC group. A linear regression model demonstrated that, if BMI decreased by 1 unit, the total WEL score increased by 4.49 points. Significant negative correlations were found in the total WEL score and a change in BMI of R = -0.356 (p = 0.006). Between-group differences in the FACT-G were significant from baseline in the fatigue domain at three months (p = .008) and in the physical domain at six months (p = .048). No other significant differences were found.

CONCLUSION

Overall, this study shows promise for targeted interventions to help improve SE, thus improving BMI.

A double-blind randomized trial of pyridoxine versus placebo for the prevention of pegylated liposomal doxorubicin hydrochloride-related palmar-plantar erythrodysesthesia

5594

Background: To compare the efficacy of pyridoxine versus placebo in the prevention of palmar-plantar erythrodysesthesia (PPE) and on quality of life (QOL) in patients treated with pegylated liposomal doxorubicin hydrochloride for ovarian, breast, or endometrial cancer. Methods: All patients received pegylated liposomal doxorubicin hydrochloride 40 mg/m2 IV q 4 weeks over 1 hour every 28 days for a maximum of 6 cycles. Patients received pyridoxine 100 mg (group A) by mouth or placebo (group B) twice daily. Nurses conducted standard PPE education for all patients. Patients with Grade 2 or 3 PPE that persisted despite dose reductions/delays were unblinded, and were given pyridoxine if taking placebo. Patients completed the Functional Assessment of Cancer Therapy (FACT) assessment tool. Analyses were conducted by group and comparisons were also made between patients who experienced grade 2/3 PPE versus grade 0/1. Chi-square or Fisher's exact test were used. Results: Thirty-four patients were enrolled with 18 randomized to group A and 16 to group B. Mean age was 64 years (SD=9.6; range 45–81 years). Five patients (group A, 3; group B, 2) were unevaluable (due to pegylated liposomal doxorubicin hydrochloride reaction during first chemotherapy cycle). Overall 15/29 (52%) patients had incidence of PPE (all grades), with 10/29 (34%) having grade 2/3 events (no grade 4 events observed). In group A, 8/15 (53%) patients had a PPE event and 7/14 (50%) in group B; p=0.857. For grade 2/3 events, there was no difference as 6/15 (40%) occurred in group A and 4/14 (29%) in group B; p=0.70. There were no differences in global or domain QOL scores between those patients with Grade 2/3 PPE versus Grade 0/1. Less than half [4/10 (40%)] of patients with Grade 2/3 PPE reported being bothered by side effects of pegylated liposomal doxorubicin hydrochloride treatment. Conclusions: As administered in this study, pyridoxine did not prevent PPE in patients treated with pegylated liposomal doxorubicin hydrochloride. Quality of life differences were not observed; however, not all patients with PPE reported being bothered by side effects of pegylated liposomal doxorubicin hydrochloride treatment. Pyridoxine is not indicated for prevention of PPE during chemotherapy.

[Table: see text]

[Table: see text]

Endometrial cancer survivorship in obese patients: A lifestyle intervention program

5596

Background: The majority of early stage endometrial cancer (EC) survivors are obese, have cardiovascular disease and are at significant risk of death from causes other than cancer. The purpose of this study was to examine outcomes at 6 and 12 months in obese EC survivors enrolled in a randomized trial of a nutrition and exercise counseling program. Methods: Patients (pts) with early stage (I or II) EC with a body mass index ≥ 25 diagnosed from 1999–2005 were invited to participate. The intervention (I) group received 6 months of nutritional and exercise counseling while the control (C) group received an informational brochure only. Primary outcome variable was weight loss. Quality of life (QoL) was measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and Medical Outcomes Short-form (SF-36) survey. Exercise [leisure score index (LSI)] and eating patterns (quantitative food records) were assessed at baseline, 3, 6 and 12 mos. Repeated measures ANOVA and independent samples t-test were used for analysis. A sample size of 50 pts with a type1=0.05 and type 2=0.20 error rate was used to test the hypothesis that pts in the I group would lose weight as compared to the C group. Results: 45 pts were enrolled and 23 were randomized to I and 22 to the C group, stratified by BMI. Baseline QoL was decreased in morbidly obese pts (BMI ≥ 40) as compared to pts with a BMI < 40 (FACT-G: 78.0 vs. 83.7; p=0.140; physical SF-36: 40.6 vs. 49.1 p=0.008). Women in the I group lost weight and increased exercise over the 12 mos as compared to controls ( Table ). Repeated measures ANOVA demonstrated a borderline significant interaction effect for weight (F=2.7, p=.074) and a significant interaction effect for exercise (F=5.0; p=.005) over time. The I group had lower intake of calories and total fat during the intervention. Conclusions: Obese EC survivors can undergo and maintain positive lifestyle changes. Future studies will examine long-term changes in co-morbidities and mortality.

[Table: see text]

No significant financial relationships to disclose.

Hepatitis C virus: immunosuppression by complement regulatory pathway

Hepatitis C virus (HCV) infection in humans is almost invariably associated with viral persistence and chronic hepatitis. HCV-induced chronic hepatitis is a major risk factor for the development of hepatocellular carcinoma. The high incidence of HCV persistence suggests that this virus has evolved one or more mechanisms to evade and possibly suppress host immune responses. To understand the mechanism(s) involved in the establishment of HCV persistence, we have identified an HCV core protein as an immunomodulatory molecule to suppress host immune response. We have further determined a molecular mechanism of HCV core-mediated immune suppression by searching for a potential host protein(s) capable of associating with the HCV core protein. Interestingly, the Clq complement receptor, gC1qR, can bind to the HCV core. Clq is a ligand of gClqR and is involved in the early defense against viral infection as well as regulation of adaptive immune response. Similar to Clq, the HCV core can inhibit human T-lymphocyte proliferative response through its interaction with the gC1qR. It implicates that HCV core/gClqR-induced immune suppression may play a critical role in the establishment of persistent infection.

A phase II trial of docetaxel for peripheral blood stem cell mobilization for patients with breast cancer and ovarian cancer

As docetaxel is known to have significant antineoplastic activity against breast and ovarian cancer, we explored its application as a peripheral blood stem cell mobilizing agent in 33 women with stage lll-IV ovarian carcinoma (n = 10) or stage ll-lV breast cancer (n = 23) who were in preparation for high-dose chemotherapy. Eleven patients had bone and/or bone marrow involvement with their disease. The median number of prior regimens received before mobilization was two (range 1-3). The three dose levels administered were 100 mg/m(2), 110 mg/m(2) and 120 mg/m(2). Patients received one dose of docetaxel in the outpatient setting followed by G-CSF (10 microg/kg/day) starting 4 days after docetaxel administration. Leukapheresis commenced when WBC >1.0 x 10(9)/l or when the WBC began to rise after reaching a nadir. Ninety-seven percent of patients began leukapheresis within 7-9 days after receiving docetaxel (range 7-10 days). The collection goal was >/=2 x 10(6) CD34(+) cells/kg. Twenty-seven (82%) patients reached this goal in a median of 2 leukapheresis days (range 1-3). No grade 2-4 nonhematologic toxicities were noted. Thirteen patients (55%) showed a WBC nadir >1.0 x 10(9)/l. None of the patients experienced neutropenic fever or required blood or platelet transfusion support. In conclusion, docetaxel + G-CSF is an effective, well-tolerated regimen for PBPC mobilization which can be safely administered in the outpatient setting with minimal toxicity.

Synchronous ovarian and endometrial malignancies

Synchronous ovarian primaries are infrequently found in patients with endometrial cancer. Although numerous investigators have examined the characteristics of these women, most include patients with tumors of similar histology, which may simply represent ovarian metastases. To overcome this problem, we present here patients found to have tumors of dissimilar histology. Of 499 patients with endometrial cancer undergoing primary surgery between 1980 and 1997, 18 (3.6%) were found to have endometrial and ovarian primaries of dissimilar histology. The median age was 64.2 years. Most had stage I, grades I and II, minimally invasive endometrial adenocarcinomas and stage IA mucinous or serous ovarian cystadenocarcinomas. Most ovarian tumors were either borderline or grades I and II. The 5-year actuarial disease-free (DFS) and cause-specific survivals of the entire group were 81.2% and 89.5%, respectively. Those with both stage I ovarian and endometrial primaries had a trend to a better DFS (100 versus 68.6%, p = 0.07) than did women with higher stage disease. Our data demonstrate that synchronous ovarian primaries of dissimilar histology are infrequently found in women undergoing surgery for endometrial cancer. These women seek treatment at a relatively advanced age, and have early-stage, low grade disease in both sites. Their outcome is favorable, particularly those with stage I disease in both sites.

Age as a prognostic factor for recurrence in patients with endometrial carcinoma

PURPOSE

The aim of this study was to evaluate age as a prognostic factor for recurrence in endometrial cancer patients treated with primary surgery.

METHODS

Between 1983 and 1998, 455 endometrial cancer patients underwent primary surgery at our institution. Patients were divided into three age groups based on age at diagnosis: Group A (age <60, n = 156), B (age 60-69, n = 147), and C (age >/=70, n = 152). Clinicopathologic, treatment factors, and outcome were compared among the three groups. Prognostic factors were evaluated by univariate and multivariate analysis.

RESULTS

The three age groups had a similar distribution of most pathologic features including stage, histology, cervical involvement, positive cytology, adnexal involvement, nodal metastases, serosal involvement, and lymphovascular invasion (LVI). Older women had a higher rate, however, of deep (>1/2) myometrial invasion (P < 0.0001) and grade 3 tumors (P < 0.0001). The extent of surgical staging and use of adjuvant radiation therapy were similar. Five-year disease-free survivals (DFS) of Groups A, B, and C were 74.3, 70.2, and 60.3%, respectively (P = 0.08). A significant difference in DFS was seen when Groups A and B were combined and compared with Group C (72.0 vs 60.3%, P = 0.03). Multivariate analysis confirmed the significance of race, stage, grade, and LVI. Age was not found to be associated with recurrence (HR 1.1, 95% C.I. 0.91-1.5, P = 0.21).

CONCLUSION

Our results reveal that, in a large cohort of comparably staged and treated endometrial carcinoma patients, age is not a prognostic factor for recurrence.

Characteristics and outcome of endometrial carcinoma patients age 45 years and younger

Recent reports have suggested that the pathologic features of young patients with endometrial cancer are less favorable than previously thought. We retrospectively reviewed the characteristics and outcome of young patients with endometrial cancer at our institution. A total of 457 surgically staged patients were divided in 2 groups: Group A (age < or =45 years, n = 41) and B (age >45, n = 416). Groups A and B had a similar distribution of tumor stage, grade, histology, lymphovascular invasion, synchronous ovarian primaries, and positive cytology. Although group A tumors had less myometrial invasion (MI) (p = 0.004) and were lower grade (p = 0.06), a trend to more frequent nodal involvement was seen in group A women (p = 0.09). Adverse pathologic features, in particular deep MI, were more common in group A patients older than age 40. Group A patients had a disease-free (p = 0.56) and cause-specific (p = (0.26) survival that was similar to that of group B patients. Young patients with endometrial cancer have a distribution of most pathologic features and equivalent outcome similar to that of older women. However, adverse features are not equally distributed in young women. A discordance may also exist between MI, grade, and nodal involvement.

Phase I study of paclitaxel, carboplatin, and increasing days of prolonged oral etoposide in ovarian, peritoneal, and tubal carcinoma: a gynecologic oncology group study

PURPOSE

Given the activity of prolonged oral etoposide in platinum and paclitaxel-resistant ovarian carcinoma, a phase I trial was conducted that combined increasing days of oral etoposide therapy with paclitaxel and carboplatin in chemotherapy-naive patients with ovarian peritoneal and tubal carcinoma to establish a maximum-tolerated dose (MTD) of this combination.

PATIENTS AND METHODS

Paclitaxel at 175 mg/m(2) given over 3 hours and carboplatin at an area under the curve of 5 were administered on day 1 followed by oral etoposide 50 mg/m(2)/d beginning on day 2. The number of days of etoposide therapy was escalated on the basis of toxicity. Toxicity end points included neutropenic sepsis, grade 4 thrombocytopenia, or grade 3 neutropenia or thrombocytopenia during etoposide administration. Cycles were repeated every 21 days for a maximum of six courses. Due to hematologic toxicity, the duration of the paclitaxel infusion was decreased to 1 hour for a second stage of accrual.

RESULTS

Of 52 patients studied, 29 were in the first stage of accrual. Dose-limiting toxicity occurred with 8 days of oral etoposide, making the MTD six days of therapy. Twenty-three patients were entered into the second stage of accrual. Dose-limiting toxicity occurred at 12 days of oral etoposide, making the MTD 10 days of therapy. Three patients developed acute myeloid leukemia 16, 27, and 35 months after receiving a cumulative dose of 200 mg/m(2), 1,200 mg/m(2), and 2,400 mg/m(2), respectively.

CONCLUSION

One-hour paclitaxel, carboplatin, and oral etoposide at 50 mg/m(2)/d for 10 days is tolerable without supportive therapy. The leukemogenic potential is cause for concern and precludes its use in chemotherapy-naive ovarian carcinoma.

Phase II evaluation of 24-h continuous infusion topotecan in recurrent, potentially platinum-sensitive ovarian cancer: A Gynecologic Oncology Group study

OBJECTIVES

The aim of this study was to develop an alternative effective and more convenient administration schedule for intravenous topotecan when used as palliative treatment in ovarian cancer.

METHODS

The Gynecologic Oncology Group conducted a Phase II trial of 24-h infusional topotecan (8.5 mg/m(2)) with treatment repeated every 3 weeks in 29 patients with platinum-sensitive recurrent ovarian cancer (prior response to platinum-based chemotherapy with a minimum treatment-free interval >/=6 months).

RESULTS

The major toxicities of therapy were grade 4 neutropenia and thrombocytopenia which developed in 86 and 14% of patients, respectively. Other severe side effects were uncommon. Only 2 partial responses (7%) were observed in the 28 patients evaluable for response.

CONCLUSIONS

Despite the relatively favorable ovarian cancer patient population treated in this trial (platinum-sensitive recurrent disease), the response rate was disappointingly low. Considering the three- to fivefold higher objective response rates observed in other trials employing topotecan in individuals with platinum-sensitive ovarian cancer utilizing a 5-day treatment program (delivered every 3 weeks), the results of the current study provide strong support for the conclusion that clinically relevant antineoplastic activity of this agent is highly schedule dependent.

Acute problems during low-dose-rate intracavitary brachytherapy for cervical carcinoma

OBJECTIVE

To estimate the incidence and severity of problems arising during the hospitalization of cervical carcinoma patients undergoing low-dose-rate intracavitary brachytherapy (ICB).

METHODS

One hundred seventy ICB implants in 128 cervical carcinoma patients undergoing curative radiation therapy were reviewed. All events during the hospitalization requiring physician evaluation and/or intervention were scored as a "problem" and divided into 10 categories (fever/infection, pain, gastrointestinal, renal, pulmonary, cardiac, dermatologic, gynecologic, endocrinologic, psychiatric). Problems were scored as mild (no significant morbidity, therapy not discontinued), moderate (therapy discontinued but no significant morbidity), or severe (significant morbidity or mortality). Patient and treatment factors were correlated with acute problems.

RESULTS

Forty-two implants (24.7%) were associated with acute problems (95% minor, 5% moderate, 0% severe). The most common types were fever/infection (14.1%) and gastrointestinal problems (5. 9%). Other problem types occurred in <3% of implants. No patient or treatment factor including age, comorbid disease, weight, implant duration, or anesthesia type was significantly correlated with acute problems. Patients who developed acute problems had a survival (P = 0.21) and risk of late sequelae (P = 0.74) similar to those of patients without acute problems.

CONCLUSION

Problems occur during the hospitalization in approximately one-quarter of cervical carcinoma patients undergoing low-dose-rate ICB. However, most are minor and do not result in morbidity, require discontinuation of therapy, or adversely impact on outcome.

Identification of benzo[a]pyrene metabolites in cervical mucus and DNA adducts in cervical tissues in humans by gas chromatography-mass spectrometry

Epidemiological studies indicate that cigarette smoking increases the risk of cervical cancer. To address questions regarding possible mechanisms of tobacco-related cervical carcinogenesis, in a pilot study, using supercritical fluid extraction and a gas chromatographic-mass spectrometric (GC-MS) technique, we detected and characterized benzo[a]pyrene and its metabolites, namely B[a]P-dihydrodiols, phenols and tetraols in cervical mucus samples from eight smokers and non-smokers. Twenty-eight epithelial and stromal cervical tissue samples from seventeen patients undergoing surgery for non-malignant disease were quantitatively analyzed for BPDE-DNA adducts by a GC-MS technique. BPDE-DNA adducts were found in 25 samples. The mean level of BPDE-DNA adducts in epithelial cervical tissues of smokers was nearly two-fold greater than that in self-reported non-smokers; P = 0.02. The mean number of BPDE-adducts (+/- SD) in epithelial cervical tissues of smokers was 3.5 +/- 1.06 adducts/10(8) nucleotides while that in non-smokers was 1.8 +/- 0.96 adducts/10(8) nucleotides. The mean number of BPDE-DNA adducts in stromal cervical tissues of the same subjects was 1.8 +/- 0.96 adducts/10(8) nucleotides in smokers and that in the stromal tissues of non-smokers was 1.4 +/- 1.1 adducts/10(8). These results suggest that polynuclear aromatic hydrocarbons (PAHs) from tobacco smoke and other environmental sources can be transported to the cervix where they are metabolized in the cervical epithelium to ultimate carcinogenic agents, although transport of ultimate carcinogenic metabolites from other organs to the cervix cannot be ruled out. Exposure of cervical epithelia to PAHs and their carcinogenic metabolites suggests a potential role of such carcinogens in the pathogenesis of cervical cancer in humans.

Comparative response of normal and of human papillomavirus-16 immortalized human epithelial cervical cells to benzo[a]pyrene

Laboratory evidence suggests synergism of human papillomavirus (HPV) infection with cigarette smoking behaviors in enhancing the risk of cervical cancer. In this preliminary investigation, we tested the hypothesis that HPV infection may alter the metabolic activation of tobacco smoke carcinogens, such as benzo[a]pyrene (B[a]P), thereby playing a role in the etiology of cervical cancer. We examined in vitro the metabolism and DNA adduct formation of [3H]B[a]P in normal and HPV-16 immortalized human epithelial cervical cells in culture, and investigated the effect of [3H]B[a]P on growth of these cells. Cultures of normal human cervical cells and of HPV-16 immortalized cervical epithelial cells were exposed to 0.2 microM [3H]B[a]P for 24 and 48 h. [3H]B[a]P inhibited growth of both normal and HPV-16 immortalized cervical cells. However, the growth inhibition of normal cells was more profound than that of HPV-16 immortalized cells. Comparison of the metabolism of [3H]B[a]P in these cells indicated that they both metabolize [3H]B[a]P predominantly to [3H]trans-9,10-dihydroxy-9,10-dihydrobenzo[a]pyrene ([3H]B[a]P-9, 10-diol), [3H]r-7,t-8, 9,c-10-tetrahydroxy-7,8,9, 10-tetrahydrobenzo[a]pyrene ([3H]trans-anti-B[a]P-tetraol), and unknown polar products. Enzymatic hydrolysis of water-soluble metabolites indicated that the levels of glucuronide and sulfate conjugates in these cells are negligible. Similarly, both cell lines form similar [3H]B[a]P-DNA adducts. However, the level of the (+)[3H] anti-B[a]P diol epoxide (BPDE)-deoxyguanosine adduct in HPV-16 immortalized cells after 24 and 48 h exposures was 3.8 and 3. 1 pmol/mg DNA, respectively, which is 2.2-fold and 2.6-fold greater than the level of this adduct in normal cells. Under the conditions and within the time frame employed in these assays, both the cell growth and DNA damage induced by [3H]B[a]P appear to be higher in HPV-16 immortalized cells than those detected in normal cells. The results, although preliminary, suggest that HPV-16 immortalized cervical cells are more susceptible to DNA damage by BaP which, in part, may enhance their transformation to malignant cells.

Surgery and postoperative radiation therapy in stage II endometrial carcinoma

The traditional approach to patients with stage II endometrial carcinoma is preoperative radiation therapy (RT) followed by surgery. Currently, many patients are treated with primary surgery and postoperative RT. We retrospectively reviewed the outcome of 44 stage II (32 IIA, 12 IIB) patients who underwent surgery and postoperative RT. Nine (20%) had microscopic cervical involvement noted before surgery, and 35 (80%) had occult involvement noted postoperatively. Postoperative RT consisted of whole pelvic RT (WPRT) (50%), vaginal brachytherapy (VB) (18%), or both (32%). At a median follow-up of 40 months, the 5-year actuarial disease-free survival was 72.4%. Two patients (4%) had recurrence in the pelvis (one vagina, one lateral pelvis). Eighteen stage IIA patients treated with WPRT alone and eight stage IIA patients, without deep myometrial invasion (MI), were treated with VB alone, and remained controlled in the pelvis. Extrapelvic recurrences occurred in 12 patients (25%), primarily in those with deep MI and/or grade 2-3 disease. Our results suggest that patients with stage II endometrial carcinoma with microscopic or occult cervical involvement treated with surgery and postoperative RT have a favorable outcome. A high rate of pelvic control is achieved with RT tailored to the pathologic findings.

The significance of adnexal involvement in endometrial carcinoma

OBJECTIVE

To evaluate the prognostic significance of and predictive factors for adnexal involvement (AI) in patients with endometrial carcinoma.

METHODS

We retrospectively reviewed the pathological features and outcomes of endometrial carcinoma patients. The prognostic significance of AI was examined by univariate and multivariate analyses. Median follow-up was 30.7 months.

RESULTS

Of the 382 cases reviewed, 40 (10.5%) had AI. Patients with AI had a worse 5-year disease-free (DFS) survival (73.1 vs 37.1%, P < 0.0001) than patients without AI. However, patients with AI had multiple adverse features, including high grade disease, lymphovascular invasion, and additional sites of extrauterine disease. After controlling for these factors on multivariate analysis, AI lost its prognostic significance (P = 0.56). The 12 AI patients without other extrauterine disease had a favorable outcome (5-year DFS of 70.9%). Factors predictive of AI on logistic regression were metastatic disease, positive peritoneal washings, cervical involvement, and unfavorable histology.

CONCLUSION

Endometrial carcinoma patients with AI have relatively poor prognoses. However, AI per se has little, if any, independent prognostic significance. The poor outcomes seen in these patients appear to result from the preponderance of other adverse pathologic factors.

External pelvic radiation therapy in stage IC endometrial carcinoma

OBJECTIVE

To evaluate outcomes of patients with stage IC endometrial carcinoma treated with external whole pelvic radiation but not vaginal brachytherapy.

METHODS

Sixty-one women with stage IC endometrial carcinoma had postoperative pelvic radiation without vaginal brachytherapy. The median age was 69 years (range 44-87 years). Most subjects had histologic findings of adenocarcinoma (71%) and grade 2 or 3 disease (74%). The median pelvic irradiation dose was 48.6 Gy (range 43.2-50.4 Gy). No patients received adjuvant chemotherapy or hormonal therapy. The median follow-up time was 69.5 months (range 7-196 months).

RESULTS

The 5-year actuarial disease-free and overall survivals of the entire group were 86.7% and 97.6%, respectively. No patient developed local (vaginal) recurrence. One patient had recurrent disease in the lateral pelvis. Ten patients (16.4%) had distant (extrapelvic) metastases. No serious sequelae were noted, including vaginal necrosis, small bowel obstruction, proctitis, or fistulae.

CONCLUSION

Local control was excellent in stage IC endometrial carcinoma treated with adjuvant radiation therapy alone. Attention needs to be focused on efforts to control extrapelvic recurrence in patients with this disease.

Preoperative intracavitary brachytherapy in early-stage cervical carcinoma

Local failure within the central pelvis is a common site of recurrence in patients with early stage cervical carcinoma who experience recurrence after radical hysterectomy and pelvic lymphadenectomy. To reduce the risk of local failure, the authors treated selected patients with early stage cervical carcinoma with a moderate dose (45 Gy) of preoperative intracavitary brachytherapy before radical hysterectomy and pelvic lymphadenectomy. Given the low risk of recurrence in patients with small (<2 cm) tumors, the authors included only patients with tumors 2 cm or more in size. Forty-three patients (37 with stage IB disease, six with stage IIA disease) were treated from 1986 through 1995. Forty-two completed intracavitary brachytherapy; intracavitary brachytherapy was stopped early in one patient secondary to a low-grade fever. Exploratory laparotomy and planned radical hysterectomy were performed 2 weeks later. Radical hysterectomy was aborted in patients found to have extrauterine disease. At a median follow-up of 45 months, only one local failure has been noted, which occurred in the patient unable to complete intracavitary brachytherapy as planned. The most significant factor correlated with poor outcome was nodal involvement (p < 0.0004). A trend to a better disease-free survival was seen in patients with no residual or only microscopically residual disease. No patients developed significant chronic bowel or bladder toxicity, including fistulae. The results suggest that preoperative intracavitary brachytherapy in selected patients with early stage cervical carcinoma is a promising approach and is associated with a high rate of local control without significant adverse sequelae. Further data is needed to determine whether this approach improves the long-term outcome of these patients.

Biological characteristics of myelodysplastic syndrome patients who demonstrated high versus no intramedullary apoptosis

Spontaneous intramedullary apoptosis was measured in bone marrow (BM) biopsies of 175 patients with myelodysplastic syndromes (MDS) using in situ end-labeling (ISEL) of fragmented DNA. Two groups of high (n=71) versus low (n =43) levels of apoptosis were identified while 61 patients were ISEL-negative. Semiquantitative assessment of 3 cytokines, the number of macrophages and in vivo labeling indices (LI) were also determined from consecutive sections of the biopsy. Patients with high apoptosis levels tended to have a high LI (p=0.013), more macrophages in their BM biopsies (p=0.006) and higher tumor necrosis factor alpha (TNF-alpha) levels (not significant) compared to patients with no apoptosis. In addition, low risk MDS patients had significantly lower rates of apoptosis (p = 0.047) and lower levels of TNF-alpha (p = 0.055) compared to high-risk MDS patients. We conclude that the genesis of cytopenias in MDS is of multifactorial origin and that cytokine-associated apoptosis clearly identifies a distinct biological subgroup of patients who may benefit selectively by use of anti-cytokine therapies.

Phase I trial of concomitant chemoradiotherapy for cervical cancer and other advanced pelvic malignancies

Purpose. The aim of this study was to determine the feasibility and toxicity of concomitant hydroxyurea (HU) and escalating doses of 5-fluorouracil (5-FU) in locally advanced cervical cancer and other pelvic malignancies undergoing radiation therapy (RT). Methods. Treatment consisted of 5-FU, HU, and pelvic RT delivered in an alternate-week fashion. 5-FU was administered as a continuous intravenous infusion at a starting dose of 600 mg/m2/day and was escalated to 1000 mg/m2/day in cohorts of three patients. The HU dose was 500 mg twice daily. Chemoradiotherapy was administered on a 5-day cycle. Following a 9-day rest, the cycle was repeated until the completion of the pelvic RT. Results. Twenty-one patients (18 cervix, 1 bladder, 1 vagina, 1 ovary) were enrolled. 5-FU escalation to 1000 mg/m2/day was well tolerated. No patients developed grade 3-4 hematologic toxicity. Grade 2 leukopenia was noted in 3 patients (14.3%). Grade 3 mucositis, diarrhea, and dermatitis occurred in 10, 10, and 5% of patients, respectively. None of the 99 treatment cycles were delayed secondary to acute toxicity. The overall response rate in the 18 cervical cancer patients was 89% (78% complete, 11% partial). Conclusions. Concomitant continuous infusion 5-FU, twice daily HU, and pelvic RT delivered in an alternate-week fashion is well tolerated. Further study is necessary to evaluate the therapeutic efficacy of this regimen in patients with advanced cervical and other pelvic malignancies.

Race and clinical outcome in patients with carcinoma of the uterine cervix treated with radiation therapy

OBJECTIVES

The aim of this study was to examine factors underlying differences in outcome between African-American (AA) and Caucasian (C) patients undergoing radiation therapy (RT).

METHODS

Patient, tumor, treatment characteristics, and the outcome of 316 AA and 94 C cervical cancer patients who underwent RT were compared. Median follow-up was 72.4 months.

RESULTS

AA patients had a trend to a poorer 8-year cause-specific survival (47.9 vs 60.6%) (P = 0.10) compared to C patients with a significant difference seen in stage IIB-IVA disease (34.3 vs 59.5%) (P = 0.04). Several factors correlated with poor outcome were present in the AA group including lower mean hemoglobin levels during RT (P = 0.001), lower median income (P = 0.001), and less frequent intracavitary RT (P = 0.09). In addition, while uncommon in C patients, health problems were major reasons for treatment protraction and inability to undergo intracavitary RT in the AA patients. Multivariate analysis demonstrated that race was not an independent prognostic factor after controlling for difference in patient, tumor, and treatment factors.

CONCLUSIONS

AA cervical cancer patients possess multiple factors that adversely impact upon the efficacy of RT. These findings may add further insight into the observed differences in outcome of cervical cancer patients based on race.

Cervical cancer in the elderly treated with radiation therapy

OBJECTIVES

The aim of this study was to evaluate the tolerance and outcome of elderly cervical carcinoma patients treated with radiation therapy (RT).

METHODS

Three hundred ninety-eight patients with stage I-III cervical carcinoma treated with definitive RT were analyzed. Patients were divided into nonelderly (ages 35-69) (n = 338) and elderly (ages >/= 70) (n = 60) groups. A comparison of patient, tumor and treatment factors, morbidity, and outcome was performed. Median follow-up was 81 months.

RESULTS

Elderly patients had a higher rate of comorbid conditions including diabetes (P = 0. 02), coronary artery disease (P = 0.003), and hypertension (P = 0. 001) than younger patients. Comorbid conditions in the elderly resulted in more frequent treatment breaks and less ability to undergo definitive treatment with intracavitary RT (ICRT). While the 5-year actuarial disease-free (DFS) and cause-specific (CSS) survival rates were comparable between the two groups, disease recurrence and death from cervical cancer were more common beyond 5 years in the elderly group. When patients not undergoing ICRT and those with treatment protraction were excluded, differences in the DFS and CSS curves were no longer evident. The frequency and severity of acute and chronic sequelae were similar.

CONCLUSIONS

Elderly cervical carcinoma patients have an equivalent overall outcome following radiation therapy to younger patients when comparable treatment is delivered. Age per se is not associated with a higher rate of acute or chronic sequelae. Comorbid conditions adversely impacted on the quality and delivery of RT in the elderly group and help explain observed differences in outcome based on age.

Prolonged oral etoposide in recurrent or advanced squamous cell carcinoma of the cervix: a gynecologic oncology group study

OBJECTIVE

Previous studies by the Gynecologic Oncology Group have demonstrated no activity with bolus etoposide in squamous cell carcinoma of the cervix. Prolonged oral etoposide, which exploits the schedule dependency of this agent, has demonstrated activity in non-small cell carcinoma of the lung and has been studied in combination therapy with cisplatin. To evaluate prolonged oral etoposide in previously treated squamous cell carcinoma of the cervix, the current Phase II trial was conducted.

METHODS

Eligibility included squamous cell cancer of the cervix, measurable disease, allowed no more than one prior chemotherapy regimen which did not include etoposide, WBC >/=3000/microliter, platelet count >/=100, 000/microliter, serum creatinine </=2 mg%, and adequate hepatic function. The starting dose was 50 mg/m2/day (40 mg/m2/day for prior radiotherapy) as a single daily dose for 21 days, every 28 days. Based on toxicity, a dose escalation to a maximum dose of 60 mg/m2/day was prescribed.

RESULTS

Twenty-five patients were entered on this study; 24 were evaluable for toxicity. A median of 2 courses was given (range 1-8). All but one had received radiation therapy and 20 had received prior chemotherapy. Oral etoposide was not well tolerated with grade 4 neutropenia occurring in 33.3% and grade 4 thrombocytopenia occurring in 15%. Seven patients were unable to complete their first cycle due to toxicity and 8 patients received only one course of therapy. Of the remaining patients, 6 required dose reductions to 30 mg/m2/day. Only 3 patients were able to be dose-escalated to 50 mg/m2/day. Seventeen patients completed one course of therapy and were evaluable for response, of whom 16 had received prior radiotherapy and 15 prior chemotherapy. Two responses (11.8%) were observed, one complete response and one partial response. Both of these patients had disease in nonirradiated sites and one was chemotherapy-naive. Based on an intent-to-treat analysis, the response rate was 8.3%.

CONCLUSION

Prior radiation therapy limited the ability to deliver prolonged oral etoposide. At the maximum tolerated dose, this regimen is not significantly active as second-line chemotherapy in squamous cell carcinoma of the cervix.

Viral ribonucleoprotein complex formation and nucleolar-cytoplasmic relocalization of nucleolin in poliovirus-infected cells

The poliovirus 3' noncoding region (3'NCR) is involved in the efficient synthesis of viral negative-stranded RNA molecules. A strong interaction between a 105-kDa host protein and the wild-type 3'NCR, but not with a replication-defective mutant 3'NCR, was detected. This 105-kDa protein was identified as nucleolin which predominantly resides in the nucleolus and has been proposed to function in the folding of rRNA precursor molecules. A functional role for nucleolin in viral genome amplification was examined in a cell-free extract which has been shown to support the assembly of infectious virus from virion RNA. At early times of viral gene expression, extracts depleted of nucleolin produced less infectious virus than extracts depleted of fibrillarin, another resident of the nucleolus, indicating a functional role of nucleolin in the early stages of the viral life cycle in this in vitro system. Immunofluorescence analysis of uninfected and infected cells showed a nucleocytoplasmic relocalization of nucleolin, but not of fibrillarin, in poliovirus-infected cells. Relocalization of nucleolin was not simply a consequence of virally induced inhibition of translation or transcription, because inhibitors of translation or transcription did not induce nucleolar-cytoplasmic relocalization of nucleolin. These findings suggest a novel virus-induced mechanism by which certain nucleolar proteins are selectively redistributed in infected cells.

Late rectal sequelae following definitive radiation therapy for carcinoma of the uterine cervix: a dosimetric analysis

PURPOSE

This study attempted to correlate patient, treatment, and dosimetric factors with the risk of late rectal sequelae in patients treated with radiation therapy (RT) for cervical carcinoma.

METHODS AND MATERIALS

A total of 183 patients with cervical carcinoma (67 Stage I, 93 Stage II, and 23 Stage III) treated with definitive RT with a minimum of 2 years follow-up were evaluated. Treatment consisted of external beam pelvic RT (EBRT) followed by intracavitary RT (ICRT) consisting of one or two insertions. Complications were scored and analyzed as a function of 25 patient and treatment factors. Conventional total rectal doses were obtained by adding together the EBRT and ICRT rectal doses. To account for differences in dose rate between the ICRT and EBRT, and variations in EBRT fractionation schemes, biologically equivalent rectal doses (BED) were calculated using a linear quadratic model. In addition, the influence of the varying proportions of EBRT and ICRT rectal doses were evaluated.

RESULTS

Twenty-eight patients (15.3%) developed late rectal sequelae (13 Grade 1, 3 Grade 2, and 12 Grade 3). Diabetes (p = 0.03), Point A dose (p = 0.04), and conventional EBRT dose (p = 0.03) were the most significant factors on multivariate analysis. Logistic regression analysis demonstrated a low risk (<10%) of late rectal sequelae below conventional and biological rectal doses of 75 Gy and 135 BED, respectively. The percentage of rectal dose delivered by the EBRT significantly influenced the dose-response relationship. A defined threshold percentage above which rectal sequelae were more common was identified over the range of doses evaluated. This threshold was 87% at a total rectal dose of 60 Gy and decreased to 60% at 80 Gy.

CONCLUSION

Diabetes, Point A, and EBRT doses are the most significant factors associated with the risk of late rectal sequelae in patients treated with RT for cervical carcinoma. The percentage of rectal dose delivered by the EBRT significantly affects the conventional and biological dose-response relationship. This suggests that the volume of rectum irradiated is an important and independent parameter in the development of late rectal sequelae.

Monosomy 22 in two ovarian granulosa cell tumors

Cytogenetic studies of ovarian sex cord stromal cell tumors, although limited in number, have found trisomy 12 to be a recurring abnormality, especially in fibromas and granulosa cell tumors (GCTs). However, recent fluorescence in situ hybridization (FISH) studies have failed to confirm a high prevalence of trisomy 12 in GCTs. We describe the karyotypic findings in one adult and one juvenile GCT. Only the juvenile GCT had an extra, abnormal chromosome 12, but both the adult and juvenile GCT had monosomy 22. In light of these findings and the data in the literature, we suggest that monosomy 22 may be important in the genesis of these relatively rare tumors.

Acute myelomonocytic leukemia with abnormal eosinophils presenting as an ovarian mass: a report of two cases and a review of the literature

Acute myelomonocytic leukemia is a neoplastic blood disease that can occur as an extramedullary tumor called a granulocytic sarcoma. Granulocytic sarcoma can be the presenting feature of acute leukemia and can occur as an abdominal or pelvic mass. Two cases of granulocytic sarcomas presenting as ovarian masses in patients with acute myelomonocytic leukemia with a characteristic inversion of chromosome 16 are described and the current literature regarding treatment and prognosis is reviewed.

Clinical assessment of 111In-CYT-103 immunoscintigraphy in ovarian cancer

The ability of 111In-CYT-103 immunoscintigraphy to aid in the diagnosis of patients with primary or recurrent/residual ovarian cancer was evaluated in a multicenter trial. The 111In-labeled immunoconjugate of the monoclonal antibody B72.3 was prepared using a site-specific conjugation method. A total of 103 patients received a 1 mg infusion of 111In-CYT-103 and subsequently underwent surgery or biopsy. The infusion of 111In-CYT-103 was well tolerated; only 1 patient experienced a modest elevation in blood pressure that was likely related to the infusion. 111In-CYT-103 immunoscintigraphy correctly identified surgically confirmed tumor in 68% of patients with ovarian adenocarcinoma. The sensitivity of 111In-CYT-103 immunoscintigraphy was positively influenced both by the size of the tumor lesion and the tumor TAG-72 antigen expression. The overall sensitivity of 111In-CYT-103 immunoscintigraphy was greater than that of CT imaging (44%). Antibody imaging detected occult disease in 20 of 71 patients with surgically documented ovarian adenocarcinoma; 6 patients being evaluated after initial surgery and chemotherapy had an otherwise negative presurgical workup and a normal CA 125 serum level. The results of this trial also indicate that 111In-CYT-103 immunoscintigraphy can contribute to the medical and surgical management of some patients with ovarian cancer. The results of this trial indicate that 111In-CYT-103 immunoscintigraphy should be a valuable addition to the presurgical evaluation of patients with suspected persistent or recurrent ovarian cancer.

Reverse hysterocolposigmoidectomy (RHCS) for resection of panpelvic tumors

Lateral retroperitoneal approaches to abdominopelvic masses are commonly employed; the reverse hysterocolposigmoidectomy (RCHS) in addition utilizes transabdominal entry of the vaginal and rectovaginal spaces to provide medial access to the uterosacral and cardinal ligaments as well expose a tumor-free segment of the rectosigmoid for en bloc resection of panpelvic tumors. Thirty-one patients underwent reverse hysterocolpectomy for extensive, symptomatic pelvic malignancies. All patients had complete resection of pelvic tumor, and there were no perioperative deaths. Sigmoid resection was required in 25 patients with 22 primary reanastomosis and 3 end colostomies performed. In 6 patients, vaginal entry facilitated tumor resection while sparing the rectosigmoid. Average operative blood loss was 2677 cc. Early postoperative morbidity (1-30 days) occurred in 13 patients; febrile morbidity (6 patients) was the common complication. Late morbidity (1-6 months) was seen in 10 patients, including 1 fatal pulmonary embolism at 5 months. Subsequent therapy was tolerated well. Mean survival/follow-up is 15.7 months (range, 1 to 49 months). Seventeen patients are alive, seven patients without evidence of disease (average 13.4 months), and ten patients are alive with disease (average follow-up, 28.3 months). Thirteen patients are dead of disease or complication (average survival, 13.7 months). We conclude that RHCS facilitates resection of extensive pelvic tumors with acceptable morbidity.

Manometric characterization of rectal dysfunction following radical hysterectomy

Bladder dysfunction thought to be due to partial denervation has been described following radical hysterectomy. Some patients experience acute and chronic rectal dysfunction characterized by difficulty with defecation and loss of defecatory urge. To define this abnormality, anorectal pressure profiles were examined in 15 patients with Stage I carcinoma of the cervix before and after radical hysterectomy. Profiles were done using standard anorectal manometry with a water-infused system. In all patients preoperative manometric profiles were normal; postoperative studies were abnormal in all patients. Features seen include altered relaxation of the internal sphincter, increased distension needed to trigger relaxation, and decreased rectal sensation; external sphincters and resting internal sphincters were unchanged. Postoperatively, 12 patients reported problems with rectal function. A physiologic defect is definable in patients undergoing radical hysterectomy; this suggests disruption of the spinal reflex arcs controlling rectal emptying. These physiologic abnormalities correlate with the clinical symptomatology experienced by some patients. Continuing definition and evaluation of management options in this situation should be useful in developing effective therapy for rectal dysfunction following radical hysterectomy.

Rapid dysplastic transformation of human genital cells by human papillomavirus type 18

This study delineates differences in biologic activity between human papillomavirus (HPV) types 16 and 18. Human cervical and foreskin epithelial cells were cultured and transfected with recombinant HPV-16 and -18 DNA, resulting in immortalized cell lines. Normal epithelial cells as well as HPV-16 and -18 immortalized cells of both early passages (less than 40 population doublings) and late passages (greater than 180 population doublings) were transplanted in athymic mice. Normal squamous cells formed well-stratified epithelium, while HPV immortalized cells developed either normal-appearing epithelium or typical dysplastic changes. Dysplastic changes were seen in none of the 13 grafts with early-passage HPV-16 cell lines, while 9 of 14 grafts with early-passage HPV-18 cell lines developed dysplasias (P less than 0.0004). These results support previous clinical observations suggesting that HPV-18 may be associated with a more aggressive and rapidly progressive form of cervical neoplasia.

Human cervical and foreskin epithelial cells immortalized by human papillomavirus DNAs exhibit dysplastic differentiation in vivo

Human papillomavirus (HPV) DNAs are detected in approximately 90% of anogenital carcinomas. To assess directly the effect of HPV on squamous differentiation, normal human cervical and foreskin epithelial cells and cells immortalized by recombinant HPV DNAs were transplanted beneath a skin-muscle flap in athymic mice. Xenografts containing normal cells formed well-differentiated stratified squamous epithelia 2 to 3 weeks after transplantation, but cell lines immortalized by four HPV types (HPV16, HPV18, HPV31, and HPV33) detected in anogenital cancer exhibited dysplastic morphology and molecular alterations in gene expression characteristic of intraepithelial neoplasia. Morphological alterations were accompanied by delayed commitment to terminal differentiation, alterations in the pattern of involucrin expression, and reductions in levels of involucrin and keratin 1 RNAs. HPV18-immortalized cells developed dysplastic changes more rapidly than cells immortalized by HPV16 DNA. These results show that human genital epithelial cells immortalized by HPV DNAs detected in genital cancers undergo dysplastic differentiation in vivo.