Clinicopathologic characteristics associated with long-term survival in advanced epithelial ovarian cancer: an NRG Oncology/Gynecologic Oncology Group ancillary data study

OBJECTIVE

To identify clinicopathologic factors associated with 10-year overall survival in epithelial ovarian cancer (EOC) and primary peritoneal cancer (PPC), and to develop a predictive model identifying long-term survivors.

METHODS

Demographic, surgical, and clinicopathologic data were abstracted from GOG 182 records. The association between clinical variables and long-term survival (LTS) (>10years) was assessed using multivariable regression analysis. Bootstrap methods were used to develop predictive models from known prognostic clinical factors and predictive accuracy was quantified using optimism-adjusted area under the receiver operating characteristic curve (AUC).

RESULTS

The analysis dataset included 3010 evaluable patients, of whom 195 survived greater than ten years. These patients were more likely to have better performance status, endometrioid histology, stage III (rather than stage IV) disease, absence of ascites, less extensive preoperative disease distribution, microscopic disease residual following cyoreduction (R0), and decreased complexity of surgery (p<0.01). Multivariable regression analysis revealed that lower CA-125 levels, absence of ascites, stage, and R0 were significant independent predictors of LTS. A predictive model created using these variables had an AUC=0.729, which outperformed any of the individual predictors.

CONCLUSIONS

The absence of ascites, a low CA-125, stage, and R0 at the time of cytoreduction are factors associated with LTS when controlling for other confounders. An extensively annotated clinicopathologic prediction model for LTS fell short of clinical utility suggesting that prognostic molecular profiles are needed to better predict which patients are likely to be long-term survivors.

Evaluation of a chemoresponse assay as a predictive marker in the treatment of recurrent ovarian cancer: further analysis of a prospective study

BACKGROUND

Recently, a prospective study reported improved clinical outcomes for recurrent ovarian cancer patients treated with chemotherapies indicated to be sensitive by a chemoresponse assay, compared with those patients treated with non-sensitive therapies, thereby demonstrating the assay's prognostic properties. Due to cross-drug response over different treatments and possible association of in vitro chemosensitivity of a tumour with its inherent biology, further analysis is required to ascertain whether the assay performs as a predictive marker as well.

METHODS

Women with persistent or recurrent epithelial ovarian cancer (n=262) were empirically treated with one of 15 therapies, blinded to assay results. Each patient's tumour was assayed for responsiveness to the 15 therapies. The assay's ability to predict progression-free survival (PFS) was assessed by comparing the association when the assayed therapy matches the administered therapy (match) with the association when the assayed therapy is randomly selected, not necessarily matching the administered therapy (mismatch).

RESULTS

Patients treated with assay-sensitive therapies had improved PFS vs patients treated with non-sensitive therapies, with the assay result for match significantly associated with PFS (hazard ratio (HR)=0.67, 95% confidence interval (CI)=0.50-0.91, P=0.009). On the basis of 3000 simulations, the mean HR for mismatch was 0.81 (95% range=0.66-0.99), with 3.4% of HRs less than 0.67, indicating that HR for match is lower than for mismatch. While 47% of tumours were non-sensitive to all assayed therapies and 9% were sensitive to all, 44% displayed heterogeneity in assay results. Improved outcome was associated with the administration of an assay-sensitive therapy, regardless of homogeneous or heterogeneous assay responses across all of the assayed therapies.

CONCLUSIONS

These analyses provide supportive evidence that this chemoresponse assay is a predictive marker, demonstrating its ability to discern specific therapies that are likely to be more effective among multiple alternatives.

A Gynecologic Oncology Group study of associations between polymorphisms in ABC transporter genes (ABCB1, ABCC2, and ABCG2) and outcome in advanced stage epithelial ovarian cancer treated with platinum and taxane chemotherapy

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Background: This study evaluated the relationship between known functional variants in three ATP-binding cassette (ABC) transporter genes (ABCB1 [MDR1], ABCC2 [MRP2], and ABCG2 [BCRP]) and clinical outcomes in epithelial ovarian cancer (EOC). These genes induce resistance to multiple anticancer drugs and some polymorphisms appear to affect expression, stability or activity of these transporters. Methods: Genotypes for common polymorphisms in ABCB1 (G2677T/A, A893S/T -RS2032582 and C3435T, synonymous-RS1045642), ABCC2 (G1249A, V417I-RS2273697), and ABCG2 (C421A, Q141K-RS2231138) were determined in normal blood DNA from 385 women with optimal stage III ECO who participated in a randomized phase III trial (GOG 172 or 182) and were treated with intravenous or intraperitoneal platinum+paclitaxel. Associations between polymorphisms and progression-free survival (PFS) and overall survival (OS) were examined using logrank test and adjusted Cox regression analysis. Results: The genotype distribution for the C421A polymorphism in ABCG2 was 80.7%, 18.5% and 0.8% for CC, CA and AA, respectively. Median time to disease progression or death for the CA+AA versus (vs.) CC genotype in ABCG2 was 30.3 vs. 18.1 months (p = 0.023), or 69.8 vs. 51.6 months (p = 0.172), respectively. After adjusting for clinical covariates, women with the CA+AA vs. CC genotype in ABCG2 had a significant reduction in the risk of disease progression (hazard ratio [HR] = 0.67, 95% confidence interval [CI] = 0.49–0.91, p = 0.01) but not death (HR = 0.77, 95% CI = 0.56–1.08, p = 0.125). The results were consistent across treatments. Adjusted Cox modeling demonstrated that polymorphisms in ABCB1 (G2677T/A or C3435T) and ABCC2 (G1249A) were not associated with PFS or OS. Conclusions: The ABCG2 C421A polymorphism, but not the ABCB1 G2677T/A, ABCB1 C3435T, or ABCC2 G1249A polymorphism, appears to be an independent prognostic factor for disease progression in optimal stage III EOC treated with platinum + paclitaxel therapy.

No significant financial relationships to disclose.

Recurrent metastatic vulvar carcinoma treated with cisplatin plus cetuximab

Recurrent vulvar carcinoma with metastasis has few effective treatment options, which are mainly directed toward palliation of symptoms. A 70-year-old woman was originally treated in 1999 for vulvar squamous cell carcinoma (SCC) with radical vulvectomy and bilateral inguinofemoral groin dissection. She represented in 2005 with a new lesion distinct from the margin of her first disease occurrence. Although treatment of this area included surgical resection and chemoradiation, she recurred 3 months later. Despite radical surgical resection with an anal perineal resection, she presented 2 months later with widely metastatic disease. Epidermal growth factor receptor (EGFR) staining of the tumor cells showed 3+ staining in 100% of the cells. She was treated with palliative radiation therapy (RT) and a cetuximab plus cisplatin chemotherapy protocol. A partial response was obtained for 5 months with palliation of symptoms. Few treatment options exist for recurrent metastatic vulvar carcinoma. The combination of the EGFR antagonist cetuximab with cisplatin has shown modest success in other metastatic SCCs. The partial response experienced in our patient suggests its potential use in women with recurrent or metastatic vulvar carcinoma

Relationship between polymorphisms in cordon 118 and C8092A in ERCC1 and clinical outcome in optimally-resected, stage III epithelial ovarian cancer treated with intraperitoneal or intravenous cisplatin and paclitaxel: A gynecologic oncology

21050

Background: The association between polymorphisms in the excision nuclease ERCC1 and progression-free survival (PFS) or overall survival (OS) was examined in women with epithelial ovarian cancer (EOC) treated with cisplatin and paclitaxel. Methods: Women who were evaluable for the phase III trial, GOG-172, with sufficient leukocyte DNA for testing were eligible for this study. Participants were randomized to intraperitoneal (IP) or intravenous (IV) cisplatin and paclitaxel. Single nucleotide polymorphism (SNP) analysis was carried out by direct pyrosequencing. Results: Among the 233 eligible cases, the genotype distribution at codon 118 was 17% with C/C, 43% with C/T and 40% with T/T and at C8092A was 56% with C/C, 37% with C/A and 7% with A/A. Adjusted Cox regression analysis revealed that the codon 118 polymorphism was not significantly associated with disease progression or death, but women with the C/A or A/A genotype compared with the C/C genotype at C8092A had an increased risk of disease progression (hazard ratio [HR]=1.48, 95% confidence interval [CI]=1.09–2.00, p=0.011) and death (HR=1.46, 95% CI=1.04–2.04, p=0.029). Subset analysis stratified by treatment suggested that the C8092A polymorphism was significantly associated with increased risk of PFS and OS in the IP but not the IV arm. Conclusions: Although the ERCC1 codon 118 polymorphism does not appear to be associated with clinical outcome, the C8092A polymorphism in ERCC1 was an independent predictor of PFS and OS in optimally-resected EOC treated with cisplatin- paclitaxel chemotherapy. The preferential clinical utility of the C8092A polymorphism in the IP but not the IV arm requires validation.

No significant financial relationships to disclose.

Termination of intraperitoneal chemotherapy is driven by treatment toxicity rather than catheter dysfunction

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Background: Three separate studies have shown increased survival for women with epithelial ovarian carcinoma treated with intraperitoneal (IP) chemotherapy. Barriers to its use have included toxicity concerns. We compared the morbidity associated with IP cisplatin- based chemotherapy and IP immunologic therapies. Methods: A retrospective cohort analysis of patients diagnosed with epithelial ovarian carcinoma treated with IP chemotherapy at a single institution from 1996–2006 was performed. Patients were separated into those who received IP Interleukin-2 or Interleukin-12 and those who received cisplatin-based IP chemotherapy. Primary endpoint was completion of the intended treatments. Complications arising from the placement or use of the catheter were deemed catheter-related and included obstruction of flow or catheter site infection. Those felt to be caused by treatment toxicity (e.g. nausea, pain, fever) or progression of disease were deemed treatment-related. Chi square test was used for all univariate analysis. Results: Seventy-five patients were identified. Thirty-five (46.6%) received IL-2 or IL-12, while 40 (53.4%) received cisplatin-based chemotherapy. There were 16 complications that led to treatment termination (21.3%). Immunologic therapy had an increased frequency of early termination (n=13, 37.1%) compared to cisplatin-based therapy (n=3, 7.5%) (p=0.002). There were 3 (8.6%) catheter-related complications in the immunologic group and 2 (5%) in the cisplatin-based group (p=0.54). Reasons for termination of therapy in the immunologic therapy group were progression of disease (n=5), catheter site infection (n=3), grade 3/4 nausea (n=3), and grade 3/4 abdominal pain (n=2). In the cisplatin therapy group, reasons for termination included catheter site infection (n=1), catheter site leak (n=1), and progression of disease (n=1). Conclusion: Local-regional immunotherapy produces significantly more complications and local symptoms than cisplatin-based regimens. Catheter complications were not significantly different between the two groups, and accounted for a small percentage of the treatment terminations in this series.

No significant financial relationships to disclose.

Hematologic changes after splenectomy for cytoreduction: implications for predicting infection and effects on chemotherapy

Postsplenectomy leukocytosis and thrombocytosis are common findings in trauma patients. The intent of this study is to describe postsplenectomy hematologic changes in gynecological oncology surgery and subsequent chemotherapy. We performed a retrospective record review of gynecological oncology patients at our institutions. Postsurgical hematologic changes, infectious morbidity, and pre- and post-chemotherapy hematologic changes were noted. Data were analyzed using repeated measures analysis of variance. We identified 27 patients who underwent cytoreductive surgery with splenectomy. Thirteen patients with splenectomy had postoperative chemotherapy data available, and we matched these patients with 13 control patients who underwent cytoreduction surgery without splenectomy and postoperative chemotherapy. Nine of the 27 splenectomy patients had documented infectious morbidity. There was a significant difference in postoperative platelet counts between the infected and the noninfected splenectomy patients (P= 0.037), and a significant difference between splenectomy and control patients for white blood cell (WBC) counts (P = 0.007). Patients with splenectomy had higher precycle WBC, absolute neutrophil count (ANC), platelet counts, and higher postcycle nadir levels in all cycles compared to control patients. There was a significant overall difference between splenectomy patients and controls with regard to WBC (P = 0.001), ANC (P = 0.005), and platelet counts (P = 0.016) during chemotherapy cycles. Median postchemotherapy nadir WBC was 4.4 (range: 3.4-4.8) for the splenectomy group versus 2.8 (range: 2.5-3.0) for the control group. Median postchemotherapy nadir ANC was 1800 (range: 1320-2450) for the splenectomy group and 1001 (range: 864-1064) for the control group. Median postchemotherapy nadir platelet count was 222 (range: 181-277) for the splenectomy patients and 169 (range 164-215) for the control patients. In conclusion, the patients who undergo splenectomy as part of cytoreductive surgeries have a statistically significant leukocytosis and insignificant thrombocytosis relative to the control patients. Leukocytosis alone is not an accurate indicator of infection. Splenectomy is not associated with an increased risk of chemotherapy-related neutropenia and thrombocytopenia.

Uterine adenosarcoma with sarcomatous overgrowth versus uterine carcinosarcoma: comparison of treatment and survival

OBJECTIVE

Uterine adenosarcoma with sarcomatous overgrowth (ASSO) is a rare variant of uterine sarcoma first described in 1989. This clinicopathologic study was undertaken to compare the treatment and survival of uterine adenosarcoma with sarcomatous overgrowth to that of uterine carcinosarcomas.

METHODS

A review of uterine sarcomas diagnosed at Washington Hospital Center from January 1988 to December 1998 was performed. Records were reviewed for demographic data, surgical staging, primary and adjuvant therapy, metastatic site, disease recurrence, and survival. All pathology was reviewed and diagnosis confirmed. Statistical analysis included chi(2) test and Student's t test. Kaplan-Meier survival curves were plotted to estimate the median and 5-year survival times. The log-rank test was used to compare survival times. A P value <0.05 was considered significant.

RESULTS

Sixty patients were diagnosed with uterine sarcoma at Washington Hospital Center. Of these, 33 (55%) were uterine carcinosarcomas, 11 (18%) ASSOs, 6 (10%) adenosarcomas, and 10 (17%) leiomyosarcomas. Of the patients diagnosed with uterine ASSO, 3 (27%) were stage I, 3 (27%) stage II, 1 (9%) stage III, and 4 (36%) stage IV. All 11 patients with uterine ASSO underwent total abdominal hysterectomy with bilateral salpingo-oophorectomy and tumor debulking. Postoperative adjuvant therapy included chemotherapy (n = 4), radiation (n = 4), combination radiation and chemotherapy (n = 1), and no adjuvant therapy (n = 2). The overall median survival time of patients with uterine ASSO was 13 months. Nine of eleven patients are dead of disease, and two patients (both with stage I) are alive without evidence of disease at 18 and 19 months. Thirty-three patients with carcinosarcoma were identified, with follow-up available on 29 patients. Of these, 10 (34%) were stage I, 6 (22%) stage II, 3 (10%) stage III, and 10 (34%) stage IV. Twenty-seven of the twenty-nine patients diagnosed with carcinosarcoma underwent surgical therapy to include total abdominal hysterectomy, bilateral salpingo-oophorectomy, staging and tumor debulking. Two patients died prior to treatment. Postoperative adjuvant therapy included chemotherapy (n = 9), radiation (n = 13), combination (n = 1), and no further therapy (n = 4). Twenty of the twenty-nine patients are dead of disease; there were nine surviving patients at the time of this report (stage I-5, stage II-3, stage III-1). The median survival of these patients was 31 months, with an overall 5-year survival of 22%. Comparison of the Kaplan-Meier survival curves using the log-rank test suggests a worse prognosis for uterine ASSO. However, this did not reach statistical significance (P = 0.0522).

CONCLUSIONS

Patients diagnosed with uterine ASSO have a poor prognosis similar to that of carcinosarcoma. Management should include complete surgical staging. Additional therapy in the form of radiation, chemotherapy, or both has been reported; however, the superiority of one modality could not be determined from our data.

Cervical adenocarcinoma in situ: a systematic review of therapeutic options and predictors of persistent or recurrent disease

The incidence of cervical adenocarcinoma in situ is increasing in frequency, and our limited knowledge about this lesion presents the physician with a therapeutic dilemma. Treatment for this lesion has included conservative therapy, large loop excision or cold-knife cone biopsy, or definitive therapy consisting of hysterectomy. But, rates of residual adenocarcinoma in situ after cone biopsy with negative margins vary from 0% to 40%, and residual disease rates as high as 80% have been noted when the margins are positive. Despite these recent data on follow-up after conservative therapy such as cone biopsy, it seems that this method is safe and gaining acceptance by many physicians and patients. However, the short follow-up duration and small number of patients limit the conclusions of many studies. The relative infrequency of this diagnosis has precluded extensive clinical experience with the natural history of this lesion.

Large cell neuroendocrine cervical carcinoma: a report of two cases and review of the literature

BACKGROUND

Large cell neuroendocrine cervical carcinoma is a rare malignancy. These tumors appear to mimic the aggressive behavior of small cell neuroendocrine tumors. Metastasis and recurrent disease are common. Due to the low incidence of these tumors, optimal therapy has not been delineated.

CASES

Two patients presented with large cell neuroendocrine cervical carcinoma, stage IB1 and IIA, at our institution from 1997 to 1999. We describe the clinical course for these two patients and review the relevant literature for the management of large cell cervical carcinoma.

CONCLUSION

Unlike squamous cell carcinoma, early-stage large cell neuroendocrine tumors of the cervix are aggressive. Disease recurrences are frequent and distant metastasis is common. Multimodal therapy should be considered at the time of initial diagnosis.

Abnormal fragile histidine triad (FHIT) expression in advanced cervical carcinoma: a poor prognostic factor

The FHIT gene is a candidate tumor suppressor gene that has been implicated in the development of cervical carcinoma. We hypothesized that abnormal Fhit expression might be a poor prognostic factor for patients with cervical cancer. The tumors from 59 high-risk patients (stage II-III) were evaluated for abnormal Fhit expression by immunohistochemical staining. Abnormal Fhit expression (absent or reduced) was noted in 66% of the specimens. There was no statistical difference with respect to stage, performance status, para-aortic node metastasis, completion of therapy, grade, race, age, and HIV status between the normal and abnormal Fhit expression groups. The 3-year survival for patients whose tumors displayed normal Fhit expression versus abnormal Fhit expression was 74% versus 37%, respectively. Univariate analysis demonstrated a difference in survival that was statistically significant for age <55 years versus > or =55 years (P = 0.015), normal Fhit expression versus abnormal Fhit expression (P = 0.015), and stage II versus stage III (P = 0.033). Multivariate analysis showed that abnormal Fhit expression was a poor prognostic factor (P = 0.015).

Primary appendiceal malignancy mimicking advanced stage ovarian carcinoma: a case series

BACKGROUND

Primary appendiceal malignancy metastatic to the ovaries is a rare condition that may mimic late stage ovarian cancer. This condition is rarely diagnosed preoperatively.

CASES

Three patients referred to our institution from 1994 to 1999 for presumed late stage ovarian cancer were found to have primary appendiceal adenocarcinoma, adenocarcinoid, and mucinous cystadenocarcinoma metastatic to the ovaries at laparotomy. We describe the clinical course of these patients and review the relevant literature.

CONCLUSION

It is important for the gynecologic oncologist to be aware of the clinicopathological features and surgical management of these malignancies, as the incidence, prognosis, and recommended treatment vary with histological subtype.

Conservative management of isolated posthysterectomy fever

OBJECTIVE

To demonstrate that an isolated fever in the absence of other signs or symptoms of infection following hysterectomy does not require empiric antibiotics and laboratory tests.

METHODS

Retrospective analysis of all the charts of patients who had a hysterectomy from July 1995 to December 1996 at our institution. Patients with a postoperative temperature > 38 degrees C had a physical examination. If the examination was normal, no studies were ordered, and antibiotic therapy was not initiated. If a patient was febrile after 72 hours postoperatively, laboratory studies and radiographic tests were ordered. If the results were negative, the patient did not appear septic, and physical examination was normal, no antibiotics were given. Outcomes were measured by comparing patients with postoperative infections and fever to those without infections.

RESULTS

Of 132 patients, 112 were included in the study. Seventy-two hysterectomies were abdominal and 40 vaginal. Postoperative fever during the first 72 hours following hysterectomy occurred in 51/112 (46%) patients. Clinically significant infection was documented in seven patients, all of whom manifested signs and symptoms of infection > 72 hours postoperatively.

CONCLUSION

Postoperative fever in the first 72 hours after hysterectomy is common and nonspecific. If a febrile patient does not show any other signs or symptoms of infection, it is safe to forego routine laboratory and imaging studies as well as therapeutic antibiotics.

Recurrent invasive adenocarcinoma after hysterectomy for cervical adenocarcinoma in situ

BACKGROUND

Unlike its squamous counterpart, therapy for cervical adenocarcinoma in situ with positive endocervical cone margin remains controversial.

CASE

A 52-year-old gravida 2, para 1,0,1,1, presented with vaginal bleeding. Gynecologic history was significant for cervical cold knife conization with a positive endocervical margin and endocervical curettage with atypical endocervical cells. Repeat cone biopsy was considered unsafe given the large initial cone specimen. An extrafascial hysterectomy was performed 5 weeks later and pathology confirmed a disease-free cervix. Pap smear performed 1 year later was interpreted as recurrent adenocarcinoma but later downgraded to inflammation. Inspection and random biopsies of the vaginal cuff revealed only inflammation. Two subsequent Pap smears also returned inflammation. Seventeen months after the hysterectomy physical examination revealed a 2 x 3-cm smooth mass at the vaginal cuff. Biopsy revealed invasive adenocarcinoma. The patient underwent an upper vaginectomy followed by postoperative pelvic radiation.

CONCLUSION

This case suggests that despite extrafascial hysterectomy for presumed adenocarcinoma in situ of the cervix, a residual focus could remain and present later as invasive adenocarcinoma.

Kielland vs. nonrotational forceps for the second stage of labor

OBJECTIVE

To examine and compare maternal and neonatal morbidity after use of two types of obstetric forceps used in the management of the second stage of labor.

STUDY DESIGN

This retrospective investigation was conducted from January 1993 to December 1995 and included 55 infants delivered with Kielland forceps as compared to 213 infants delivered with nonrotational forceps. The maternal and neonatal charts were reviewed for data collection. Maternal complications compared included blood loss, vaginal lacerations, postpartum hemorrhage, and third- and fourth-degree perineal lacerations. Infant data collected compared fetal lacerations, nerve palsies, shoulder dystocias, blood gas values and admissions to the neonatal intensive care unit. Statistical analysis was performed by Fisher's exact, chi 2 and Student's t test.

RESULTS

Women in both groups were similar with respect to age, gravidity, parity and estimated gestational age at delivery. Infants were similar in both groups with respect to fetal weight, admissions to the neonatal intensive care unit, nerve compromise, scalp lacerations and facial bruising. The Kielland group had statistically significantly longer labor, 671 +/- 285.8 vs. 614 +/- 226.5 minutes (P < .05) and longer second stage of labor 184 +/- 74.71 vs. 161 +/- 65.79 minutes (P < .05). The Kielland group also had a statistically higher percentage of one-minute Apgar scores < 6, 18.2% vs. 4.7% (P < .05), and meconium present at delivery, 14.5% vs. 5.6% (P < .05).

CONCLUSION

Management of the second stage of labor can be accomplished safely with Kielland forceps and rotation of the fetal head. Supervision by an experienced operator will allow residents to be trained with respect to appropriate patient selection and application of these forceps.