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Volume 3, Number 3 – March, 2004 |
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The following articles appeared in this month's issues of the surveyed journals. Articles that seem to be of most interest to the practicing gynecologic oncologist are included. The journals that are surveyed are New England Journal of Medicine, Journal of Clinical Oncology, Gynecologic Oncology, Cancer, American Journal of Obstetrics and Gynecology, Lancet, Cancer Research, Obstetrics and Gynecology, Journal of the National Cancer Institute, Journal of the American Medical Association and American Journal of Surgical Pathology. The participants in this program are the active clinical fellows at Memorial Hospital: Mario Leitao, Christopher Awtrey, Sarah Ferguson, Alan Schlaerth, Destin Black and Margrit Juretzka. The managing editor is Douglas Levine. Comments, questions, complaints and suggestions are always welcome, please E-mail us at: VJC@smgo.org or click here. To subscribe or unsubscribe to the VJC, click here. Gynecologic Oncology – Christopher Awtrey Title: A phase III trial of surgery with or without adjunctive external pelvic radiation therapy in intermediate risk endometrial adenocarcinoma: a Gynecologic Oncology Group study Authors: Henry M. Keys , James A. Roberts , Virginia L. Brunetto , Richard J. Zaino , Nick M. Spirtos , Jeffrey D. Bloss , Andrew Pearlman , Mitchell A. Maiman and Jeffrey G. Bell Source: Gynecologic Oncology, Volume 92, Issue 3, March 2004, Pages 744-751 Summary: Few studies have been so eagerly anticipated by the gynecologic community as GOG-99, which evaluated the role of adjuvant WPRT for patients with intermediate risk endometrioid endometrial cancer, Stage IB, IC and occult stage II, who had a full staging procedure, defined as TAH/BSO/pelvic LND. There were 392 patients that were randomized to receive WPRT or no further therapy. The patients receiving radiation were prescribed 50.40 Gy to the pelvis and of the 190 patients in the radiation arm there was a 6.8% recurrence rate at a median follow up of 68 months. Of the 13 patients in the RT group that had recurrences only 3 of them had loco-regional recurrences and the rest, 10 or 5.3% had distant recurrences. Of note 2 of the 3 patients with LR recurrences had refused radiation therapy, but had been included in the intention to treat analysis. There were 31 recurrences in the control group, a recurrence rate of 15.3%. Of these 13 were vaginal recurrences and a local regional recurrence rate of 8.9% compared to 1.6% for the treated group. Although there was a difference in recurrence rate there was no difference in overall 4-yr survival (86% in the control arm and 92% in the RT arm, RH: 0.86; P = 0.557). The authors identified a sub-group that was at higher risk for recurrence, which included patients with moderately to poorly differentiated tumors, presence of LVSI and outer 1/3 invasion. There was a significant increase in toxicity in the treated group. Grade 3 or 4 GI toxicity was noted in 8% of the treated group versus less than 1% in the control group. The authors conclude that adjuvant RT in early stage EMCA decreases the risk of recurrence, but should be limited to patients that fit into the ‘high intermediate risk’ definition. Two editorials can be found in the same issue by Drs. Berman and Creutzberg. Click here for abstract from Gynecologic Oncology Journal of Clinical Oncology - Mario Leitao Title: Mucinous Epithelial Ovarian Cancer: A Separate Entity Requiring Specific Treatment Authors: Hess, Viviane, A'Hern, Roger, Nasiri, Nazar, King, D. Michael, Blake, Peter R., Barton, Desmond P.J., Shepherd, John H., Ind, T., Bridges, J., Harrington, K., Kaye, Stanley B., Gore, Martin E. Source: J Clin Oncol 2004 22: 1040-1044 Summary: The purpose of this study is to determine whether it is appropriate to treat mucinous ovarian cancer (mEOC) according to guidelines established for EOC in general. Women with advanced mEOC who underwent first-line platinum-based chemotherapy were compared with women with other histologic subtypes of EOC in a case-controlled study. 81 patients (27 cases, 54 controls) treated with platinum-based regimens were analyzed. The response rates for cases and controls were 26.3% (95% CI, 9.2% to 51.2%) and 64.9% (95% CI, 47.5% to 79.8%), respectively (P = .01). The odds ratio for complete or partial response to chemotherapy for mEOC was 0.19 (95% CI, 0.06 to 0.66; P = .009) compared with other histologic subtypes of EOC. The overall survival was 12.0 months (95% CI, 8.0 to 15.6 months) versus 36.7 months (95% CI, 25.2 to 48.2 months; P < .001) for cases and controls, respectively. The hazard ratio for death was 3.08 (95% CI, 1.69 to 5.6; P < .001) for mEOC patients as compared with controls. Patients with advanced mEOC have a poorer response to platinum-based first-line chemotherapy compared with patients with other histologic subtypes of EOC, and their survival is worse. Specific alternative therapeutic approaches should be sought for this group of patients. Click here for abstract from JCO Title: Pelvic Irradiation With Concurrent Chemotherapy Versus Pelvic and Para-Aortic Irradiation for High-Risk Cervical Cancer: An Update of Radiation Therapy Oncology Group Trial (RTOG) 90-01 Authors: Eifel, Patricia J., Winter, Kathryn, Morris, Mitchell, Levenback, Charles, Grigsby, Perry W., Cooper, Jay, Rotman, Marvin, Gershenson, David, Mutch, David G. Source: J Clin Oncol 2004 22: 872-880
Summary: 403 women with cervical cancer were randomly assigned to
receive either extended-field radiotherapy (EFRT) or pelvic radiotherapy
with concomitant fluorouracil and cisplatin (CTRT) . Patients were
eligible if they had stage IIB to IVA disease, stage IB to IIA disease
with a tumor diameter Click here for abstract from JCO Journal of the National Cancer Institute – Alan Schlaerth Title: Dietary Folate Intake and Incidence of Ovarian Cancer: The Swedish Mammography Cohort Authors: Susanna C. Larsson, Edward Giovannucci, and Alicja Wolk Source: J Natl Cancer Inst 2004; 96: 396-402 Summary: This study from Sweden investigated the association between dietary folate intake and the incidence of total epithelial ovarian cancer. A population-based prospective cohort of 61,084 women aged 38-76 years old were cancer-free at baseline (1987-1990). Through June 30,2003, 266 incident cases of invasive epithelial ovarian cancer were diagnosed. Overall, dietary folate intake was weakly associated with total ovarian cancer risk (RR=0.67, 95% CI 0.43-1.04, p=.08). However, in women who drank at least 20 g of alcohol per week (two drinks), the RR=0.26, the 95% CI = 0.11 to 0.60, p=.001. Additionally, the association between dietary folate intake and cancer risk did not vary among subtypes of epithelial ovarian cancer. Thus, the authors conclude that high dietary folate intake may reduce the risk of ovarian cancer, especially in women who consume alcohol. Comment: Though there exists biological plausibility to support the relationship between folate levels and cancer prevention, an explanation for why this would be restricted to alcohol users is not apparent. Since the primary association was not statistically significant despite a very large sample size, these resutls should be interpreted with caution. Click here for abstract from JNCI Obstetrics and Gynecology – Margrit Juretzka Title: Subcutaneous Tumor Implantation After Laparoscopic Procedures in Women With Malignant Disease Authors: Abu-Rustum, Nadeem R., Rhee, Eunice H., Chi, Dennis S., Sonoda, Yukio, Gemignani, Mary, Barakat, Richard R. Source: Obstet Gynecol 2004 103: 480-487 Summary: This large retrospective review reports the incidence of clinically detected laparoscopy-related subcutaneous tumor implantation in women with malignant disease. Over a 12 year period from 1991 to 2003, 1,288 women with malignant disease who underwent laparoscopy were identified. Thirteen patients (n=.97%) developed subcutaneous tumor implantations but there were no "isolated" trocar-related subcutaneous metastasis during the study period. Implants occurred with carcinomatosis, with synchronous metastases to other sites, and when the preceding laparoscopy was performed in the presence of advanced or recurrent abdominopelvic disease. The authors conclude that laparoscopy-related subcutaneous tumor implantation is rare and subcutaneous implantation appears to occur in patients with known metastatic disease. The risk of subcutaneous tumor implantation should not be used as an argument against laparoscopy in women with gynecologic malignancies managed by gynecologic oncologists. Click here for abstract from OB/GYN American Journal of Obstetrics and Gynecology – Sarah Ferguson Title: P16 as a molecular biomarker of cervical adenocarcinoma Authors: John O. Schorge, Jayanthi S. Lea, Keren J. Elias, Ramababu Rajanbabu, Robert L. Coleman, David S. Miller and Raheela Ashfaq Source: American Journal of Obstetrics and Gynecology, Volume 190, Issue 3, March 2004, Pages 668-673 Summary: The objective of this study was to find a molecular biomarker that may help identify cervical adenocarcinoma in situ (AIS) and invasive cervical adenocarcinoma. The investigators looked at several cell cycle regulatory proteins in normal endocervix, AIS and invasive adenocarcinoma by immunohistochemistry and confirmed by Western blotting. They used a scoring system from 0 to 8 to measure the amount of staining. They found that p16, a cyclin-dependent kinase inhibitor, had a higher mean p16 expression score for AIS (7.4; P < 0.0001) and invasive cervical adenocarcinoma (6.6; P < 0.0001), compared to normal endocervix. A cutoff p16 expression score of 5 had a sensitivity of 94.5% and specificity of 100% in both AIS and invasive adenocarcinoma of the cervix. The authors concluded that p16 is able to discriminate in situ and invasive cervical adenocarcinoma from benign endocervical tissue. They suggest it may have an adjunctive role in cervical screening but this needs to be evaluated further. Click here for abstract from AM J OB/GYN New England Journal of Medicine – Mario Leitao Nothing of interest this month Journal of the American Medical Association – Margrit Juretzka Nothing of interest this month Cancer – Destin Black Title: Restaging surgery for women with borderline ovarian tumors Authors: Raffačle Fauvet, M.D., Joëlle Boccara, M.D., Charlotte Dufournet, M.D., Emmanuel David-Montefiore, M.D., Christophe Poncelet, M.D., Ph.D., Emile Daraď, M.D., Ph.D. Source: Cancer, Volume 100, Issue 6, Pages 1145-1051 Summary: This retrospective multicenter study evaluated 54 women with borderline ovarian tumors who underwent a restaging operation. Epidemiologic, surgical, and histologic parameters and risk of recurrence were compared between women who underwent restaging (n = 54) and those who did not (n = 244). Eight (14.8%) of the 54 women who underwent restaging had their tumors upstaged: 7 of the 41 cases initially diagnosed as Stage IA tumors were upstaged to Stage IB (n = 3) or to Stage IIA, IIB, IIIA, or IIIC (n = 1 for each); in the eighth case, a Stage IC tumor was upstaged to Stage IIIA. There was no significant difference in histological features, surgical features, or preoperative CA-125 serum levels found between women who were upstaged and those who were not; however, upstaging tended to be more common in women with serous borderline tumors (P = 0.06) and in women who underwent cystectomy (P = 0.08). There was no difference in recurrence rates whether or not a restaging operation was performed. The authors concluded that women who initially were diagnosed with Stage IA serous borderline tumors or who had a previous cystectomy may derive benefit from a restaging operation. Click here for abstract from Cancer Title: Secondary cytoreductive surgery for patients with relapsed epithelial ovarian carcinoma: Who benefits? Authors: Rong-Yu Zang, M.D., Ph.D., Zi-Ting Li, M.D., Jie Tang, M.D., Xi Cheng, M.D., Shu-Mo Cai, M.D., Zhi-Yi Zhang, M.D., Nelson N. Teng, M.D., Ph.D. Source: Cancer, Volume 100, Issue 6, Pages 1152-1061 Summary: This prospective trial evaluated 117 patients with relapsed epithelial ovarian carcinoma (EOC) who underwent secondary cytoreductive surgery (SCR). After SCR, 11 patients were rendered macroscopically disease free, 61 patients had residual disease that measured ≤1 cm in greatest dimension, and 45 patients had bulky intraabdominal residual disease. Survival was influenced by the size of residual disease after SCR, the extent of relapse disease, the number of cycles of salvage chemotherapy after SCR, and the ECOG performance status. The outcome of SCR was influenced by the extent of relapse disease (multiple sites [51.2%] vs. solitary sites [87.9%]; relative risk [RR] = 9.1237; P = 0.0002) and by the use of bowel resection (yes [60.9%] vs. no [37.5%]; RR = 0.3828; P = 0.0106). The authors concluded that optimal SCR may provide a survival benefit particularly when surgery is supported by multiple courses of salvage chemotherapy. Click here for abstract from Cancer Lancet – Sarah Ferguson Nothing of interest this month Cancer Research – Destin Black Nothing of interest this month American Journal of Surgical Pathology – Alan Schlaerth Title: Polypoid Endometriosis: A Clinicopathologic Analysis of 24 Cases and a Review of the Literature Authors: Parker RL, Dadmanesh F, Young RH, and Clement PB Source: Am J of Surg Path. Vol 28, No. 3, March 2004: 285-297 Summary: The authors describe 24 cases of polypoid endometriosis which have important features in distinguishing from a low-grade mullerian neoplasm. The patients were 23 to 78 years old (mean 52.5 years). Seven were on unopposed estrogen, four on combination estrogen progestin therapy, and one had a synchronous ovarian thecoma. Clinical presentations included pelvic mass, vaginal polypoid masses, and large bowel obstruction. Intraoperative evaluation revealed lesions up to 14cm in size. In 22 out of 24 of the cases, the polypoid endometriosis lacked periglandular stromal hypercellularity, stromal atypia, and intraglandular stromal papillae, helping to distinguish it from adenosarcoma. Followup of 17 of these patients revealed 15 to be alive without residual disease, 1 alive with residual endometriosis, and 1 died of other causes. |
5 cm, or
positive pelvic lymph nodes. The median follow-up time was 6.6 years. The
overall survival rate for patients treated with CTRT was significantly
greater than that for patients treated with EFRT (67% v 41% at 8
years; P < .0001). There was an overall reduction in the risk of
disease recurrence of 51% (95% CI, 36% to 66%) for patients who received
CTRT. The rate of serious late complications of treatment was similar for
the two treatment arms. Mature analysis confirms that the addition of
fluorouracil and cisplatin to radiotherapy significantly improved the
survival rate of women with locally advanced cervical cancer without
increasing the rate of late treatment-related side effects. © 2004 SMGO, All Rights Reserved.