Should pelvic and para-aortic lymphadenectomy be different depending on histological subtype in epithelial ovarian cancer?

BACKGROUND: The aim of this study was to determine the influence of the different histological subtypes (serous versus non-serous) on the location of nodal metastases in patients undergoing pelvic and para-aortic lymphadenectomies during the initial management of epithelial ovarian tumors. METHODS: We carried out a retrospective analysis of data concerning patients fulfilling the following inclusion criteria: (1) an epithelial ovarian tumor; (2) a complete pelvic and bilateral para-aortic lymphadenectomy up to the level of the left renal vein; (3) surgical procedures including lymphadenectomies performed before adjuvant chemotherapy; and (4) a description of the distribution of positive nodes removed between pelvic and para-aortic areas. Patients were classified into two groups according to the histological subtypes: serous (group 1) and non-serous (group 2) tumors. RESULTS: Of patients treated between 1989 and 2005, 148 fulfilled the inclusion criteria: 73 had a serous tumor and 75 a non-serous tumor. Positive nodes were observed in 70 (47%) patients-47 (64%) in group 1 and 23 (31%) in group 2 (P < 0.05). But the distribution of involved nodes between pelvic and para-aortic areas in patients with positive nodes was not statistically different between the two groups. In both groups, the most common site for positive nodes in the para-aortic area was the left para-aortic group: 74% in group 1 and 61% in group 2 (NS). CONCLUSIONS: This series suggests that the histological subtype has no impact on the distribution of positive nodes in pelvic and para-aortic areas in patients with epithelial ovarian tumors.

Para-aortic involvement and interest of para-aortic lymphadenectomy after chemoradiation therapy in patients with stage IB2 and II cervical carcinoma radiologically confined to the pelvic cavity.

BACKGROUND: Pelvic radiation therapy with concomitant chemotherapy (PCRT) is the standard treatment of stage IB2/II cervical carcinoma. The impact of concomitant chemotherapy on positive para-aortic nodes (PA+), however, remains unknown. The aim of this study was twofold: to evaluate the rate of histological PA+ after PCRT and to determine the survival of patients with PA+. METHODS: Patients fulfilling the following inclusion criteria were studied: (1) stage IB2/II cervical carcinoma, (2) histological subtype: squamous cell, adenocarcinoma or an adenosquamous tumor, (3) exclusion of patients with radiological PA+ (CT scan/MRI), (4) pelvic external radiation therapy of 45 Gy with concomitant chemotherapy (cisplatin 40 mg/m2/week) + utero-vaginal brachytherapy, and (5) completion surgery after the end of PCRT including at least a para-aortic lymphadenectomy. RESULTS: Seventy-three patients (16 stage IB2, 57 stage II) treated between 1998 and 2004 fulfilled all the inclusion criteria. PA+ after PCRT were observed in 13 patients (18%) with a median of five (range, 2-22) positive nodes. Overall and disease-free survival at 24 months in patients with PA+ was 40% and 17%. Only two patients with PA+ are currently alive and in remission. CONCLUSIONS: The rate of PA+ remains high after PCRT in patients treated for stage IB2/II cervical carcinoma. Furthermore, the survival rate of patients with PA+ is very low. These important results suggest that detection of PA + at the time of completion surgery (after PCRT) is not beneficial for improving survival.

Endometrial disorders in patients with peritoneal serous papillary carcinoma.

BACKGROUND: The purpose of this study was to evaluate the incidence rate of endometrial disease, particularly endometrial carcinoma, in patients with primary peritoneal serous papillary carcinoma (PSPC). METHODS: Retrospective review of clinical and histological data from 32 women undergoing surgery (with hysterectomy) for stage III or IV PSPC. RESULTS: Six patients underwent primary debulking surgery and 26 underwent interval debulking surgery after 3 or 4 courses of platinum-based chemotherapy. Six patients (18%) had endometrial disease (hyperplasia in four). Two patients had endometrioid adenocarcinoma of the uterine body (stage IA grade 1 in one case, and stage IB grade 1 in the other) associated with the PSPC. CONCLUSIONS: Endometrial carcinoma of the uterine body may be associated with PSPC (6% cases in the present series). This result suggests that systematic hysterectomy should be performed at the time of debulking surgery in PSPC, even in the absence of peritoneal spread within pelvic cavity.

Growing teratoma syndrome after ovarian germ cell tumors.

OBJECTIVE: To analyze a series of occurrences of growing teratoma syndrome after ovarian germ cell tumors. METHODS: We analyzed a database containing 103 patients affected by pure or mixed ovarian immature teratoma. RESULTS: We report 12 patients fulfilling growing teratoma syndrome criteria (incidence 12%). The median interval between the diagnosis of ovarian immature teratoma and growing teratoma syndrome was 9 months (range 4-55). Growing teratoma syndrome was revealed by radiological examinations in nine cases (75%). In all cases but one, growing teratoma syndrome occurred in the site involved by the primary tumor. The peritoneum was the first site involved (10 cases, 83%). A complete surgical resection of the growing teratoma syndrome was done in eight cases. The median follow-up was 144 months. Four patients presented a late growing teratoma syndrome recurrence after treatment (second event), more than 5 years after the initial diagnosis, and 14 years later for one patient. All patients but one (lost to follow-up) were still alive at the end of the study. CONCLUSION: The treatment of growing teratoma syndrome consists of the surgical resection of the tumor, as completely as possible. Because of the possibility of very late recurrence of growing teratoma syndrome, a prolonged follow-up of patients treated for ovarian immature teratoma is mandatory.

Anatomy of pelvic and para-aortic nodal spread in patients with primary fallopian tube carcinoma.

BACKGROUND: To describe characteristics of patients with nodal spread and the anatomy of pelvic and para-aortic node involvement in primary fallopian tube carcinoma. STUDY DESIGN: Between 1985 and 2003, 19 women with primary fallopian tube carcinoma underwent systematic bilateral pelvic and para-aortic lymphadenectomy up to the level of the left renal vein. Initial lymphadenectomy (without chemotherapy) was performed in 6 patients and in 13 patients lymphadenectomies were performed after chemotherapy at the time of second-look operation. RESULTS: Nine patients had nodal involvement: four in the pelvic area and eight in the para-aortic nodes. Two, one, and six patients had stages I, II, or III disease, respectively. When para-aortic nodes were involved, the left para-aortic chain above the level of the inferior mesenteric artery was the site most frequently involved (six patients). CONCLUSIONS: In patients with primary tubal carcinoma, the left para-aortic chain above the level of the inferior mesenteric artery is the most frequently involved. Lymphadenectomy should involve all pelvic and para-aortic chains up to the level of the left renal vein, even in patients with stage I disease.

Impact of surgical staging in patients with macroscopic "stage I" ovarian borderline tumours: analysis of a continuous series of 101 cases.

The aim of this study was to assess the patient's clinical outcome following complete or incomplete surgical staging in cases treated for an early stage low-malignant-potential ovarian tumour (LMPOT). One-hundred and one patients treated between 1965 and 1998 for a early stage I LMPOT were reviewed according to whether the initial surgical staging was complete (Group 1/defined by peritoneal cytology + peritoneal biopsies + infracolic omentectomy) or incomplete (Group 2/omission of at least one of the peritoneal staging procedures described above). Complete and incomplete surgical stagings were carried out in 48 (48%) and 53 (52%) patients, respectively. Four (8%) LMPOT recurrences were observed in Group 2, all following conservative management, but there were no recurrences in Group 1. No relapses with invasive carcinoma or peritoneal disease and no tumour-related deaths were observed. The absence of complete peritoneal staging in patients with an apparent "stage I" LMPOT increased the recurrence rate. However, this surgical restaging (in cases of incomplete initial surgery) does not modify the survival of patients with apparent "stage I" LMPOT misdiagnosed during the initial surgery. This procedure could probably be omitted: (1) if the peritoneum is clearly reported as "normal" during the initial surgery; (2) in the absence of a micropapillary pattern; and (3) if the patient agrees to be carefully followed-up.

Port-site implantation after laparoscopic treatment of borderline ovarian tumors.

BACKGROUND: The aim of this article is to report 3 cases of port-site implantation after laparoscopic treatment of a borderline ovarian tumor. CASES: Three patients underwent a laparoscopic procedure for a serous (2 patients) or mucinous (1 patient) borderline ovarian tumor. In 2 patients, the port-site implantation was discovered during a later surgical procedure, and one was discovered clinically 11 months after the initial laparoscopic oophorectomy. Surgical resection of the port-site was the only treatment in all cases. These women are currently alive and disease-free 11, 23, and 51 months after the treatment of the scar metastasis. CONCLUSIONS: These results suggest that, unlike port-site metastasis in other gynecologic malignancies, the prognosis in patients with a port-site implantation after laparoscopic management of borderline ovarian tumor is excellent. The treatment of this complication is surgical resection.

Lymph node disorders and prognostic value of nodal involvement in patients treated for a borderline ovarian tumor: an analysis of a series of 42 lymphadenectomies.

BACKGROUND: The aim of this study is to evaluate the rate and the clinical outcomes of lymph node involvement in patients treated for borderline ovarian tumor (BOT). STUDY DESIGN: Forty-two patients were treated for BOT with a procedure that included lymphadenectomy. Twenty-four patients underwent a pelvic lymphadenectomy, 6 a paraaortic lymphadenectomy, and 12 both procedures. Thirty-two patients underwent systematic lymphadenectomy, five because of associated cancer (uterine cervix or corpus) and five because of bulky nodes discovered during the surgical procedure. RESULTS: An endosalpingiosis was present in 11 (26%) patients who underwent lymphadenectomy. Eight patients had nodal involvement related to the BOT. All patients with nodal involvement had serous BOT with peritoneal implants. None of the patients with a mucinous tumor had nodal involvement. None of the patients with early-stage disease (without peritoneal disease) had nodal involvement discovered after routine lymphadenectomy. None of the patients with nodal involvement died of borderline tumor. One patient died of a complication of adjuvant therapy (leukemia after chemotherapy). CONCLUSIONS: The prognosis of patients with borderline tumors of the ovary and nodal involvement is excellent. Routine lymphadenectomy should not be performed in patients with early-stage disease. This procedure should be carried out in patients with serous tumor and enlarged lymph nodes.

Results of interval debulking surgery compared with primary debulking surgery in advanced stage ovarian cancer.

BACKGROUND: Results of IDS (after three to four courses of induction chemotherapy) were compared with PDS followed by chemotherapy in patients treated for advanced stage ovarian cancer (stage IIIC or IV). STUDY DESIGN: A retrospective study was done on a group of 57 patients who underwent IDS (because of an unresectable tumor) compared with a group of 28 patients treated with PDS (for resectable disease) followed by chemotherapy. All patients were treated between 1996 and 2001 by the same team of surgeons and received the same regimen of chemotherapy (platinum based plus paclitaxel). RESULTS: Optimal cytoreductive surgery (residual disease < or = 2 cm) was achieved in IDS and PDS groups in 84% (48 of 57) and 100% (28 of 28) of patients, respectively. Complete resection was observed in 51% (29 of 57) of patients in the IDS group and 54% (15 of 28) of patients in the PDS group. The rates of bowel resection, large peritoneal resection, and postoperative morbidity were significantly reduced in the IDS group. After adjusting for the size of residual disease (< or /= 2 cm and absence of residual tumor), overall and event-free survival were not different in the two groups. CONCLUSIONS: Survival rates were similar in patients with advanced stage ovarian cancer who underwent IDS or PDS. The rates of surgical resection and morbidity were reduced after IDS. IDS can be safely used in unresectable advanced stage ovarian cancer.

Lymph node involvement in epithelial ovarian cancer: analysis of 276 pelvic and paraaortic lymphadenectomies and surgical implications.

BACKGROUND: The purpose was to determine the factors influencing nodal involvement and topography of pelvic and paraaortic node involvement in ovarian carcinoma. STUDY DESIGN: Between 1985 and 2001, 276 women with epithelial ovarian carcinoma underwent systematic bilateral pelvic and paraaortic lymphadenectomy. RESULTS: The overall frequency of lymph node involvement was 44% (122 of 276). The frequency of pelvic and paraaortic metastases were 30% (82 of 276) and 40% (122 of 276), respectively. The frequency of lymph node metastases according to the stage of the disease (stages I, II, and III + IV) were: 20% (17 of 85), 40% (6 of 15), and 55% (99 of 176), respectively. In patients with stage IA, IB, and IC disease, the rates of nodal involvement were 13% (8 of 60), 33% (4 of 12), and 38% (5 of 13), respectively. None of 15 patients with stage IA grade 1 disease had nodal involvement. None of the 20 patients with mucinous tumors confined to the ovary(ies) (stage I disease) had nodal involvement. When paraaortic nodes were involved, the left paraaortic chain above the level of the inferior mesenteric artery was the most frequently involved site (70 patients, 63%). One of nine patients (11%) with a macroscopic stage I unilateral tumor and paraaortic involvement had contralateral metastases. CONCLUSIONS: Lymphadenectomy should be performed even in patients with stage IA disease. This procedure could be omitted in patients with mucinous apparent stage I disease and stage I grade 1 tumor. Lymphadenectomy should involve the whole pelvic and paraaortic chain up to the level of the left renal vein. A bilateral dissection should be performed even in cases of patients with a unilateral tumor.

[Gynecological cancers and pregnancy: the point of view of the oncology gynecologist]. / Cancers gynécologiques et grossesse: le point de vue du gynécologue oncologue.

Cervical cancer and nonepithelial ovarian cancer are the most frequent gynecological tumors diagnosed during the pregnancy. The management of patients with a malignant tumor discovered during her pregnancy depends on the type of the tumor, the tumor stage and the term of the pregnancy. In most of cases, a conservative management of the pregnancy could be offered without affect the optimal approach for the treatment of the tumor nor the survival of the patient. But such management needs to be determined in a multidisciplinary staff with oncologists, neonatologists, obstetricians but also the point of view of the patient.

[Conservative management of malignant and borderline ovarian tumor]. / Chirurgie conservatrice des tumeurs malignes et borderline de l'ovaire.

Conservative management of at least a part of one ovary and the uterus, in order to preserve fertility-potential, could be propose in most of patients with nonepithelial and borderline ovarian tumor. This conservative management could be performed even in patients with borderline ovarian tumor associated with noninvasive peritoneal implants (if complete resection of peritoneal disease). A removal of the preserved ovary after completion of the pregnancy(ies) is not necessary if patients agree to a careful follow-up procedure. In patient with epithelial ovarian cancer, conservative management could be performed only in case of young patients who desire to preserve fertility function with: unilateral tumor (stage IA), grade 1 (and 2?), who underwent an adequate staging surgery (including peritoneal washings, omentectomy, multiple peritoneal biopsies, uterine curettage and complete pelvic and paraaortic lymphadenectomy) and with a careful follow-up. A conservative management should not be performed in patients with tumor stage > IA and/or grade 3. Removal of preserved ovary should be performed after completion of pregnancy(ies) in order to reduce the risk of ovarian recurrence.

[Identification and management of hereditary predisposition to cancer of the breast and the ovary (update 2004)]. / Identification et prise en charge des prédispositions héréditaires aux cancers du sein et de l'ovaire (mise à jour 2004).

BACKGROUND: Since the last recommendations, up to 2,500 new references had been published on that topic. METHODOLOGY: On the behalf of the health Minister, the Ad Hoc Committee consisted of 13 experts carried out a first version revisited by five additional experts who critically analyzed the first version of the report. MAIN UPDATING: Breast and ovarian cancer seem to be associated with fewer deleterious mutation of BRCA12 and BRCA2 than previously thought. The screening of ovarian cancer is still not an attractive option while in contrast MRI may be soon for these young women with dense breast, the recommended option for breast cancer screening. The effectiveness of prophylactic surgeries is now well established. French position is to favor such surgeries with regard to a quality of life in line with the expected benefit, and providing precise and standardized process described in the recommendation. CONCLUSIONS: Due to methodological flaws, the low power and a short follow-up of the surveys, this statement cannot however aspire to a high stability.

[Standards, Options and Recommendations for the management of invasive cervical cancer patients (non metastastic)]. / Standards, Options and Recommandations Cancers invasifs du col utérin stades non métastatiques, version abrégée.

CONTEXT: The "Standards, Options and Recommendations" (SOR) project, started in 1993, is a collaboration between the Federation of French Cancer Centers (FNCLCC), the 20 French cancer centers and specialists from French public university and general hospitals and private clinics. Its main objective is the development of clinical practice guidelines to improve the quality of health care and outcome for cancer patients. The methodology is based on literature review and critical appraisal by a multidisciplinary group of experts, with feedback from specialists in cancer care delivery. OBJECTIVES: To develop, according to the definitions of the Standards, Options and Recommendations, clinical practice guidelines for the management of invasive cervical cancer patients. Methods : Data were identified by searching Medline and the personal reference lists of members of the expert groups, then submitted for review to independent reviewers. RESULTS: This is a synthesis of the Standards, Options and Recommendations elaborated by a working group of experts. Pretherapeutic assessment, classification, diagnosis, therapeutic modalities (surgery, radiotherapy, radiochemotherapy, chemotherapy), therapeutic strategies by disease stage and follow-up are covered. Algorithms for the management of patients are also included.

[Management of advanced stage ovarian cancer]. / Traitement initial des cancers épithéliaux de l'ovaire de stade avancé.

The management of advanced stage ovarian cancer was deeply modified during last years. The standard treatment of advanced stage ovarian cancer in 2004 remains the initial surgery (in order to obtain ideally a total resection of all macroscopic disease) followed by adjuvant chemotherapy (6 courses of platinum based chemotherapy). But in patients with massive spread, interval debulking surgery (performed after 3 or 4 courses of neo-adjuvant chemotherapy) is becoming an interesting option (and perhaps will become a standard management). This treatment is actually studied in randomized trials.

Patterns of care and outcome in elderly cervical cancer patients: a special focus on brachytherapy.

BACKGROUND: The mean age of the general population has been prolonged and the incidence of cancer in elderly patients has increased. The purpose was to evaluate outcome of brachytherapy (BT) as an integrated part of the treatment of elderly patients with cervical cancer. PATIENTS AND METHODS: From November 1997 to January 2006, 1073 patients diagnosed with uterine cervical cancer with stages I-IV (FIGO) have completed BT at the Institut Gustave Roussy. A retrospective analysis was carried out with 113 patients aged over 70-year-old treated by conventional low dose rate (LDR) BT as a part of their treatment. RESULTS: The median age was 76 years (range, 70.7-94.4). Eighty-four percent of the patients presented a squamous cell carcinoma. Fifty-two percent of the patients were treated by a sequence excluding surgery. The mean 15 and 60 Gy treated volumes were 235 cm(3) (range, 30-371) and 138 cm(3) (range, 81-234), respectively. For the 15 Gy treated volume, the mean ICRU bladder and rectal points were 18.5 Gy (range, 6-35) and 33 Gy (range, 5-63), respectively. For the 60 Gy treated volume, the mean ICRU bladder and rectal points were 33 Gy (range, 12-64) and 41 Gy (range, 23-65), respectively. Rectal, small bowel and urinary tract complications were observed in 25 (22.1%), 5 (4.4%), and in 16 patients (14.2%), respectively. Rectal complications Grades I/II, III/IV and V (fatal) crude incidences were 19.4% (22/113), 1.8% (2/113) and 0.9% (1/113), respectively. Acute toxicity death occurred in one patient with major diarrhea associated with a hemodynamic shock. Small bowel complications Grades I/II and III/IV crude incidences were 3.5% (4/113) and 0.9% (1/113), respectively. Urinary tract complications Grades I/II and III/IV crude incidences were 11.5% (13/113) and 2.7% (3/113), respectively. With a median follow-up of 3.1 years, 10 patients developed distant metastases and 10 others presented local relapses. The 3-year specific overall survival rate was 88.6% (95%CI, 77-92) and the corresponding disease-free survival rate was 81% (95%CI, 72-88). CONCLUSIONS: Elderly women with cervical cancer tolerated BT well and had excellent local disease-free and specific survival rates. Age did not influence the effectiveness of BT in elderly patients and BT should be considered whenever possible, even in elderly patients presenting with a cervix cancer.

[Medical treatment of metastatic or recurrent cancer of the cervix]. / Traitement médical des cancers du col utérin métastatiques ou récidivants.

Cervical cancer is the most frequent gynaecological cancer worldwide. Incidence is decreasing in industrialized countries but remains high in poorest countries. In metastatic or recurrent disease, the treatment is more often palliative. Chemotherapy yields some efficiency in non-irradiated fields but the benefit should be balanced with the treatment toxicities. In this setting, cisplatin is considered as the drug of reference, but responses rates are poor. So far, combined chemotherapy has not been shown better than cisplatin alone. Recently, results for cisplatin associated with topotecan appear to be promising while used for treatment in metastatic or recurrent disease. However, the bad prognosis of this illness leads to keep on looking for better treatments. Targeted therapeutics and immunotherapy against human papilloma virus could bear significant progress for treatment of cervical cancer.

Advances in the surgical management of invasive cervical cancer.

PURPOSE OF REVIEW: Cervical cancer is the second most frequent cancer in women in the world. Surgery plays a major role, particularly in patients with early-stage disease. This review focuses on the evaluation of important papers published since January 2003 on the management of invasive cervical cancer. RECENT FINDINGS: Patients are classified as having early-stage (stage IB1) or advanced-stage (stage IB2 or greater) disease. Several papers are devoted to the evaluation of prognostic factors in patients with early-stage disease and negative nodes. Several recurrences after radical trachelectomy have been reported that remind us that strict selection criteria are mandatory for conservative management. The development of sentinel node and laparoscopic procedures has gained momentum. For patients with advanced-stage disease, the place of staging procedures in para-aortic areas or pelvic surgery after chemoradiation therapy continues to be debated and is currently being investigated in randomized studies. Several papers also continue to debate surgical treatment modalities for recurrent disease (the place of laparoscopy and reconstructive surgery). SUMMARY: Several interesting papers have been published since 2003 about the surgical treatment of cervical cancer. Laparoscopic surgery and the sentinel node procedure have developed considerably, particularly for the surgical management of early-stage disease. The results of ongoing studies are awaited to determine the value of pelvic surgery (after neoadjuvant treatment) in patients with advanced-stage disease.

A need for laparoscopic evaluation of patients with endometrial carcinoma selected for conservative treatment.

BACKGROUND: The aim of this paper was to report two cases of extrauterine disease in patients with early stage endometrial cancer (EC) who desired fertility-sparing management. CASES: Two patients presenting an apparent early stage EC and desiring conservative management. The two patients, aged 35 and 36 years old, had a grade 1 and grade 2 EC diagnosed after curettage or hysteroscopic resection of a polyp. Ultrasound (US) imaging was normal (ovary). Once informed about the risk of recurrence, both patients opted for conventional therapy (hysterectomy with bilateral salpingo-oophorectomy). A small ovarian carcinoma was found in one patient and isolated positive peritoneal cytology in the other. CONCLUSIONS: These cases seem to suggest that laparoscopic evaluation including adnexal exploration and peritoneal cytology (and possibly pelvic lymphadenectomy) should be performed in patients with early stage EC selected for conservative management to confirm the absence of extrauterine disease.