Is postoperative CA125 level in patients with epithelial ovarian cancer reliable to guess the optimality of surgery?

INTRODUCTION: Cytoreductive surgery is a pivotal component of primary treatment in patients with ovarian epithelial caner (OEC) and several studies have shown better outcomes of optimal debulking. The aim of this prospective study was to determine if optimum versus suboptimal cytoreductive surgery predicts CA125 levels two weeks after surgery. MATERIAL AND METHODS: Sixty patients with epithelial ovarian cancer scheduled for cytoreductive surgery in Imam Khomeini Hospital, Tehran, Iran were enrolled in this study. Two groups of patients were to undergo optimal or suboptimal cytoreductive surgery. Optimal cytoreduction was defined as the largest volume of residual disease < 1 cm in maximal dimension. CA125 levels were measured in all patients preoperatively and at two, seven and 14 days after surgery. CA125 levels were converted to a log scale. RESULTS: The distribution of staging, grading and types of tumors in each group were statistically equal but insignificant (chi square). The difference in mean of CA125 before and two weeks after surgery was statistically significant (paired t-test; p = 0.0001) but the grade, stage and type of tumors did not have any impact on CA125 regression. However, regression of CA125 two weeks after the operation did not differ statistically between the optimal and suboptimal cytoreduction groups (repeated measure ANOVA). CONCLUSION: Although, postoperative CA125 decreased significantly in two weeks after tumor cytoreduction in patients with epithelial ovarian cancer, its regression did not differ according to optimal or suboptimal groups.

Centralization of ovarian cancer surgery: do patients benefit?

BACKGROUND: The aim of the study was to compare the effect of surgery in patients with ovarian cancer by gynecologist-oncologists and general gynecologists on overall survival. MATERIAL AND METHODS: In a retrospective study all patients diagnosed with primary ovarian cancer at Vali-e-Asr Hospital (Tehran, Iran) between April 1999 and January 2005 were eligible for enrollment. A total 157 consecutive patients with ovarian cancer were available for analysis. There were no significant differences between the two groups with respect the stage, age and histological type of tumor. Of 157 patients, 60 were treated by gynecologist-oncologists and 95 by general gynecologists, and two patients were treated by general surgeons. RESULTS: The number of patients who had optimal cytoreductive surgery performed was higher in the gynecologist-oncologist group than the number in the general gynecologist group (p < 0.001). The majority of patients in the general gynecologist group needed a second operation while only a few in the gynecologist-oncologist group needed one (p < 0.001).The interval between initial surgery and beginning of chemotherapy was significantly longer in the gynecologist-oncologist group as compared to the general oncologist group (p = 0.001). Overall survival and disease-free survival were considerably better in the gynecologist-oncologist group but the difference was not significant. CONCLUSION: Patients with ovarian cancer should be referred to Gynecology-Oncology Departments for optimal treatment.

Fertility sparing in young women with ovarian tumors.

BACKGROUND: Surveys have shown that fertility sparing in patients with ovarian tumors has proven to be effective. Thus this approach in ovarian tumor cases has been carried out. The purpose of this study was to evaluate the clinical outcome and pregnancies in women who suffered from ovarian tumor and underwent conservative treatment. MATERIALS AND METHODS: All cases who received conservative treatment and those who had recurrence of the disease during the follow-up period were evaluated at Vali-Asr Hospital from 2000-2004. RESULTS: 60 of 410 patients with ovarian tumor (age range: 13-34) were treated conservatively. Three patients (5%) were infertile. Histology of tumors showed: 26 (43.3%) germ cell tumors, 15 (25%) borderline tumors, ten (16.7%) epithelial tumors and nine (15%) sex cord tumors. The cases were followed for 12-48 months. Seven term pregnancies occurred in six patients. Three in the borderline group, two in the germ cell group, one in the epithelial group and one in the sex-cord group. Nine recurrences were reported among our cases. Two of the patients (serous carcinoma and immature teratoma, both Stage IIIc) died during follow-up due to refusal to undergo radical surgery. CONCLUSION: Fertility preserving surgery in young women with epithelial ovarian tumors, borderline and sex-cord tumors Stage I, grade 1 and 2 is recommended.

Preservation of pregnancy in a patient with advanced ovarian cancer at 20 weeks of gestation: case report and literature review.

To report a case of FIGO stage III papillary serous carcinoma of ovary, diagnosed during pregnancy at 20 weeks of gestation and treated with unilateral salpingo-oophorectomy and surgical staging, then initial combination chemotherapy while preserving the pregnancy. The patient underwent cesarean section at 35 weeks after four courses of taxol plus carboplatin. She delivered a healthy baby. After that total hysterectomy, omentectomy, pelvic and para-aortic lymphadenectomies were carried out. The surgical resection was complete and no macroscopic residual diseases were seen. During histologic examination, traces of resistant disease were found. The patient underwent three postoperative courses of chemotherapy (carboplatin plus paclitaxel regimen). After 6 months follow-up, the patient remained in complete remission and the child's development was normal. Combination chemotherapy during pregnancy with preservation of the fetus could be considered, and should be discussed with caution in case of epithelial ovarian cancer diagnosed during the second trimester of the pregnancy.

Neoadjuvant chemotherapy and radical surgery compared to radical surgery alone in bulky stage IB-IIA cervical cancer.

AIM: The aim of this study was evaluation of the efficacy of neoadjuvant chemotherapy (NACT) and radical hysterectomy on long-term survival in stage IB-IIA locally advanced cervical cancer as compared with radical surgery alone. METHODS: We reviewed all patients with cervical cancer stage IB-IIA who were treated with two treatment modalities, i.e. NACT followed by radical hysterectomy and lymphadenectomy, and radical hysterectomy alone between March 1996 and March 2004. There were 22 patients in the NACT group (group 1) and 160 patients in the immediate radical surgery group (group 2). All patients in group 1 were followed for more than 108months, and long-term survival and factors affecting recurrence were evaluated. RESULTS: Nineteen patients in the NACT arm underwent radical surgery. Pelvic lymph node metastasis was found in 8 patients in this group and in 36 in the radical surgery group. Eighteen patients in the NACT group and 96 patients in the radical surgery group were scheduled for adjuvant postoperative chemoradiation. During the 9-year follow-up, recurrence rate was 47.1% and 30.2% in NACT and control groups, respectively. In the NACT group lymph node metastasis was a significant independent risk factor for recurrence. Overall survival in the NACT arm was not statistically significantly lower than the control arm (p=0.06). CONCLUSION: NACT did not improve long-term overall survival of bulky early-stage cervical cancer patients compared to primary radical surgery.

Successful treatment of two patients with gestational trophoblastic neoplasm presenting with emergent neurologic symptoms.

The objective of this study is to present the successful treatment of two young patients with gestational trophoblastic neoplasms (GTN) presenting with emergent neurologic symptoms without any gynecological problems. Case 1, a 22-year-old patient, was admitted to an infectious disease ward, with admitting diagnosis of encephalitis due to neurologic symptoms. Case 2, a 33-year-old patient, underwent craniotomy due to hemorrhagic brain tumor in the neurosurgery department. The diagnosis of GTN should be considered in any woman of reproductive age who has neurologic symptoms. It seems that multiagent chemotherapy in conjunction with whole-brain irradiation results in acceptable survival rate in brain metastatic GTN patients. Craniotomy is often necessary in fulminant cases.

Good fetal outcome of pregnancies with gynecologic cancer conditions: cases and literature review.

Gynecologic malignancies frequently occur in women of reproductive age and are estimated to complicate 1 in 1000 pregnancies. Cancer diagnosis may be delayed because of difficulties in distinguishing symptoms from physiologic changes in pregnancy. Another problem is applying the standard workup in pregnant women. These reports describe the good fetal outcome of pregnancies in patients with vulvar and ovarian carcinoma. Patients underwent multimodality treatment, and their infants were developmentally normal. Vulvar and ovarian cancer is a rare finding in pregnancy. Early diagnosis and appropriate treatment offer the best prognosis. Aggressive postoperative chemotherapy also continues to better the outcome.

Unusual location of ovarian mixed germ cell tumor.

Intra-abdominal unusual location of mixed germ cell tumor of ovary, which consisted of endodermal sinus tumor and immature teratoma components, has been reported. Patient was a 21-year-old girl with a chief complaint of abdominal pain and mass. Ultrasound and computed tomography scan showed lobulated cystic mass. Laparotomy was performed, and due to specific localization, in which tumor localized as a tumoral bridge between two ovaries, we just performed maximal fertility-sparing surgery by preserving ovaries, tubes, and uterus. After that, four courses of chemotherapy (bleomycin, etoposide, and cis-platinum) were done to cure her. The alfa-fetoprotein became negative after three courses of chemotherapy, and she is under observation for the time being.

Patient delay in women presenting with advanced breast cancer: an Iranian study.

INTRODUCTION: Due to the lack of systematic screening programmes for early detection of breast cancer in Iran and the predominance of advanced cases, we aimed to study the extent and determinants of patient delay in women with advanced breast cancer. MATERIALS AND METHODS: In this 1-year cross-sectional study, all consecutive women with advanced breast cancer (stages IIb, III or IV) who initially presented to a university hospital were studied. RESULTS: Sixty-eight percent (136/200) of cases had delayed their first visit by >1 month and 42.5% by >3 months. The median patient delay was 12 weeks. Delay was associated with: older age, being married, lower income, less education, place of residence (small cities), negative family history of breast cancer, belief in the fatality of breast cancer, lack of access to health care services, lack of knowledge of breast cancer symptoms, and denying the importance of breast self-examination. The main reasons given for the delay were: lack of knowledge regarding the necessity of such a visit, fear, negligence, lack of access to physicians, and poverty. DISCUSSION: In contrast to some other studies, this study found that married women and those with a negative family history of breast cancer waited longer than others before seeking care. Public education initiatives focused on encouraging women (especially high-risk groups such as older women, married women, and those living in small cities or villages) to see a doctor promptly for evaluation of breast symptoms can decrease delay and improve patient outcome.

Evaluation and management of brain metastatic patients with high-risk gestational trophoblastic tumors.

A retrospective study to evaluate the characteristics of brain metastatic patients with gestational trophoblastic tumors (GTT) and to analyze the results of treatment has been performed. During 1996-2001, 40 patients with metastatic GTT were diagnosed at Vali-e-Asr Hospital, Tehran, Iran. Of them, nine with brain metastases, which were documented with the help of computed tomography scan, were evaluated retrospectively. Eight patients received EMA-EP regimen (etoposide, methotrexate, actinomycin, etoposide, and cisplatinum) and one received EMA-CO (etoposide, methotrexate, actinomycin, cyclophosphamide, and vincristin). All cases received whole brain irradiation therapy concurrently. The median age of the patients at diagnosis was 30 years (range: 17-53). Six of them were of early group (five with symptoms of central nervous system and one was detected during workup) and three were of late group (relapsed group). Five (56%) patients responded to treatment and four (44%) were deceased (three of them belonged to late group). It seems that multi-agent chemotherapy (EMA-EP) concurrently with whole brain irradiation results in acceptable survival rates in GTT patients with brain metastases.

Is normal beta-hCG regression curve helpful in the diagnosis of persistent trophoblastic disease?

OBJECTIVE: The aim of this study was to evaluate the probable usefulness of normal beta-human chorionic gonadotropin (beta-hCG) regression curve in the diagnosis of persistent trophoblastic disease (PTD). METHODS: A log-value regression curve was developed from the means and 95% confidence limits of serial weekly serum beta-hCG titers of 43 patients with uneventful complete hydatidiform moles and 14 patients, who were previously confirmed as PTD. RESULTS: All 14 PTD patients (100%) had abnormal values, beyond normal range, within 4 weeks. beta-hCG was in its upper values, compared to normal regression curve at 2.29 +/- 0.19 weeks. This was earlier than plateau or rise detection at 4.21 +/- 0.33 weeks (P < 0.001). Within 3 weeks of evacuation, 13 of 14 (92.86%) PTD patients' beta-hCG values exceeded the normal range, whereas only six of 14 (42%) showed a rise or plateau. CONCLUSION: Our finding indicates that the normal beta-hCG regression curve may be useful for quicker detection of PTD than the plateau or rise of level.

Visual inspection with acetic acid as a feasible screening test for cervical neoplasia in Iran.

The aim of this study was to estimate the sensitivity and specificity of visual inspection of the uterine cervix with acetic acid (VIA) as a screening test for cervical carcinoma and its precursors. One thousand and two hundred eligible women were screened by VIA and Papanicolaou smear. Those positive on one or both of these screening tests (n = 308) or those who had clinically suspicious lesions, even if the tests were negative [25% of remainders (n = 290)], were referred for colposcopy. Three hundred and fifty five of 598 women at colposcopy underwent biopsies or endocervical curettage. Those with cervical intraepithelial neoplasia I (CIN I) or worse lesions, diagnosed by histology, were considered true positive. VIA was positive in 191 women (16.1%). In 175 true-positive cases, VIA detected 130 cases, yielding a sensitivity of 74.3% and a specificity of 94%. By considering atypical squamous cell of undetermined significance or worse lesions on Papanicolaou smear as referring threshold for colposcopy, the sensitivity and specificity of cytology were 72 and 90.2%, respectively. In conclusion, the sensitivity and specificity of VIA is high and comparable with that of cytology. Hence, VIA can be undertaken as a feasible method of screening in cervical cancer in countries where access to cytopathology is limited.

EMA-EP regimen, as firstline multiple agent chemotherapy in high-risk GTT patients (stage II-IV).

Multiple agent chemotherapy in high-risk metastatic gestational trophoblastic tumor patients is a problem for any medical team. In this study, EMA-EP chemotherapy (etoposide, methotrexate, actinomycin, and cisplatinum) was evaluated as firstline chemotherapy to manage high-risk GTT metastatic patients. Seventeen high-risk metastatic patients, including 14 without and 3 with brain metastasis, who were candidates to firstline multiple agent chemotherapy between April 2000 and March 2003 in Vali-e-Asr hospital took part in a prospective study under EMA-EP regimen. EMA-EP was prescribed in two periods: EMA in two consecutive days in week 1 and EP in 1 day in the following week with a week interval between these two (each cycle was repeated every 2 weeks). In brain metastasis group, patients got high-dose medication (methotrexate) together with brain radiotherapy. Remission, toxicity, full dose tolerance, and recurrences of patients were evaluated. Median age of patients was 30 (15-49), and they received 100 courses of chemotherapy including 75 low-dose courses and 25 high-dose courses. 71% of courses were done in full dosage (83% in low dose and 36% in high dose). The most common cause for dosage reduction was leukopenia. Two patients did not complete the regimen, one due to hypersensitivity and the other due to fever and leukopenia leading to death. All others, who received complete courses, achieved remission. In the group without brain metastasis, one case of recurrence was observed. Grade 3 anemia, grade 3 and 4 leukopenia, and grade 3 and 4 thrombocytopenia were observed in 3, 12, and 3% of patients, respectively. In current study, EMA-EP regimen in patients with high-risk metastatic GTN patients (with or without brain metastasis) lead to remission in all patients who completed the treatment courses.

Multiple, disseminated cutaneous metastases of vulvar squamous cell carcinoma.

Cutaneous metastases of vulvar carcinoma are extremely rare and have been reported in six patients so far. Our patient, who is the seventh one, is a 38-year-old woman with a history of diabetes mellitus. After detecting stage III squamous cell carcinoma of the vulva, she underwent radical vulvectomy and bilateral inguinal lymphadenectomy. She received 6000 cGy external beam radiation for positive margins. Six months later, she came back with multiple advanced skin lesions. Biopsy was performed and lesions were confirmed as cutaneous metastases. For her palliation, some chemotherapy drugs were prescribed. She is on her sixth chemotherapy cycle, but these skin lesions are somewhat a preterminal event and there is no well-established treatment for this phase of disease.

Borderline ovarian tumours: clinical analysis of 38 cases.

Thirty-eight patients with ovarian tumours of low malignant potential (borderline) were diagnosed and treated in Tehran University Gynecology Oncology Department from 1991 to 2002, and have been reviewed. In this study age, clinical behavior, symptoms, surgical stage, type of tumour, surgery, adjuvant treatment, survival and recurrences were evaluated. A retrospective chart review was performed on these 38 patients who were treated for histopathologically confirmed tumours of low malignant potential between 1991-2002. The mean age was 34.4 years, range (14-83) (SD: 18.33). Post surgical FIGO staging was: Stage I=93.75%, stage III 6.25%. Histologic subtypes were: Serous 76.31% (29 patients), Mucinous 21.05% (8 patients), Mixed types 2.63% (1 patient). Mean pre-operative CA125 value was 114.90 (SD: +/- 90.30). Thirty-three percent of patients had only a simple cyst in ultrasonography. Conservative surgery was performed in 76.32% (29 patients). More radical surgery (TAH + BSO) was performed in 9 patients (23.68%). There were 6 recurrences. Three patients with recurrence and invasive implants received chemotherapy and secondary surgery was performed. Survival rate was 100% at 3 years for all stages and 89% at 5 years. One patient died of recurrent disease at 48 months after initial diagnosis. Our data suggest that LMP tumours are most frequently diagnosed in stage I. Most common histological type was serous, and 5 of the recurrences of (6 patients) were initially diagnosed at stage I, and had been treated with conservative surgery with no adjuvant therapy.

First-line chemotherapy with 5-FU and platinum for advanced and recurrent cancer of the cervix: a phase II study.

This study was designed to assess the role of first-line chemotherapy with 5-fluorouracil (5-FU) and platinum in the treatment of advanced or recurrent cervical cancer. Ten patients with advanced or recurrent cancer of the cervix with no prior chemotherapy were entered in a phase II trial from October 2000 to November 2001. Eight patients were treated with Cis-platinum (50 mg/m2 over 60 minutes on the first day) followed by 5-FU (1 g/m2 over 24 hours for 4 days) and two patients with impaired renal function were treated with carboplatin (300 mg/m2 over 15 minutes on the first day) followed by 5-FU (1 g/m2 over 24 hours for 4 days) every 3 weeks until progression of disease or prohibitive toxicity had been observed. Median age was 52 years (range 28-70 years). Ten patients received a total of 42 cycles of chemotherapy. The mean number of chemotherapy cycles was 4.2 (median 4, range 3-7). Three patients had a partial response (30%, 95% CI, 1.7-58.5%). Mean duration of response was 198 days (range 122-273 days). Four patients required red blood cell transfusions; three of them had Grade II and one of the Grade III nausea and vomiting. Two had fever and neutropenia (one developed acute renal insufficiency), and there were no treatment related mortalities. First-line chemotherapy with platinum and 5-FU for advanced and recurrent cervical cancer is promising and deserves consideration for a larger phase III trial.

Effect of a five-week swimming program on rat bone: a histomorphometric study.

To specify the exercise-induced changes on different skeletal sites, the effect of a 5-week endurance swim training was studied in rats. Eighteen Lyon strain (Sprague-Dawley) 5-week old female rats were divided into nine sedentary and nine swimming rats. Each swim training session was increased by 15 minutes from 2-6 hours per day. A histomorphometric study was performed at the primary and secondary spongiosa of the distal femur and at the secondary spongiosa of lumbar and thoracic vertebral bodies. After training, bone loss was observed in the secondary spongiosa of lumbar vertebral bodies (24.7%) and in the primary spongiosa of distal femur (15.2%). A tendency to bone loss was also detected in the secondary spongiosa of distal femur (10.8%), whereas no change was detected in thoracic vertebral bodies. In secondary spongiosa, bone loss was accompanied with a thinning of trabeculae. Total eroded surfaces and osteoid surfaces were significantly decreased in the three studied skeletal sites, suggesting a decreased bone turnover. The decreased thickness of osteoid seams in both lumbar vertebrae and distal femur could mean that the osteoblastic activity has also been altered at the cell level, leading to thinning of trabeculae. Five-week swim training with such duration and intensity of exercise appears unable to increase bone volume in rats and, therefore, causes adverse effects. The three studied bones seemed to adapt differently to experimental conditions. The lack of ground reaction forces induced by water immersion might have contributed to the observed bone loss. "Normal" gravity would be an important cofactor in the osteogenic effects of exercise.