Conservative treatment for lower gynecological tract malignancies in children and adolescents: the Institut Gustave-Roussy experience.

Between 1972 and 1986, 37 patients with lower genital tract malignancies were treated with intracavitary or interstitial brachytherapy. Thirteen patients presented with clear cell adenocarcinoma, 14 patients with embryonal rhabdomyosarcoma, 6 patients with endodermal sinus tumor, 3 patients with sarcoma, and 1 patient with an undifferentiated tumor. FIGO classification was: Stage I, 16%; Stage II, 47%; and Stage III, 37%. Treatment policy included initial exploratory laparotomy with lymph node biopsy and ovarian transposition, chemotherapy (except in clear cell adenocarcinoma) and/or external radiotherapy prior to interstitial brachytherapy. Chemotherapy consisted of a combination of VAC-Ad (V = vincristine, A = D actinomycin, C = cyclophosphamide, Ad = adriamycin) in rhabdomyosarcoma and sarcomas, and MAC-Ad (M = methotrexate) in endodermal sinus tumor. External radiotherapy was used in seven patients: in one to reduce a bulky clear cell adenocarcinoma (20 Gy) and in six for pelvic nodal involvement (45 Gy). Brachytherapy techniques depended on tumor site and extent, and on the anatomy of the patients. Vulvar tumors were implanted with iridium-192 wires by an afterloading plastic tube technique. Cervical and vaginal tumors were treated with individually tailored moulded vaginal applicators loaded with either cesium-137 or iridium-192, with or without interstitial implants by plastic tube or guide gutter technique. Computerized dosimetry allowed calculation of treatment volumes and doses delivered on the tumor and adjacent critical organs. The prescribed dose (including external radiotherapy) was 60-75 Gy with 1-3 brachytherapy applications of a low dose rate (0.2 Gy/hr). Six patients are dead: one from chemotherapy complication, three of metastases (two sarcomas, one endodermal sinus tumor) and two of pelvic failures and metastases (two clear cell adenocarcinoma). The overall disease free 5-year survival is 72%. Actuarial 5-year local control is 84%, but including salvage is 94%: three (two rhabdomyosarcoma, one clear cell adenocarcinoma) of the five local failures were salvaged by surgery, chemotherapy and/or brachytherapy. Metastases occurred in six patients, one (sarcoma) salvaged by chemotherapy and external radiotherapy. Complications requiring surgery occurred in five patients: two hydronephroses, one urethral stricture, one ileo-cecal obstruction, and one vesicovaginal fistula. Twelve of the 17 patients (71%) over 12 years of age are normally menstruating. Two patients have produced three normal children. This multidisciplinary management of lower gynecological tract tumors including brachytherapy is both conservative and effective.

Preoperative radiation therapy in advanced carcinoma of the ovary.

Preoperative radiotherapy in advanced ovarian carcinoma was evaluated. The overall 5-year survival rate in the irradiated group was 27%. When tumour mass remaining after operation was less than 2 cm in diameter, this figure rose to 52%. Comparison was made between those in whom operation became feasible only after preoperative irradiation and patients in advanced stages who were primarily successfully operated to less than 2 cm and with a 5-year survival rate of 44%. Selection of the cases for preoperative radiotherapy is obviously necessary. Fixed, bulky tumours in the pelvis, with or without metastases, may be suitable for preoperative radiotherapy.

Endodermal sinus tumor of the vagina: radiation therapy and progeny.

BACKGROUND: Extraovarian endodermal sinus tumor generally originates in the vagina or cervix of young girls. Some 50 cases are known, all younger than 3 years of age. Many were treated with outdated regimens, and there are 5-year survival data on only nine of them. We describe a curative outcome of primary radiation only. CASE: A 40-year-old woman had a history of localized endodermal sinus tumor of the vagina, stage I, treated by brachytherapy at the age of 6 months. Radiation had a severe impact upon the later functioning of her pelvic organs, with marked deformity of the pelvic floor, vagina, urethra, and bones of the pelvic outlet. She conceived by homologous insemination at the age of 34. Delivery was by cesarean at 31.5 weeks' gestation. CONCLUSION: Current forms of management give preference to limited excisional surgery and multi-agent chemotherapy, analogous to that used for the treatment of endodermal sinus tumor of the ovary. This is the first report of a patient treated by radium needles and the only known patient who had a subsequent pregnancy.

Combination chemotherapy in the management of ovarian germ cell malignancies.

Twenty-four patients with ovarian germ cell malignancies received combination chemotherapy in the present series. Fifteen patients received intensive vincristine, actinomycin-D, and cyclophosphamide therapy for 12 to 18 courses, and 13 are alive and free of disease 34 to 86 months later. One patient with a stage III pure endodermal sinus tumor and one patient with a stage III mixed germ cell tumor composed predominantly of endodermal sinus tumor elements failed vincristine, actinomycin-D, and cyclophosphamide therapy, but each transiently responded to cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy. Nine patients subsequently were treated on a new protocol that used the intensive vincristine, actinomycin-D, and cyclophosphamide regimen for five to six courses for all stage I ovarian germ cell malignancies and cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy for advanced stage tumors containing endodermal sinus tumor. Each patient on the new protocol is alive and free of disease 14 to 26 months later. Short-term intensive vincristine, actinomycin-D, and cyclophosphamide therapy is recommended for all stage I ovarian germ cell malignancies requiring adjuvant chemotherapy. Preservation of ovarian and reproductive function is appropriate in the present group of patients. Vincristine, actinomycin-D, and cyclophosphamide therapy is also recommended for biomarker negative advanced stage ovarian germ cell malignancies. Cis-diamminedichloroplatinum, vinblastine, and bleomycin therapy is recommended for advanced stage biomarker positive ovarian germ cell malignancies. Serial alpha-fetoprotein (AFP) titers accurately reflect the status of endodermal sinus tumor elements and may be used as a guide to discontinue treatment for patients with pure endodermal sinus tumor malignancies, obviating the need for second-look surgery.

Slipped upper femoral epiphysis after radiotherapy.

Eight slipped upper femoral epiphyses in patients who had had radiotherapy are described. These cases involved five patients in an "at risk" population of 48. This increased incidence is highly significant.

[Primary intracranial germ cell tumor with abnormal high value of alpha-fetoprotein after the radiation therapy].

A 7-year-old boy was admitted to Hokkaido University Hospital complaining of headache and vomiting. On admission he was slightly confused and presented Parinaud's sign. CT scan revealed abnormal high density mass with contrast enhancement effect at the pineal region and obstructive hydrocephalus. Laboratory studies showed the normal value of human chorionic gonadotropin and no trace of alpha-fetoprotein. Germinoma was most suspected based on the findings of CT scan and laboratory studies. The radiation therapy was carried out for a month and CT scan taken after the radiation therapy revealed marked reduction of the size of the tumor at the pineal region, and he was discharged. But he was re-admitted 3 months after the discharge complaining of headache and vomitting again. CT scan showed the recurrence of the tumor and laboratory studies showed abnormal high value of A.F.P. After the ventriculo-peritoneal shunt, the sub-occipital craniectomy was performed by the Stein's approach, and the tumor was removed. Pathologically the tumor was a typical yolk sac tumor. This case is a very interesting case because it suggests an alternation of the element of the germ cell tumor by the radiation therapy. At first admission, germinoma was the main element of the tumor judging from the effectiveness of the radiation therapy and laboratory studies. But the main element of the tumor seemed to have changed to yolk sac tumor after the radiation therapy. The relation between the tumor markers and the types of the germ cell tumor and histopathological characters of the intracranial germ cell tumor were discussed.

[Combination of radiation and PVB chemotherapy for intracranial malignant germ cell tumor].

Intracranial malignant germ cell tumors such as embryonal carcinoma, endodermal sinus tumor, and choriocarcinoma are neoplasms of poor prognosis in the pediatric age group. Recently evidences of effectiveness of combination chemotherapy using cisplatin, vinblastine, and bleomycin (PVB therapy) have been reported. The authors experienced two cases with these tumors treated with radiation therapy and PVB therapy. PVB therapy was performed along with irradiation in hoping the effect of radiation sensitizer of cisplatin. Both patients showed no signs of tumor recurrence and no re-elevation of tumor makers even in the cerebrospinal fluid after more than ten months from the onset. Cisplatin has radiation sensitizing effect besides antitumor activity, but its permeability through the blood-CSF barrier is very poor. Also true is that germ cell tumors often disseminate in the cerebrospinal fluid. From these points, combination of irradiation and chemotherapy using cisplatin seems reasonable, though the superiority of this radiochemotherapy to simple PVB therapy can not be concluded from the present experience. Side effects of this combination therapy were the same as PVB therapy alone and tolerable.

[Intra-operative irradiation of solid tumors in children].

For the purpose of getting better therapeutic ratio of radiation therapy, an intra-operative irradiation was scheduled and attempted. The advantages of this modality are 1) only the target area is irradiated under the direct vision, 2) unnecessary area is not irradiated due to the selected field and selected electron beam energy, and 3) repeated fractionated irradiation are not necessary and an intensive post-operative chemotherapy can be started earlier. Electron beams of betatron are used according to the necessary depth of tumor volume: usually 8 or 10 MeV are used. The irradiation fields changed by the plastic treatment cones 4 cm to 12 cm in diameter according to the necessary tumor field. One of the biggest problems in an actual attempt of intraoperative irradiation was the determination of a single radiation dose. Actual time-dose relationship of the cured cases of Wilms' tumor and neuroblastoma was investigated by world literature. The single doses for 2 years old patients were calculated from Ellis' formula. They were 9.4-11.8 Gy for Wilms' tumor and 6.5-12.2 Gy for neuroblastoma. Consequently, the single dose was started from 10 Gy and increased up to 15 Gy at the present time. External irradiation was scheduled for supplement if necessary. The details of irradiation on 5 cases were discussed. The clinical evaluation of this treatment method will take time, and many problems remain to be solved clinically and experimentally, such as the radiation effect and side effect of a large single dose.

[Malignant germ cell tumors in the mediastinum].

Mediastinal germ cell tumors are divided into seminomas and non-seminomatous germ cell tumors. The former is a radiosensitive tumor that can be successfully treated by surgery and radiation. The latter is much more malignant than the former, however, the therapy has been making remarkable progress owing to CDDP. Nevertheless, the median survival time of patients with mediastinal involvement is 14 months, much lower than that seen in patients with testicular involvement. From our 12 patients and a review of the literature, we drew the following conclusions. If malignant germ cell tumors are suspected among anterior mediastinal tumors affecting male patients of around 20 years old, tumor markers such as AFP and HCG must be investigated and then, tissue histology should be diagnosed from specimens obtained by mediastinoscopy or anterior mediastinotomy. In the case of NSGCT, or AFP and/or hCG producing seminoma, the first choice is the chemotherapy including CDDP. Seminomas, that do not produce either AFP or HCG, can be treated by surgery and radiation. If the patients have tumor markers such as AFP and/or HCG, these are very useful to evaluate the efficacy of the therapy. When the efficacy of chemotherapy reaches the maximum, adjuvant surgery may be indicated. Chemotherapy should be continued, when malignant tissues are present in the resected mass.

Carcinoma of the vagina in young adults.

PIP: Adenocarcinoma in young women is not well known, but because of tumor association with vaginal adenosis, there seems to be a mullerian origin. Estrogen administration to patients' mothers is suggested as a causative factor in 7 out of 8 cases studied. Because of misleading biopsy reports, due to a histological similarity to hypernephroma, treatment may be delayed while searching for a primary growth elsewhere. Treatment usually involves pelvic exenteration but favorable progress may be obtained by intracavity radium. Stilbesterol was common treatment for recurrent abortion in Liverpool from the late 1940's to the early 1950's, but only 2 cases of vaginal carcinoma have been reported between 1950 and 1972. Histological diagnosis may have been uncertain due to a lack of awareness of adenocarcinoma.^ieng

[Preserving ovarian function in the treatment of epithelial and special (other) malignant ovarian tumors]. / Erhaltung der Ovarialfunktion in der Behandlung der epithelialen und speziellen (anderen) malignen Ovarialtumoren.

About 90% of malignant tumors of the ovary in Scandinavia develop from the germinal epithelium. There are great differences in the incidence rates between countries in the Western world and in Africa and Asia. The WHO classification of ovarian malignancies is generally used. The epithelial tumors comprise the serous, mucinous, endometrioid, clear cell, undifferentiated and mixed true carcinomas. In addition, borderline lesions of especially the serous and mucinous types are of interest when the question of preservation of ovarian function comes into notice. Conservative surgery, which means removal of only the afflicted ovary should be restricted to young women of the childbearing age who want to preserve the possibility of becoming pregnant. However, certain prerequisites must be fulfilled. The tumor must be located to one ovary only (Stage Ia) and must be either a borderline lesion or a Grade 1 true carcinoma of either the serous, mucinous or endometrioid type. There must be no ascites and peritoneal washings must be negative for cancer cells. Germ cell tumors are usually found in young women. Only the dysgerminomas are regularly bilateral in 10-15% of the cases. All other germ cell tumors are rarely bilateral. But both in borderline lesions, Grade 1 true carcinomas, and in germ cell tumors, a biopsy of the normal looking contralateral ovary should always be performed. Endodermal sinus tumors and immature teratomas may well be treated conservatively by surgery, but modern triple chemotherapy (VAC, PVB) must be added. Granulosa theca cell tumors are bilateral in only about 5% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Endodermal sinus tumor of the infant vagina.

A case of endodermal sinus tumor of the infant vagina is reported with long-term survival after successful therapy by surgery, chemotherapy, and radiation. The previous 26 reported cases are reviewed and the problems of therapy and long-term management are discussed. Therapy of these tumors should be monitored by alpha-fetoprotein radioimmunoassay.