Upstaging pathologic stage I ovarian carcinoma based on dense adhesions is not warranted: a clinicopathologic study of 84 patients originally classified as FIGO stage II.

BACKGROUND: FIGO stage II ovarian cancer comprises 8% of ovarian cancers. It is a common but not universal practice to upstage densely adherent pathologic stage I tumors to stage II. FIGO guidelines are not clear, and data supporting this practice are sparse. METHODS: We retrospectively reviewed patients with stage II ovarian cancer and grouped them based upon histologic evidence of extraovarian extension. Tumors densely adherent to extraovarian structures but without histologic tumor outside the ovary were considered pathologic stage I. All others were considered surgical-pathologic stage II. Three histologic patterns of extraovarian tumor involvement were identified. RESULTS: Eighty-four patients were studied. Twenty-four patients had pathologic stage I disease and 60 had histologic evidence of extraovarian pelvic spread and were surgical-pathologic stage II. The 5-year survival for stage I was 100%, and the median survival was not reached. The 5-year survival for those with surgical-pathologic stage II disease was 56.8% and the median survival was 73 months. There were no differences observed based upon pattern of extraovarian spread. The survival difference between pathologic stage I and surgical-pathologic stage II was significant (p<0.001). There were no differences seen in 5-year survival among surgical-pathologic stage II patients with serous, endometrioid or clear cell histologies (64.5%, 64.8% and 64.3% respectively). CONCLUSION: These retrospective data suggest that the practice of upstaging densely adherent pathologic stage I tumors to stage II may not be warranted. Cell type is not a prognostic factor in stage II.

Prognostic factors for stage I ovarian carcinoma.

Stage I ovarian carcinoma is relatively uncommon, and data on prognostic factors are conflicting. The clinical and pathologic features of 51 International Federation of Gynecology and Obstetrics stage I ovarian carcinomas were analyzed. There were 22 stage IA, 1 stage IB, and 28 stage IC cases. The mean follow-up was 6.1 years. The 5-year and 10-year disease-specific survival rates for the entire cohort were 92% and 78%, respectively. Among 51 patients, there were 6 tumor deaths, and 1 patient died of unrelated causes. All patients who died of disease were stage IC. Significant adverse prognostic factors were serous histology [relative risk (RR) 5.4, 95% confidence interval (CI) 1.3-22.0] and stage IC (RR 1.3, 95% CI 1.1-1.5). Among factors associated with stage IC, only positive washings or ascites affected survival (RR 9.25, 95% CI 1.9-44.4). The 5-year survival rates for stages IA and IC were 100% and 83%, respectively (P<0.025, log rank test). For comprehensively staged patients, the 5-year survival rate was 96% as compared with 72% for all others (P<0.025, log rank test). Tumor rupture, surface involvement, histologic grade and clear cell histology were not of adverse prognostic significance. Serous histology and positive washings or ascites are adverse prognostic factors in stage I. The prognostic importance of tumor grade, rupture, surface involvement and clear cell histology remains unclear. Patients who are International Federation of Gynecology and Obstetrics stage I on the basis of comprehensive surgical staging have an excellent prognosis.

Epstein-Barr virus-associated uterine leiomyosarcoma in an adult lung transplant patient.

BACKGROUND: Multiple viruses have been associated with carcinogenesis in solid-organ transplant patients. Although Epstein-Barr virus (EBV) has been associated with lymphomas in immunocompromised patients, an association with smooth muscle tumors recently has been described. CASE: An EBV immunoglobulin G-positive woman underwent bilateral lung transplant for sarcoidosis. She was placed on immunosuppression and prophylaxis for opportunistic infections. She presented 5 months later with an EBV-positive uterine leiomyosarcoma. Postoperative therapy included a decrease in immunosuppression and antiviral therapy. Recurrence was noted after 1 year; the patient developed sepsis while undergoing chemotherapy and declined further therapy. CONCLUSION: Epstein-Barr virus-associated leiomyosarcoma can occur in the uterus in immunosuppressed patients.

Carcinomas of the female genital tract occurring after pelvic irradiation: a report of 15 cases.

The concept of postradiation sarcoma is widely appreciated, however carcinomas arising in previously irradiated fields, the putative "postradiation carcinoma," are less well understood. Fifteen patients who developed gynecological malignancies after pelvic radiation therapy were studied. Five of these patients had HPV-related tumors both pre- and post- irradiation. Ten were irradiated for cervical cancer, one for endometrial carcinoma, one for vulvar carcinoma, one for colon cancer and 2 for benign conditions. The mean and median latent periods from the initiation of radiation therapy to the development of the second malignancy were 22.8 and 19 years, respectively (22.4 and 19.5 years, respectively, for non-HPV-related cancers; 24 and 18 years for HPV-related cancers). The "postradiation" malignancies included 2 ovarian carcinomas, 5 vaginal carcinomas (3 invasive, 2 in situ), 4 endometrial carcinomas, one cervical carcinoma, one vulvar carcinoma, one distal urethral carcinoma, and one pelvic carcinoma of unclear primary site. Gynecological carcinomas may occur many years after pelvic irradiation. Although the evidence for a causative role is circumstantial, these tumors appear to have a similar latent period as postradiation sarcomas.

Sustained response to bevacizumab in refractory well-differentiated ovarian neoplasms.

BACKGROUND: Bevacizumab has demonstrated activity against a variety of solid tumors, including ovarian carcinoma. However, there have not been reproducible prognostic features associated with its activity. CASES: One patient each with recurrent, refractory well-differentiated serous-endometrioid ovarian carcinoma, micropapillary serous carcinoma of the ovary, and primary peritoneal micropapillary serous carcinoma were treated with single agent bevacizumab (15 mg/kg [DOSAGE ERROR CORRECTED] intravenously every 3 weeks). All three have had dramatic sustained responses of 15, 15, and 22 months' duration. CONCLUSION: Bevacizumab may have significant activity against well-differentiated ovarian carcinoma and micropapillary serous carcinomas of the ovary or peritoneum. Since these tumors are generally indolent and not responsive to adjuvant therapy, further investigation is warranted.

Testing of two binary grading systems for FIGO stage III serous carcinoma of the ovary and peritoneum.

OBJECTIVE: A variety of histologic grading systems for ovarian carcinoma have been used, but there is no widely accepted system. Binary grading systems are inherently superior to the more common three-grade systems because they are more reproducible and they correspond to the number of options in the binary treatment decision for which grade is considered important: the use of or withholding of chemotherapy. METHODS: One hundred thirteen unselected FIGO stage III serous carcinomas of the ovary and peritoneum were tested with two grading systems: a binary system recently proposed by investigators at MD Anderson Cancer Center (MDACC) and a new binary system we formulated at the Washington Hospital Center (WHC). Both of these systems are based on nuclear grade. The WHC system has a higher threshold of nuclear size for diagnosing high-grade tumors. RESULTS: The WHC system separated the cases into 89 high-grade and 24 low-grade tumors. The median survival rates were 30 and 49 months for high and low grade respectively, and the actuarial survival curves were not significantly different (P > 0.10). The MDACC system separated the cases into 103 high-grade and 10 low-grade tumors. With this system, low-grade tumors were significantly more likely than high grade to be stage IIIA (P < 0.05) and occurred at a mean age of 57 years compared to 65 years for high-grade tumors (P < 0.05). Low-grade tumors were suboptimally debulked in 10% of cases compared to 27% for high-grade tumors (P > 0.05). The median survival for high-grade tumors was 34 months, and the median for low grade has not been reached. The actuarial survival curves were not significantly different (P = 0.065). CONCLUSION: The MDACC grading system appears more promising than the WHC system. The MDACC system separates a small (9% of advanced stage serous carcinomas) but distinctive well-differentiated tumor which usually has the appearance of invasive low-grade (micropapillary) serous carcinoma. The rarity of this tumor, however, will require a larger series to demonstrate prognostic value. The WHC system, which was designed to enlarge the low-grade group to a size that would be more meaningful in clinical practice, did not demonstrate a survival difference. The failure of the WHC system suggests that attempts to enlarge the low-grade group using histologic features alone are unlikely to be successful. The potential for confounding of grade with substage, volume of residual disease and patient age are issues that may impede determination of the independence of tumor grade in prognosis, and more data, especially for low-grade tumors, are needed.

The histologic type and stage distribution of ovarian carcinomas of surface epithelial origin.

Advances over the past decade suggest a need to reassess the distribution of ovarian surface epithelial tumors. A series of 220 consecutive invasive ovarian carcinomas, including carcinosarcomas and peritoneal carcinomas, was reviewed. Notable findings include: 7% of tumors were carcinosarcomas; 22% of cases of peritoneal serous carcinomatosis were of peritoneal origin; <3% of cases were mucinous carcinomas; and only one malignant Brenner tumor (0.5%) and no pure transitional cell carcinomas were identified. If peritoneal carcinomas, carcinosarcomas, and mixed carcinomas with a serous component are combined with serous carcinomas, this group accounts for 78% of all cases and 87% of advanced stage cases, suggesting a greater uniformity to epithelial ovarian cancer than previously appreciated.

Papillary serous adenocarcinoma of the ovary diagnosed after malignant pericardial tamponade and embolic stroke.

BACKGROUND: Epithelial carcinomas of the ovary are predominantly an intraperitoneal disease. Reports of epithelial ovarian carcinomas metastatic to the pericardium are rare. CASE: A 43-year-old woman was admitted with symptoms of a pericardial tamponade, as well as an embolic cerebrovascular accident, and transferred to the ICU where a pericardiocentesis was performed. Cytology revealed malignant cells in the pericardial fluid. CT scan of the abdomen and pelvis revealed bilateral pelvic masses. A laparotomy revealed a papillary serous adenocarcinoma of ovarian primary and an infarcted spleen with capsular tumor metastases. The malignant cells in the pericardial fluid were consistent with the ovarian primary. CONCLUSION: Ovarian cancer metastasis to the heart and pericardium presented an aggressive variant of tumor spread with significant morbidity and subsequent mortality.