Clinical efficacy analysis of preoperative neoadjuvant chemotherapy with high-dose dense paclitaxel plus cisplatin in Stages IB2, IIA2, IIB cervical cancer in Iran.

PURPOSE OF INVESTIGATION: In Iran, the authors use neoadjuvant chemotherapy (NACT) prior to surgery in cervical cancer due to limited access to the radiotherapy and very prolonged waiting time in accession to radiotherapy. The study was done to analyze the efficacy of the NACT with high dose-dense paclitaxel and cisplatin before radical surgery on cure rate, survival rate, and the progression of free survival rate of bulky tumor of cervical cancer in Stages 1B2, IId A2, and IIB. MATERIALS AND METHODS: Fifty-two patients with cervical cancer in Stages Ib2, IIA2, and IIB were selected, and responding patients to chemotherapy were scheduled to undergo radical hysterectomy and bilateral pelvic lymphadenectomy with or without para-aortic lymphadenectomy. RESULTS: Fifty out of 52 patients with a median age of 50 years were evaluable for clinical response. Thirty-two patients (64%) responded to the NACT including six (12%) with a complete clinical response. There was no statistical relationship between clinical response, tumor stage and size, and parametrical involvement, however, patients with higher grade of tumor, adenocarcinoma or tumor in upper 2/3 of vagina showed a higher probability of no response to chemotherapy. Downstaging after NACT in all stages was statistically significant regarding pathologic findings and clinical response (p = 0.002). Five-year survival was 88% and factors affecting survival and disease-free survival were pathological response and tumor site based on cox-regression analysis. Overall recurrence rate was 20% and tumor size was the only significant relevant factor for recurrence (p = 0.017). CONCLUSION: Combined regimen of chemotherapy in locally advanced cervical cancer proved to be valuable and efficacious without any late complications.

Conservative management of young women with endometrial carcinoma or complex atypical hyperplasia: report of three cases and literature review.

BACKGROUND: Although endometrial cancer is primarily a postmenopausal disease, 25% of patients are in premenopausal age with 3-5% being 40 years old or younger. The younger groups of women with endometrial carcinoma are frequently nulligravid with a history of infertility and strong desire to preserve fertility, which may pose a therapeutic dilemma for both patients and physicians. CASE REPORTS: We report on three young women with atypical complex hyperplasia or early-stage endometrial cancer that were treated with conservative hormonal therapy. DISCUSSION/CONCLUSION: Hormonal therapy has been proposed for young women with endometrial cancer (grade 1) who wish to preserve their fertility. However, detailed evaluation including physical examination, history taking, performing D&C, examining the specimen by a skilled pathologist, using imaging techniques, especially contrast enhanced MRI and for some patients explorative laparoscopy with sampling of peritoneal and lymph nodes, and evaluation of adnexa is necessary. Also for patients in Stage I/grade 1, advisory sessions on the benefits and side-effects of high-dose progesterone with evaluation of the endometrium every three months until total regression is recommended.

Conservative surgery in cervical cancer: report of two radical abdominal trachelectomies and literature review.

AIM: Radical trachelectomy or removal of the cervix and uterine ligaments with uterus and ovary preservation is done in primary stages of cervical cancer in women who wish to preserve their fertility. CASES: The first case had cervical cancer in situ with lymphovascular involvement, while the second case had papillary serous adenocarcinoma, Stage Ib1 (lesion < 4 cm and limited to the cervix) diagnosed during pregnancy, who underwent surgery two months following labor. Radical trachelectomy and total pelvic lymphadenectomy to preserve the uterus were done without any intra- or postoperative complications. Both patients had regular postoperative menstruation, but in the second case, the disease relapsed in the vaginal cuff and the patient was a candidate for radical hysterectomy and radiotherapy. CONCLUSION: Radical trachelectomy as a new technique to preserve fertility in early stages of cervical cancer seems to be less effective in adenocarcinoma than squamous cell carcinoma due to a worse prognosis.

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.

Estimation of probability of malignancy using a logistic model combining color Doppler ultrasonography, serum CA125 level in women with a pelvic mass.

The goal of this study was to develop a scoring system using combination of Doppler characterization of pelvic/ovarian lesions and serum CA125 level. Our purpose was to maximize the preoperative discrimination between benign and malignant entities. In a prospective study, a total of 101 patients were evaluated preoperatively using a standard transvaginal ultrasound and color Doppler imaging with pulse spectral analysis and serum CA125 level within a week prior to surgery. The variables that were analyzed by the multivariate logistic regression method are as follows: tumor structure, ascites, presence of septum, the peak systolic velocity (PSV), the resistance index (RI), and serum CA125 level. Of the 101 patients qualified for the study, 48 patients were diagnosed with benign (47.5%) and 53 (52.5%) with malignant tumors. Each criterion used alone provides statistically significant discrimination between benign and malignant tumors. Four criteria could be combined in a malignancy score which is calculated using the product of the serum CA125 level (1 if CA125 > or =40 U/mL and 0 if CA125 <40 U/mL), the result of sonography for presence of septum in tumor (1 if there was septum > or =3 mm, 0 if there was no septum or <3 mm), result of Doppler flow imaging as RI (1 if RI < or =0.5 and 0 if RI >0.5) and the PSV (1 if PSV > or =40 cm/s and 0 if PSV <40 cm/s). This scoring system devised was statistically more effective discriminator between cancer and benign lesions than formal methods. Using malignancy score cutoff level of two, the sensitivity was 98% (CI 88.62-99.9.), the specificity was 85% (CI 71.62-93.45), the positive predictive value was 87.5%, and the negative predictive value was 97.6%. Area under curve of receiver operative characteristic curves was 0.987 (CI 0.971-1.004). These values were statistically more significant than those obtained from the independent use of RI, PSV, or serum CA125 level at their optimum decision values (P < 0.05). There is a need for a prospective evaluation of this score using a larger sample of patients.