Speciality
Spotlight

 




 


Oncology


 

 





Cervix

     

  • AJ
    Mundt, PP Connell, et al (Univ of Chicago) 
    Race and
    Clinical Outcome in Patients with Carcinoma of the
    Uterine Cervix Treated With Radiation Therapy.

    Gynecol Oncol 71: 151-158, 1998.

        

    The study included ninety-four white patients and
    316 black patients undergoing radiation therapy for
    cervical cancer.

        

    It
    was found that the 8-year cause-specific survival was
    60% in white patients and 47%.9% in black patients. 
    Survival differed significantly between races in
    the group with stage IIB to IVA disease (60% and 34%
    respectively).

       

    Conclusions
    – Many factors adversely affect the efficacy of
    radiation therapy in black patients with cervical
    cancer.  Race
    per se was not an independent risk factor for survival
    in these patients; instead, other factors, such as low
    hemoglobin levels and low socioeconomic status, were
    associated with poorer outcomes.

        

  • MA
    Varia, BN Bundy, et al (Univ of North Carolina, Chapel
    Hill;  Roswell
    Park Cancer Inst, Buffalo, NY; Wayne State Univ,
    Detroit; et al) 
    Cervical
    Carcinoma Metastatic to Para-aortic Nodes: External
    Field Radiation therapy with Concomitant 5-Fluorouracil
    and Cisplatin Chemotherapy: A Gynecologic Onoclogy Group
    Study.

    Int J Radiat Oncol Biol Phys  42:1015-1023,
    1998.

       

    Method –
    Concomitant IV cisplatin and 96-hour 5-FU infusion
    during the first and fifth weeks of pelvic and PAN
    radiation therapy was administered to 95 patients
    followed by intracavitary radiation therapy and external
    beam parametrial boost.

        

    It
    was found that combination radiation and chemotherapy
    for cervical carcinoma metastatic to para-aortic nodes
    was effective for about one third of patients and was
    relatively well tolerated. 
    It is important that PAN metastases in these
    high-risk patients be detected and treated.

        

    This
    collaborative Gynecologic Oncology Group study shows
    that treatment of para-aortic node metastases can be
    effective.  All
    those treated had biopsy evidence of tumor in their para-aortic
    nodes.  They
    received external field radiation with chemotherapy
    (platinum + 5-FU). 
    Chemoradiation does offer therapeutic advantages
    over radiation alone. 
    Although there was a high proportion of severe
    complications of grade 3 or 4, there were meaningful
    3-year progression-free intervals of 34%, which is quite
    good for patients with biopsy-proven disease.

         

  • N
    Sakuragi, C Satoh, et al (Hokkaido Univ, Sapporo, Japan)
    Incidence
    and Distribution Pattern of Pelvic and Para-aortic Lymph
    Node Metastasis in Patients With Stages IB, IIA, and IIB
    Cervical Carcinoma Treated with Radical Hysterectomy.

    Cancer 85:1547-1554, 1999.

        

    This
    is an interesting operative-anatomic study of the
    distribution of lymph node metastases in cases of
    cervical carcinoma. 
    Of 208 patients studied, 53 had lymph node
    metastases.  The
    message appears to be that lack of metastases to the
    obturator node usually meant that the para-aortic nodes
    were free.  The
    information appears to confirm the stepwise progression
    of metastatic cervical disease from pelvic to para-aortic
    nodes. These are the remarks of A.L.Herbst, M.D., editor
    of the Year Book.

        

  • A
    Sedlis, BN Bundy, et al (State Univ of New York,
    Brooklyn; Roswell Park Cancer Inst, Buffalo, NY; Bowman
    Gray School of Medicine, Winston-Salem, NC; et al)
    A
    Randomized Trial of Pelvic Radiation Therapy Versus No
    Further Therapy in Selected Patients with State IB
    Carcinoma of the Cervix After Radical Hysterectomy and
    Pelvic Lymphadenectomy: A Gynecologic Oncology Group
    Study.

    Gynecol
    Oncol 73: 177-183, 1999.

        

    Conclusions
    – The results of this prospective, multicenter,
    randomized clinical trial indicate that adjunct
    radiotherapy is beneficial for patients with stage I
    cervical cancer with risk factors such as large tumor
    diameter, deep stromal invasion, and tumor in the
    capillary lymphatic spaces. 
    Adjunct radiotherapy reduced cancer recurrence in
    these patients, with acceptable morbidity.   


        

  • HM
    Keys, BN Bundy, et al (Albany Med College, NY; Roswell
    Park Cancer Inst, Buffalo, NY; Indiana Univ,
    Indianapolis; et al) 
    Cisplatin,
    Radiation, and Adjuvant Hysterectomy Compared with
    Radiation and Adjuvant Hysterectomy for Bulky Stage IB
    Cervical Carcinoma.

    N Engl J Med 340:1154-1161, 1999

        

    Pelvic Radiation with Concurrent Chemotherapy Compared with Pelvic and
    Para-aortic Radiation for High-Risk Cervical Cancer.

    M Morris, PJ Eifel, et al (Univ of Texas MD Anderson
    Cancer Ctr, Houston; Radiation Therapy Oncology Group,
    Philadelphia; Washington Univ, St.Louis; et al)

    N Engl J Med 340:1137-1143, 1999.

        


    Of
    403 participants, 193 were available for evaluation in
    each group.   It
    was found that among women with locally advanced
    cervical cancer, survival was significantly improved
    with the addition of chemotherapy with fluorouracil and
    cisplatin to intracavitary radiotherapy.

          

    Editorial comment
    -This is one in a series of articles in the ‘New England
    Journal of Medicine’ from the Gynecologic Oncology Group
    after achievement of superior results in cervical
    carcinoma with chemoradiation (platinum plus 5 FU)
    compared with radiotherapy alone. 
    This improvement does come at a price, which in
    the acute phase resulted in markedly more hematologic
    effects, but the long-term complications (over 60 days)
    are fairly comparable. 
    Two cycles of chemoradiation were given 3 weeks
    apart along with another cycle at the second implant. 
    The results are impressive for locally advanced
    disease, which shows significantly better survival among
    those who receive chemoradiation. 
    Today most of us use weekly infusions of
    cisplatin, which appears to have similar results. 
    This comment is by A.L. Herbst, MD. 


         

  • K
    Bergmark, E Avall-Lundqvist, et al (Karolinska Inst,
    Stockholm, Huddinge Hosp, Stockholm)Vaginal
    Changes and Sexuality in Women with a History of
    Cervical Cancer.

    N Engl J Med 340:1383-1389, 1999.

        

    The
    study group consisted of 256 women with a history of
    early-stage cervical cancer, who had been treated in
    1991 and 1992 at the 7 gynecology departments in Sweden. 
    The control group consisted of 350 randomly
    selected women from the Swedish Population Register,
    matched for age and place of residence.

       

    This
    Swedish study has shown what has generally been
    suspected for many years. Women who have been treated for cervical cancer
    have an increased frequency of lack of vaginal
    lubrication and accompanying sexual difficulties. The cancer group also reported a problem with a
    short and inelastic vagina, all of which led to more
    dyspareunia. In
    spite of these problems, the frequency of orgasm
    appeared to be comparable between the cancer and control
    groups. These
    patients were aged 51 to 52 at the time of the survey,
    and those who had only surgical treatment of cervical
    cancer seemed to have problems, including lack of
    vaginal lubrication, comparable to those of the rest of
    the cancer group. These findings are important to the physician who cares for
    patients who have been treated for cervical carcinoma
    and should be kept in mind when these patients are
    counseled.

          

  • P
    Holowaty, AB Miller, et al (Univ of Toronto)

    Natural History of Dysplasia of
    the Uterine Cervix.

    J Natl
    Cancer Inst  91:
    252-258, 1999

        


    Although it is known that most cases of cervical
    dysplasia do not progress to invasive cancer, there is
    little information on the natural progression and
    regression of cervical dysplasia. 
    The Pap smear history of a cohort of Toronto
    women was related to the risk of subsequent cervical
    cancer.

        

    Methods
    – Screening histories were collected by the Ontario
    Cancer Registry between 1962 and 1980 and analyzed along
    with the outcomes and Pap smear histories of 17,217
    women given a diagnosis of dysplasia between 1970 and
    1980.

        

    They
    concluded the risks of progression increased with the
    degree of dysplasia. 
    Most patients with mild dysplasia regressed to a
    normal Pap smear within 2 years.

       

  • N
    Ylitalo, P Sorensen, et al (Karolinska 
    Institute, Stockholm; Statens Serum Institut,
    Copenhagen; Uppsala Univ, Sweden; et al)
    Smoking and Oral Contraceptives
    as Risk Factors for Cervical Carcinoma in Situ.

    Int J Cancer 81:357-365, 1999.

       

    Background
    – Human papillomavirus (HPV) is probably requisite but
    is not sufficient to cause cervical carcinoma. 
    However, it is not clear which factors in
    addition to HPV contribute to the development of
    cervical carcinoma and its precursor lesions.

       

    It was
    found that after adjustment for covariates in a
    multivariate analysis, current smokers had a 2-fold
    greater risk than those who had never smoked. 
    This association appears to be limited to women
    younger than 45 years of age. 
    Current OC use was associated with a 4-fold
    increase in overall risk, with a monotonic increase as
    duration of use increased. 
    Number of sexual partners was significantly,
    positively correlated with risk among HPV negative women
    but not among HPV positive women.

       

    Conclusions – Smoking is associated with cervical carcinoma in-situ
    (CIS), possibly in an age-dependent fashion. 
    In addition, OC use is correlated with risk of
    cervical CIS. 


        

  • NP
    Yost, JT Santoso, et al (Univ of Texas Southwestern Med
    Ctr, Dallas; Univ of Texas Med Branchm Galveston)Postpartum
    Regression Rates of Antepartum Cervical Intraepithelial
    Neoplasia II and III 
    Lesions.

    Obstet Gynecol 93:359-362, 1999.

       

    Abnormal
    Pap smears are obtained in 5% of pregnancies. 
    Whether caesarian delivery reduces cervical
    cancer is controversial. 
    The biopsy-proven, antepartum cervical
    intraepithelial neoplasia (CIN) II and III lesions and
    their regression and progression rates postpartum were
    studied, and the issue of the effect of caesarian
    section was resolved.

       

    Methods- 279
    pregnant women evaluated at Parkland Memorial Health
    Hospital and they were followed-up. 
    The effect of vaginal deliveries and caesarian
    section were reevaluated.

       

    Conclusion
    – Conservative management of pregnant women with CIN II
    and CIN III during pregnancy is warranted.

       

    Editorial
    comment:
     
    This is a small, but useful, study showing the
    course of CIN II and III diagnosed antenatally to the
    postpartum period, it shows that most of the lesions
    regress regardless of the route of delivery. 
    As the authors correctly note, these lesions
    should be followed conservatively during pregnancy and
    evaluated post partum by means of cytology, colposcopy,
    and directed biopsy.

         

  • AY
    EL-Bastawissi, TM Becker, (Swedish Med Ctr, Seattle;
    Oregon Health Sciences Univ, Portland)
    Effect of Cervical Carcinoma In Situ and its Management on Pregnancy
    Outcome.

    Obstet Gynecol 93:207-212, 1999.

       

    Cryosurgery, laser ablation, and cold-knife or laser
    conization are current treatments, with the loop
    electrosurgical excision the most-recent procedure of
    choice.

       

    Of
    1847 women diagnosed with cancer in situ during an
    8-year period.  312
    were diagnosed during pregnancy. 
    They were retrospectively reviewed and compared
    with a group of 9200 women without cancer in situ who
    gave birth during the same year.

      

    Results
    :

    A small increased risk of preterm delivery and no
    increased risk of a low birth weight infant was found
    with women with cancer in situ who were not treated with
    conization when compared with women without cancer in
    situ.  There
    was a greater likelihood 
    of delivering premature 
    infants among women with cancer in situ who had
    conization when compared with women without cancer in
    situ.

            

  • Rose PG, Adler LP, Rodriguez M, et al [ Ireland Cancer
    Ctr, Cleveland, Ohio, Univ Hosps of Cleveland, Ohio; Case Western Reserve
    Univ, Cleveland, Ohio]

    Positron Emission Tomography for Evaluating Para-aortic Nodal Metastasis in Locally Advanced Cervical Cancer Before Surgical Staging: A Surgicopathologic Study

    J Clin Oncol 17: 41-45, 1999

       

    Locally advanced cancer of the cervix at presentation have para -aortic lymph node involvement in 25%, which becomes the most important indicator of recurrence.

      

    20mCi of 2-[18F] fluoro-2-deoxy -D-glucose [FDG] uptake in
    para-aortic LN by PET is seen in 91% of cervical tumors. Yielding a positive predictor value of 75% and negative predictor value of 92% and a relative risk of 9.0 for metastatic disease. The editor comments that identifying the
    para-aortic LN would allow modification of radiation therapy field to include such site of disease.

      


 

 



 

 

Speciality Spotlight

 

 

Cervix
     

  • AJ Mundt, PP Connell, et al (Univ of Chicago)  Race and Clinical Outcome in Patients with Carcinoma of the Uterine Cervix Treated With Radiation Therapy.
    Gynecol Oncol 71: 151-158, 1998.
        
    The study included ninety-four white patients and 316 black patients undergoing radiation therapy for cervical cancer.
        
    It was found that the 8-year cause-specific survival was 60% in white patients and 47%.9% in black patients.  Survival differed significantly between races in the group with stage IIB to IVA disease (60% and 34% respectively).
       
    Conclusions – Many factors adversely affect the efficacy of radiation therapy in black patients with cervical cancer.  Race per se was not an independent risk factor for survival in these patients; instead, other factors, such as low hemoglobin levels and low socioeconomic status, were associated with poorer outcomes.
        

  • MA Varia, BN Bundy, et al (Univ of North Carolina, Chapel Hill;  Roswell Park Cancer Inst, Buffalo, NY; Wayne State Univ, Detroit; et al)  Cervical Carcinoma Metastatic to Para-aortic Nodes: External Field Radiation therapy with Concomitant 5-Fluorouracil and Cisplatin Chemotherapy: A Gynecologic Onoclogy Group Study.
    Int J Radiat Oncol Biol Phys  42:1015-1023, 1998.
       
    Method – Concomitant IV cisplatin and 96-hour 5-FU infusion during the first and fifth weeks of pelvic and PAN radiation therapy was administered to 95 patients followed by intracavitary radiation therapy and external beam parametrial boost.
        
    It was found that combination radiation and chemotherapy for cervical carcinoma metastatic to para-aortic nodes was effective for about one third of patients and was relatively well tolerated.  It is important that PAN metastases in these high-risk patients be detected and treated.
        
    This collaborative Gynecologic Oncology Group study shows that treatment of para-aortic node metastases can be effective.  All those treated had biopsy evidence of tumor in their para-aortic nodes.  They received external field radiation with chemotherapy (platinum + 5-FU).  Chemoradiation does offer therapeutic advantages over radiation alone.  Although there was a high proportion of severe complications of grade 3 or 4, there were meaningful 3-year progression-free intervals of 34%, which is quite good for patients with biopsy-proven disease.
         

  • N Sakuragi, C Satoh, et al (Hokkaido Univ, Sapporo, Japan)Incidence and Distribution Pattern of Pelvic and Para-aortic Lymph Node Metastasis in Patients With Stages IB, IIA, and IIB Cervical Carcinoma Treated with Radical Hysterectomy.
    Cancer 85:1547-1554, 1999.
        
    This is an interesting operative-anatomic study of the distribution of lymph node metastases in cases of cervical carcinoma.  Of 208 patients studied, 53 had lymph node metastases.  The message appears to be that lack of metastases to the obturator node usually meant that the para-aortic nodes were free.  The information appears to confirm the stepwise progression of metastatic cervical disease from pelvic to para-aortic nodes. These are the remarks of A.L.Herbst, M.D., editor of the Year Book.
        

  • A Sedlis, BN Bundy, et al (State Univ of New York, Brooklyn; Roswell Park Cancer Inst, Buffalo, NY; Bowman Gray School of Medicine, Winston-Salem, NC; et al)A Randomized Trial of Pelvic Radiation Therapy Versus No Further Therapy in Selected Patients with State IB Carcinoma of the Cervix After Radical Hysterectomy and Pelvic Lymphadenectomy: A Gynecologic Oncology Group Study.
    Gynecol Oncol 73: 177-183, 1999.
        
    Conclusions – The results of this prospective, multicenter, randomized clinical trial indicate that adjunct radiotherapy is beneficial for patients with stage I cervical cancer with risk factors such as large tumor diameter, deep stromal invasion, and tumor in the capillary lymphatic spaces.  Adjunct radiotherapy reduced cancer recurrence in these patients, with acceptable morbidity.   
        

  • HM Keys, BN Bundy, et al (Albany Med College, NY; Roswell Park Cancer Inst, Buffalo, NY; Indiana Univ, Indianapolis; et al)  Cisplatin, Radiation, and Adjuvant Hysterectomy Compared with Radiation and Adjuvant Hysterectomy for Bulky Stage IB Cervical Carcinoma.
    N Engl J Med 340:1154-1161, 1999
        
    Pelvic Radiation with Concurrent Chemotherapy Compared with Pelvic and Para-aortic Radiation for High-Risk Cervical Cancer.
    M Morris, PJ Eifel, et al (Univ of Texas MD Anderson Cancer Ctr, Houston; Radiation Therapy Oncology Group, Philadelphia; Washington Univ, St.Louis; et al)
    N Engl J Med 340:1137-1143, 1999.
        
    Of 403 participants, 193 were available for evaluation in each group.   It was found that among women with locally advanced cervical cancer, survival was significantly improved with the addition of chemotherapy with fluorouracil and cisplatin to intracavitary radiotherapy.
          
    Editorial comment -This is one in a series of articles in the ‘New England Journal of Medicine’ from the Gynecologic Oncology Group after achievement of superior results in cervical carcinoma with chemoradiation (platinum plus 5 FU) compared with radiotherapy alone.  This improvement does come at a price, which in the acute phase resulted in markedly more hematologic effects, but the long-term complications (over 60 days) are fairly comparable.  Two cycles of chemoradiation were given 3 weeks apart along with another cycle at the second implant.  The results are impressive for locally advanced disease, which shows significantly better survival among those who receive chemoradiation.  Today most of us use weekly infusions of cisplatin, which appears to have similar results.  This comment is by A.L. Herbst, MD. 
         

  • K Bergmark, E Avall-Lundqvist, et al (Karolinska Inst, Stockholm, Huddinge Hosp, Stockholm)Vaginal Changes and Sexuality in Women with a History of Cervical Cancer.
    N Engl J Med 340:1383-1389, 1999.
        
    The study group consisted of 256 women with a history of early-stage cervical cancer, who had been treated in 1991 and 1992 at the 7 gynecology departments in Sweden.  The control group consisted of 350 randomly selected women from the Swedish Population Register, matched for age and place of residence.
       
    This Swedish study has shown what has generally been suspected for many years. Women who have been treated for cervical cancer have an increased frequency of lack of vaginal lubrication and accompanying sexual difficulties. The cancer group also reported a problem with a short and inelastic vagina, all of which led to more dyspareunia. In spite of these problems, the frequency of orgasm appeared to be comparable between the cancer and control groups. These patients were aged 51 to 52 at the time of the survey, and those who had only surgical treatment of cervical cancer seemed to have problems, including lack of vaginal lubrication, comparable to those of the rest of the cancer group. These findings are important to the physician who cares for patients who have been treated for cervical carcinoma and should be kept in mind when these patients are counseled.
          

  • P Holowaty, AB Miller, et al (Univ of Toronto)
    Natural History of Dysplasia of the Uterine Cervix.
    J Natl Cancer Inst  91: 252-258, 1999
        
    Although it is known that most cases of cervical dysplasia do not progress to invasive cancer, there is little information on the natural progression and regression of cervical dysplasia.  The Pap smear history of a cohort of Toronto women was related to the risk of subsequent cervical cancer.
        
    Methods – Screening histories were collected by the Ontario Cancer Registry between 1962 and 1980 and analyzed along with the outcomes and Pap smear histories of 17,217 women given a diagnosis of dysplasia between 1970 and 1980.
        
    They concluded the risks of progression increased with the degree of dysplasia.  Most patients with mild dysplasia regressed to a normal Pap smear within 2 years.
       

  • N Ylitalo, P Sorensen, et al (Karolinska  Institute, Stockholm; Statens Serum Institut, Copenhagen; Uppsala Univ, Sweden; et al)Smoking and Oral Contraceptives as Risk Factors for Cervical Carcinoma in Situ.
    Int J Cancer 81:357-365, 1999.
       
    Background – Human papillomavirus (HPV) is probably requisite but is not sufficient to cause cervical carcinoma.  However, it is not clear which factors in addition to HPV contribute to the development of cervical carcinoma and its precursor lesions.
       
    It was found that after adjustment for covariates in a multivariate analysis, current smokers had a 2-fold greater risk than those who had never smoked.  This association appears to be limited to women younger than 45 years of age.  Current OC use was associated with a 4-fold increase in overall risk, with a monotonic increase as duration of use increased.  Number of sexual partners was significantly, positively correlated with risk among HPV negative women but not among HPV positive women.
       
    Conclusions – Smoking is associated with cervical carcinoma in-situ (CIS), possibly in an age-dependent fashion.  In addition, OC use is correlated with risk of cervical CIS. 
        

  • NP Yost, JT Santoso, et al (Univ of Texas Southwestern Med Ctr, Dallas; Univ of Texas Med Branchm Galveston)Postpartum Regression Rates of Antepartum Cervical Intraepithelial Neoplasia II and III  Lesions.
    Obstet Gynecol 93:359-362, 1999.
       
    Abnormal Pap smears are obtained in 5% of pregnancies.  Whether caesarian delivery reduces cervical cancer is controversial.  The biopsy-proven, antepartum cervical intraepithelial neoplasia (CIN) II and III lesions and their regression and progression rates postpartum were studied, and the issue of the effect of caesarian section was resolved.
       
    Methods- 279 pregnant women evaluated at Parkland Memorial Health Hospital and they were followed-up.  The effect of vaginal deliveries and caesarian section were reevaluated.
       
    Conclusion – Conservative management of pregnant women with CIN II and CIN III during pregnancy is warranted.
       
    Editorial comment:  This is a small, but useful, study showing the course of CIN II and III diagnosed antenatally to the postpartum period, it shows that most of the lesions regress regardless of the route of delivery.  As the authors correctly note, these lesions should be followed conservatively during pregnancy and evaluated post partum by means of cytology, colposcopy, and directed biopsy.
         

  • AY EL-Bastawissi, TM Becker, (Swedish Med Ctr, Seattle; Oregon Health Sciences Univ, Portland)Effect of Cervical Carcinoma In Situ and its Management on Pregnancy Outcome.
    Obstet Gynecol 93:207-212, 1999.
       
    Cryosurgery, laser ablation, and cold-knife or laser conization are current treatments, with the loop electrosurgical excision the most-recent procedure of choice.
       
    Of 1847 women diagnosed with cancer in situ during an 8-year period.  312 were diagnosed during pregnancy.  They were retrospectively reviewed and compared with a group of 9200 women without cancer in situ who gave birth during the same year.
      
    Results : A small increased risk of preterm delivery and no increased risk of a low birth weight infant was found with women with cancer in situ who were not treated with conization when compared with women without cancer in situ.  There was a greater likelihood  of delivering premature  infants among women with cancer in situ who had conization when compared with women without cancer in situ.
            

  • Rose PG, Adler LP, Rodriguez M, et al [ Ireland Cancer Ctr, Cleveland, Ohio, Univ Hosps of Cleveland, Ohio; Case Western Reserve Univ, Cleveland, Ohio]
    Positron Emission Tomography for Evaluating Para-aortic Nodal Metastasis in Locally Advanced Cervical Cancer Before Surgical Staging: A Surgicopathologic Study
    J Clin Oncol 17: 41-45, 1999
       
    Locally advanced cancer of the cervix at presentation have para -aortic lymph node involvement in 25%, which becomes the most important indicator of recurrence.
      
    20mCi of 2-[18F] fluoro-2-deoxy -D-glucose [FDG] uptake in para-aortic LN by PET is seen in 91% of cervical tumors. Yielding a positive predictor value of 75% and negative predictor value of 92% and a relative risk of 9.0 for metastatic disease. The editor comments that identifying the para-aortic LN would allow modification of radiation therapy field to include such site of disease.
      

 

 

 

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