Speciality
Spotlight

 




 

Obstetric & Gynaecology

 

 




Ovarian

      

  • IJ
    Jacobs, SJ Skates, et al (Queen Mary and Westfield
    College, London; Harvard Med School, Boston)


    Screening for Ovarian Cancer: A Pilot Randomized
    Controlled Trial.


    Lancet 353: 1207-1210, 1999.

      


    Postmenopausal women aged 45 years and older were
    randomized to either a screened group or a control
    group (10,000 participants respectively). The
    screened group was offered 3 annual screens
    involving measurement of serum CA-125, pelvic
    ultrasound if CA-125 was 30 U/ml or more, and
    referral for gynecologic opinion when ovarian volume
    was 8.8mL or more on ultrasound.

     


    Results: Of 464 women from the screened group with
    elevated CA-125, 29 were referred for a gynecologic
    opinion. Six of these 29 patients had an index
    cancer and 23 had false positive findings. Thus
    positive predictive value was 20.7%.

        


    Editorial comment: The study was well conducted, and
    the authors’ recommendation of a larger trial is
    warranted in view of the deadly aspects of this
    disease, but it is not clear that this approach is
    going to be a major addition to the effort to detect
    this disease early.

     

  • DW
    Cramer, RF Liberman, et al (Brigham and Women’s
    Hosp, Boston; Dartmouth-Hitchcock Med Ctr, Lebanon,
    NH)


    Genital Talc Exposure and Risk of Ovarian Cancer.


    Int J Cancer 81: 351-356, 1999.

      


    The group consisted of 563 women in eastern
    Massachusetts and New Hampshire with epithelial
    ovarian cancer, including tumors of borderline
    malignancy. With a control group of 523 randomly
    selected women.

      


    Findings: Patients were more likely than controls to
    have used talc as a body powder. Exposure appeared
    to be more harmful before the first live birth. The
    association was strongest for women with invasive
    serous cancers and weakest for those with mucinous
    tumors.

       


    Conclusions: This large population based case
    control study has demonstrated an association
    between the use of talcum powder in the genital
    region and ovarian cancer. Avoidance of talc in
    genital hygiene might reduce the occurrence of a
    highly lethal cancer by at least 10%. Formal public
    health warnings should be provided about the
    potential risk associated with the use of talcum
    powder in the genital region.

      

  • BY
    Karlan, RL Baldwin,. Et al (Univ of California, Los
    Angeles; Univ of Toronto)t


    Peritoneal Serous Papillary Carcinoma, a Phenotypic
    Variant of Familial Ovarian Cancer: Implications for
    Ovarian Cancer Screening.


    Am J Obstet gynecol 180: 917-928, 1999.

       


    During the administration of a familial ovarian
    cancer screening program that was begun in 1991 and
    based on the pedigrees of symptom-free volunteers, a
    disturbing number of “ovarian cancer”
    cases with bulky peritoneal carcinomatosis and
    normal-size ovaries, consistent with peritoneal
    serious papillary carcinoma were noted. These
    lesions may represent primary ovarian cancers that
    disseminated widely before ovarian enlargement or
    discrete tumors arising from multiple peritoneal
    surfaces predisposed to malignant transformation.
    These tumors’ clonality and association with BRCA1
    and BRCA2 mutations were reported.

      


    It was found that those carrying BRCA mutations are
    at risk for both primary ovarian cancer and
    peritoneal serous papillary carcinoma. The latter is
    clearly not amenable to early detection by vaginal
    ultrasound screening. While prophylactic
    oophorectomy reduces the risk of these types of
    cancers by 50%, it, unfortunately, does not
    eliminate the risk.

       

  • A
    Obermair, A Handisurya, et al (Univ Hosp of Vienna;
    Gen Hosp Lainz, Vienna)


    The Relationship of Pretrement Serum Hemoglobin
    level to the Survival of Epithelial Ovarian
    Carcinoma Patients: A Prospective Review.


    Cancer 83: 726-731, 1998.

       


    In malignant solid tumors and a variety of
    hematologic malignancies, tumor anemia is common.
    There are no factors other than the malignant
    disease itself in a number of patients to explain
    the presence of anemia. Previous studies have shown
    a correlation between the prognosis in patients with
    a variety of malignancies and pretreatment
    hemoglobin levels. 

       


    This study comprises of 206 patients with untreated
    epithelial ovarian carcinoma who had surgery during
    a 10-year period. Serum hemoglobin value below
    12g/dl was the definition of anemia.

       


    Authors conclude that overall survival of patients
    with ovarian carcinoma had an independent
    relationship with tumor anemia, after adjustment for
    established prognostic factors. Marked tumor anemia
    was considered an indicator of the presence of
    biologically aggressive tumor cell clones because no
    significant interaction could be found between the
    grade of anemia and chemotherapy.

       

  • R
    Lehner, R Wenzi, et al (Univ of Vienna; Hosp Lainz,
    Vienna)


    Influence of Delayed Staging Laparotomy After
    Laparoscopic Removal of Ovarian Masses Later Found
    Malignant.


    Obstet Gynecol 92: 967-971, 1998

        


    Seventy patients were reviewed who had undergone
    attempted laparoscopic excision of a suspected
    benign ovarian mass, which was later proved by
    tissue and biopsy specimens to be malignant. In 22
    patients, laparotomy was performed immediately after
    laparoscopy (immediate laparotomy group). Of the
    remaining patients, 22 underwent laparotomy 17 days
    or less after the initial examination and in 24 the
    delay between laparoscopy and laparotomy was more
    than 17 days.

       


    Findings: Early-stage ovarian cancer was
    significantly more prevalent among patients in the
    immediate and early laparotomy groups compared with
    those in the late laparotomy group (59% and 71%,
    respectively).

       


    Conclusions – Patients whose laparotomy was delayed
    more than 17 days after laparoscopy had a
    significantly increased risk of more advanced
    disease, probably because of tumor cell
    dissemination caused by the laparoscopy.

       


    Dr. Ingle’s comment: I have not understood why the
    authors have kept such an odd number of 17 days as
    cut-off line, probably this was appropriate for
    their particular group of patients.

       

  • JA
    Bridgewater, AE Nelstrop, et al (Mount Vernon Centre
    for Cancer Treatment, Northwood, England; Royal
    Marsden Hosp, London; Univ of Mississipi, Jackson;
    et al)


    Comparison of Standard and CA-125 Response Criteria
    in Patients With Epithelial Ovarian Cancer Treated
    with Platinum or Paclitaxel.


    J Clin Oncol 17: 501-508, 1999

        


    Background: The role of CA-125 in the assessment of
    patients undergoing second-line treatment with
    taxanes has been questioned. Some authorities doubt
    the reliability of CA-125 in the management of
    individual patients, and some have concluded that
    CA-125 cannot be used as a guide for determining
    response. CA-125 was evaluated as a measure of
    response in patients treated with paclitaxel.

      


    Methods: Data on 144 patients given paclitaxel in 4
    different trials and 625 patients given platinum in
    2 trials were analzyed, using precisely defined 50%
    and 75% reductions in CA-125 as responses. Standard
    and CA-125 response rates were compared.

       


    Conclusion: Precise 50% or 75% CA-125 response
    criteria are as sensitive as standard response
    criteria in evaluating treatment activity in
    patients with ovarian cancer. The standard
    measurement of complete response means disappearance
    of all disease or partial response more than 50%
    decrease.

      


    Though it is true CA-125 reduction 50-75% can be
    relied upon as response to the treatment of cancer
    with platinum or paclitaxel, the opposite does not
    hold true i.e. there can be disease response without
    a drop in CA-125.

      

  • M
    Markman, MF Brady, et al (Cleveland Clinic Found,
    Ohio; Roswell Park Cancer Inst., Buffalo, NY;
    Women’s Cancer Ctr of Northern California, Palo
    Alto; et al)


    Phase II Trial of Intraperitoneal Paclitaxel in
    Carcinoma of the Ovary, tube, and Peritoneum: A
    Gynecologic Oncology Group Study.


    J Clin Oncol 16: 2620-2624, 1998.

      


    Methods: Seventy-six eligible patients were enrolled
    in the trial. Eight-six percent were considered
    potentially cisplatin sensitive. In all patients,
    the largest residual disease was 0.5cmor less in
    maximum diameter at the end of second-look surgery.
    Some patients had been treated with paclitaxel
    previously. Treatment consisted of paclitaxel,
    60mg/m2 intraperitoneal weekly for 16 weeks,
    followed by surgical assessment in patients with no
    evidence of disease progression.

      


    Findings : Fifty-three patients (70%) received all
    16 planned treatment courses. Treatment was well
    tolerated. Microscopic disease at the beginning of
    intraperitoneal therapy had a complete response as
    defined by surgery.

      


    Authors conclude salvage intraperitoneal paclitaxel
    is active and tolerable in patients with microscopic
    residual ovarian, fallopian tube, or peritoneal
    cancer. The effect of such treatment on survival
    needs to be determined in a phase III trial.

      


    Editorial comment: Intraperitoneal therapy has yet
    to be shown an effective second-line treatment for
    most patients.

      

  • HD
    Homesley, BN Bundy, et al (Brookview Research Inc,
    Winston-Salem, NC; Roswell Park Cancer Inst,
    Buffalo, NY; Indiana Univ, Indianapolis)


    Bleomycin, Etoposide, and Cisplatin Combination
    Therapy of Ovarian Granulosa Cell Tumors and Other
    Stromal Malignancies: A Gynecologic Oncology Group
    Study.


    Gynecol Oncol 72: 131-137, 1999.

      


    Granulosa cell tumors represent about 8% of ovarian
    neoplasms and are more common in older women. These
    women usually present with early-stage disease.
    Patients with stage I tumors are usually treated
    with surgery, but those with advanced-stage tumors
    require adjunctive therapy. The efficacy and
    toxicity of a combination of bleomycin, etoposide,
    and cisplatin (BEP) as a first-line treatment for
    advanced or recurrent ovarian stromal cancers was
    investigated in a prospective trial.

      


    The study group consisted of 57 women with
    histologically confirmed stage II to IV or recurrent
    ovarian stromal tumors that had been incompletely
    resected. The patients were treated with BEP. 20
    U/m2 on the day 1, etoposide 75mg/m2 from day 1 to
    day 5 and cisplatinum 20mg/m2 from day 1 to day 5
    every 3 weeks for 4 courses.

      


    Findings: Of the 38 women who had second-look
    laparotomy at the end of the BEP treatment, 37% had
    negative findings. Grade 4 myelotoxicity occurred in
    61% of the patients treated with the BEP.

      


    Authors conclude that BEP combination appears to be
    an effective first-line chemotherapy for advanced
    and recurrent ovarian stromal cancers.

     

  • JA
    Carlson, R Ambros, et al (Albany Med College, NY)


    Vulvar Lichen Sclerosus and Squamous Cell Carcinoma:
    A Cohort, Case Control, and Investigational Study
    with Historical Perspective; Implications for
    Chronic Inflammation and Sclerosis in the
    Development of Neoplasia.


    Hum Pathol 29: 932-948, 1998.

      


    Background: Vulvar lichen sclerosus (LS) is an
    inflammatory dermatosis characterized by chronic
    sclerosis. There is no consensus about the
    relationship between LS and squamous cell carcinoma
    (SCC), although the conditions are known to occur
    together. Lichen sclerosus could be associated with
    carcinogenesis through chronic inflammation and
    proliferation. To evaluate the relationship between
    LS and SCC, clinicopathologic studies were performed
    on 32 symptomatic vulvar LS patients and 60 patients
    with vulvar SCC.

     


    A Review of the patients of 1 gynecologist from
    1980-1996 identified 32 LS patients. A further group
    of 60 patients, with invasive vulvar SCC excised at
    the Albany Medical Center from 1980 to 1995 and with
    follow-up available also formed part of the study
    group.

     


    Findings: Among the 32 LS patients, 9% developed
    vulvar intraepithelial neoplasia (VIN) and 21%
    developed invasive SCC. Symptomatic LS was detected
    an average of 4 years before diagnosis of carcinoma.
    Vulvar LS had significantly higher expression of p53
    and aneuploidy than any of the 3 control groups.

      


    Authors conclude that the compiled frequency of SCC
    in association with LS was 4.5% with an average of
    10 years of LS before diagnosis of SCC. The chronic
    inflammation and proliferation of LS can lead to
    genomic instability.

      


    Editorial comments: Tumors associated with LS tended
    to be clitoral in location. They also tended to
    occur in older patients, with a mean age of 74
    versus 65 in the non-LS group.

      

  • ZS
    Tuncer, MR Bernstein, et al (Harvard Med School,
    Boston


    Outcome of Pregnancies Occurring Before Completion
    of Human Chorionic Gonadotropin Follow-up in
    Patients with Persistent Gestational Trophoblastic
    Tumor.


    Gynecol Oncol 73: 345-347, 1999.

      


    A chart review identified 43 women with gestational
    trophoblastic tumor (GTT) who conceived before
    standard hCG follow-up was completed during the
    period from 1973 to 1998. The mean interval from hCG
    remission to new pregnancy was 6.3 months. Of the
    remaining 29 patients, 75.9% delivered live infants
    at term and 10.3% had preterm delivery.

       


    Conclusions : Pregnancies occurring before standard
    hCG follow-up is completed in women treated for
    gestational trophoblastic tumor may continue under
    close observation. Most such pregnancies have
    favorable outcomes. However, there is a low but
    important risk of delayed diagnosis of tumor relapse
    during early pregnancy.

      


    Editorial comments: It appears that the risk of
    disease is low, but it certainly exists for those
    who undertake pregnancy sooner than 1 year after
    therapy for GTT.

      

  • P
    Harrkki-Siren, J Sjoberg, A Tiitinen (Helsinki Univ)


    Urinary Tract Injuries After Hysterectomy


    Obstet Gynecol 92: 113-118, 1998.

      


    Introduction: In gynecologic surgery, urinary tract
    injuries are among the most serious complications.
    About 75% of all ureteral injuries are caused by
    gynecologic procedures. 

      


    There were 142 urinary tract injuries after
    hysterectomy that were reportd during a 5-year
    period, and these were retrospectively analyzed.
    During this study period, 62379 hysterectomies were
    performed.

      


    Results : After all hysterectomies, the total
    incidence of ureteral injury was 1 of 1000
    procedures: 13.9 of 1000 after laparoscopic, 0.4 of
    1000 after total abdominal, 0.3 of 1000 after
    supracervical abdominal and 0.2 of 1000 after
    vaginal hysterectomy. Bladder injury there were 1.3
    of 1000 procedures, 65% of reported bladder injuries
    were fistulas. The incidence was 2.2 of 1000 after
    laparoscopic hysterectomy; 1 of 1000 after total
    abdominal, 0 of 1000 after supracervical abdominal,
    and 0.2 of 1000 after vaginal hysterectomy.

       


    Conclusion: After laparoscopic hysterectomy, the
    risk of ureteral injury and even bladder injury is
    higher than with traditional hysterectomies.

        


    Editorial comment: The rates reported from Finland
    for laparoscopic procedures are much higher perhaps
    because the technique is comparatively new. As noted
    in the conclusion, if the patient is a good
    candidate for a vaginal hysterectomy there is no
    reason to change the operation to a laparoscopic
    procedure.

        

  • Ovadia Abulafia, David M Sherer (Department of Obstetrics and Gynecology, State University of New York at Brooklyn and the Department of Obstetrics and Gynecology and Women’s Health, Montefiore)

    Angiogenesis of the ovary

    Am J Obstet Gynecol, Jan.2000, 182(1), Part I, pg. 240-246.

          


    The authors present current data pertaining to angiogenesis of the ovary throughout the follicular and luteal phases of the ovarian cycle, in various ovarian pathologic conditions and in benign and neoplastic diseases. MEDLINE, Current Contents, and Index Medicus were searched for studies published between January 1966 and October 1998. All studies that incorporated human and animal models of angiogenesis of the normal ovarian physiologic state and pathologic conditions including both benign and neoplastic ovarian diseases were reviewed. 

        


    Current literature supports that angiogenesis is an important component of both follicular and luteal phases of the ovarian cycle that correlates well with maturation of secretory endometrium. Angiogenesis also participates in various pathologic processes of the ovary, including follicular cyst formation, polycystic ovary, ovarian hyperstimulation syndrome, and both benign and malignant ovarian neoplasms. In the future a knowledge of specific angiogenic patterns of various pathologic processes may assist in the application of antiangiogenic medications in targeted therapy of benign and neoplastic diseases of the
    ovary.

        

  • Rodriguez C, Patel AV, et al (American Cancer Society, Atlanta, Ga)

    Estrogen Replacement Therapy and Ovarian Cancer Mortality in a Large Prospective Study of US Women

    JAMA 285: 1460-1465, 2001

       

    Conclusion: Postmenopausal estrogen use lasting 10 years or longer was associated with an increased risk for ovarian cancer mortality. This risk persisted for up to 29 years after discontinuation of estrogen.

      

    Editor’s Comments: The results of this large, prospective study suggest that postmenopausal ERT used for 10 or more years, but not for a shorter duration, may slightly increase the risk for death from ovarian cancer. However, the results are based upon a single questionnaire administered in 1982.

      

    Thus, the body of epidemiologic evidence fails to confirm a link between ERT use and ovarian cancer, despite the findings of this single study.

         

  • Ness RB, and the SHARE Study Group (Univ of Pittsburgh, Pa; et al)

    Risk of Ovarian Cancer in Relation to Estrogen and Progestin Dose and Use Characteristics of Oral Contraceptives

    Am J Epidemiol 152: 233-241, 2000

      

    Introduction: Oral Contraceptives (OCs) are considered to be the most powerful known chemopreventive agents for ovarian cancer. Earlier trials have demonstrated that an OC with 50 mg or more of estrogen diminishes the risk of ovarian cancer. It is not known whether the newer, lower-dose formulations have this same protective effect. Reported are findings of population-based, case-control trial designed to address the impact of dose of OC on its association with ovarian cancer.

       

    Results: Compared with never-users, the adjusted risk of ovarian cancer was decreased by 40% for OC users overall. Longer duration of use provided greater protection, independent of age at initiation.

       

    Conclusion: The protection provided by OC against ovarian cancer seems to be independent of the dose of estrogen or progestin. The diminished risk of ovarian cancer from OC use continues for 30 or more years after discontinuation of the OC and is protective after relatively short durations of exposure (1 to 4 years).

        

    Editor’s Comments: Many case-control and cohort studies have consistently shown that use of OCs reduces the risk of epithelial ovarian cancer. The protective effect persists for decades after the use of OCs has ceased. In this large population-based case-control study, a significant protection against development of ovarian cancer persisted for as long as 30 years after discontinuation of OC use and protection occurred with as little as 1 to 4 years’ total duration of OC use.

       

    With 10 or more years of OC use, there was a 70% reduction in development of ovarian cancer. Most of the earlier studies reported that reduction in ovarian cancer risk occurred with higher OC dose formulations than those currently used.

       

    In this study, a similar amount of protection occurred with the lower-dose OC formulations currently being used. In this study, as well as others, there is no information about the relation of formulations containing only 20 mg of ethinyl estradiol and the subsequent risk of developing ovarian cancer.

        

      



 

 

Speciality Spotlight

 

 

Ovarian
      

  • IJ Jacobs, SJ Skates, et al (Queen Mary and Westfield College, London; Harvard Med School, Boston)
    Screening for Ovarian Cancer: A Pilot Randomized Controlled Trial.
    Lancet 353: 1207-1210, 1999.
      
    Postmenopausal women aged 45 years and older were randomized to either a screened group or a control group (10,000 participants respectively). The screened group was offered 3 annual screens involving measurement of serum CA-125, pelvic ultrasound if CA-125 was 30 U/ml or more, and referral for gynecologic opinion when ovarian volume was 8.8mL or more on ultrasound.
     
    Results: Of 464 women from the screened group with elevated CA-125, 29 were referred for a gynecologic opinion. Six of these 29 patients had an index cancer and 23 had false positive findings. Thus positive predictive value was 20.7%.
        
    Editorial comment: The study was well conducted, and the authors’ recommendation of a larger trial is warranted in view of the deadly aspects of this disease, but it is not clear that this approach is going to be a major addition to the effort to detect this disease early.
     

  • DW Cramer, RF Liberman, et al (Brigham and Women’s Hosp, Boston; Dartmouth-Hitchcock Med Ctr, Lebanon, NH)
    Genital Talc Exposure and Risk of Ovarian Cancer.
    Int J Cancer 81: 351-356, 1999.
      
    The group consisted of 563 women in eastern Massachusetts and New Hampshire with epithelial ovarian cancer, including tumors of borderline malignancy. With a control group of 523 randomly selected women.
      
    Findings: Patients were more likely than controls to have used talc as a body powder. Exposure appeared to be more harmful before the first live birth. The association was strongest for women with invasive serous cancers and weakest for those with mucinous tumors.
       
    Conclusions: This large population based case control study has demonstrated an association between the use of talcum powder in the genital region and ovarian cancer. Avoidance of talc in genital hygiene might reduce the occurrence of a highly lethal cancer by at least 10%. Formal public health warnings should be provided about the potential risk associated with the use of talcum powder in the genital region.
      

  • BY Karlan, RL Baldwin,. Et al (Univ of California, Los Angeles; Univ of Toronto)t
    Peritoneal Serous Papillary Carcinoma, a Phenotypic Variant of Familial Ovarian Cancer: Implications for Ovarian Cancer Screening.
    Am J Obstet gynecol 180: 917-928, 1999.
       
    During the administration of a familial ovarian cancer screening program that was begun in 1991 and based on the pedigrees of symptom-free volunteers, a disturbing number of “ovarian cancer” cases with bulky peritoneal carcinomatosis and normal-size ovaries, consistent with peritoneal serious papillary carcinoma were noted. These lesions may represent primary ovarian cancers that disseminated widely before ovarian enlargement or discrete tumors arising from multiple peritoneal surfaces predisposed to malignant transformation. These tumors’ clonality and association with BRCA1 and BRCA2 mutations were reported.
      
    It was found that those carrying BRCA mutations are at risk for both primary ovarian cancer and peritoneal serous papillary carcinoma. The latter is clearly not amenable to early detection by vaginal ultrasound screening. While prophylactic oophorectomy reduces the risk of these types of cancers by 50%, it, unfortunately, does not eliminate the risk.
       

  • A Obermair, A Handisurya, et al (Univ Hosp of Vienna; Gen Hosp Lainz, Vienna)
    The Relationship of Pretrement Serum Hemoglobin level to the Survival of Epithelial Ovarian Carcinoma Patients: A Prospective Review.
    Cancer 83: 726-731, 1998.
       
    In malignant solid tumors and a variety of hematologic malignancies, tumor anemia is common. There are no factors other than the malignant disease itself in a number of patients to explain the presence of anemia. Previous studies have shown a correlation between the prognosis in patients with a variety of malignancies and pretreatment hemoglobin levels. 
       
    This study comprises of 206 patients with untreated epithelial ovarian carcinoma who had surgery during a 10-year period. Serum hemoglobin value below 12g/dl was the definition of anemia.
       
    Authors conclude that overall survival of patients with ovarian carcinoma had an independent relationship with tumor anemia, after adjustment for established prognostic factors. Marked tumor anemia was considered an indicator of the presence of biologically aggressive tumor cell clones because no significant interaction could be found between the grade of anemia and chemotherapy.
       

  • R Lehner, R Wenzi, et al (Univ of Vienna; Hosp Lainz, Vienna)
    Influence of Delayed Staging Laparotomy After Laparoscopic Removal of Ovarian Masses Later Found Malignant.
    Obstet Gynecol 92: 967-971, 1998
        
    Seventy patients were reviewed who had undergone attempted laparoscopic excision of a suspected benign ovarian mass, which was later proved by tissue and biopsy specimens to be malignant. In 22 patients, laparotomy was performed immediately after laparoscopy (immediate laparotomy group). Of the remaining patients, 22 underwent laparotomy 17 days or less after the initial examination and in 24 the delay between laparoscopy and laparotomy was more than 17 days.
       
    Findings: Early-stage ovarian cancer was significantly more prevalent among patients in the immediate and early laparotomy groups compared with those in the late laparotomy group (59% and 71%, respectively).
       
    Conclusions – Patients whose laparotomy was delayed more than 17 days after laparoscopy had a significantly increased risk of more advanced disease, probably because of tumor cell dissemination caused by the laparoscopy.
       
    Dr. Ingle’s comment: I have not understood why the authors have kept such an odd number of 17 days as cut-off line, probably this was appropriate for their particular group of patients.
       

  • JA Bridgewater, AE Nelstrop, et al (Mount Vernon Centre for Cancer Treatment, Northwood, England; Royal Marsden Hosp, London; Univ of Mississipi, Jackson; et al)
    Comparison of Standard and CA-125 Response Criteria in Patients With Epithelial Ovarian Cancer Treated with Platinum or Paclitaxel.
    J Clin Oncol 17: 501-508, 1999
        
    Background: The role of CA-125 in the assessment of patients undergoing second-line treatment with taxanes has been questioned. Some authorities doubt the reliability of CA-125 in the management of individual patients, and some have concluded that CA-125 cannot be used as a guide for determining response. CA-125 was evaluated as a measure of response in patients treated with paclitaxel.
      
    Methods: Data on 144 patients given paclitaxel in 4 different trials and 625 patients given platinum in 2 trials were analzyed, using precisely defined 50% and 75% reductions in CA-125 as responses. Standard and CA-125 response rates were compared.
       
    Conclusion: Precise 50% or 75% CA-125 response criteria are as sensitive as standard response criteria in evaluating treatment activity in patients with ovarian cancer. The standard measurement of complete response means disappearance of all disease or partial response more than 50% decrease.
      
    Though it is true CA-125 reduction 50-75% can be relied upon as response to the treatment of cancer with platinum or paclitaxel, the opposite does not hold true i.e. there can be disease response without a drop in CA-125.
      

  • M Markman, MF Brady, et al (Cleveland Clinic Found, Ohio; Roswell Park Cancer Inst., Buffalo, NY; Women’s Cancer Ctr of Northern California, Palo Alto; et al)
    Phase II Trial of Intraperitoneal Paclitaxel in Carcinoma of the Ovary, tube, and Peritoneum: A Gynecologic Oncology Group Study.
    J Clin Oncol 16: 2620-2624, 1998.
      
    Methods: Seventy-six eligible patients were enrolled in the trial. Eight-six percent were considered potentially cisplatin sensitive. In all patients, the largest residual disease was 0.5cmor less in maximum diameter at the end of second-look surgery. Some patients had been treated with paclitaxel previously. Treatment consisted of paclitaxel, 60mg/m2 intraperitoneal weekly for 16 weeks, followed by surgical assessment in patients with no evidence of disease progression.
      
    Findings : Fifty-three patients (70%) received all 16 planned treatment courses. Treatment was well tolerated. Microscopic disease at the beginning of intraperitoneal therapy had a complete response as defined by surgery.
      
    Authors conclude salvage intraperitoneal paclitaxel is active and tolerable in patients with microscopic residual ovarian, fallopian tube, or peritoneal cancer. The effect of such treatment on survival needs to be determined in a phase III trial.
      
    Editorial comment: Intraperitoneal therapy has yet to be shown an effective second-line treatment for most patients.
      

  • HD Homesley, BN Bundy, et al (Brookview Research Inc, Winston-Salem, NC; Roswell Park Cancer Inst, Buffalo, NY; Indiana Univ, Indianapolis)
    Bleomycin, Etoposide, and Cisplatin Combination Therapy of Ovarian Granulosa Cell Tumors and Other Stromal Malignancies: A Gynecologic Oncology Group Study.
    Gynecol Oncol 72: 131-137, 1999.
      
    Granulosa cell tumors represent about 8% of ovarian neoplasms and are more common in older women. These women usually present with early-stage disease. Patients with stage I tumors are usually treated with surgery, but those with advanced-stage tumors require adjunctive therapy. The efficacy and toxicity of a combination of bleomycin, etoposide, and cisplatin (BEP) as a first-line treatment for advanced or recurrent ovarian stromal cancers was investigated in a prospective trial.
      
    The study group consisted of 57 women with histologically confirmed stage II to IV or recurrent ovarian stromal tumors that had been incompletely resected. The patients were treated with BEP. 20 U/m2 on the day 1, etoposide 75mg/m2 from day 1 to day 5 and cisplatinum 20mg/m2 from day 1 to day 5 every 3 weeks for 4 courses.
      
    Findings: Of the 38 women who had second-look laparotomy at the end of the BEP treatment, 37% had negative findings. Grade 4 myelotoxicity occurred in 61% of the patients treated with the BEP.
      
    Authors conclude that BEP combination appears to be an effective first-line chemotherapy for advanced and recurrent ovarian stromal cancers.
     

  • JA Carlson, R Ambros, et al (Albany Med College, NY)
    Vulvar Lichen Sclerosus and Squamous Cell Carcinoma: A Cohort, Case Control, and Investigational Study with Historical Perspective; Implications for Chronic Inflammation and Sclerosis in the Development of Neoplasia.
    Hum Pathol 29: 932-948, 1998.
      
    Background: Vulvar lichen sclerosus (LS) is an inflammatory dermatosis characterized by chronic sclerosis. There is no consensus about the relationship between LS and squamous cell carcinoma (SCC), although the conditions are known to occur together. Lichen sclerosus could be associated with carcinogenesis through chronic inflammation and proliferation. To evaluate the relationship between LS and SCC, clinicopathologic studies were performed on 32 symptomatic vulvar LS patients and 60 patients with vulvar SCC.
     
    A Review of the patients of 1 gynecologist from 1980-1996 identified 32 LS patients. A further group of 60 patients, with invasive vulvar SCC excised at the Albany Medical Center from 1980 to 1995 and with follow-up available also formed part of the study group.
     
    Findings: Among the 32 LS patients, 9% developed vulvar intraepithelial neoplasia (VIN) and 21% developed invasive SCC. Symptomatic LS was detected an average of 4 years before diagnosis of carcinoma. Vulvar LS had significantly higher expression of p53 and aneuploidy than any of the 3 control groups.
      
    Authors conclude that the compiled frequency of SCC in association with LS was 4.5% with an average of 10 years of LS before diagnosis of SCC. The chronic inflammation and proliferation of LS can lead to genomic instability.
      
    Editorial comments: Tumors associated with LS tended to be clitoral in location. They also tended to occur in older patients, with a mean age of 74 versus 65 in the non-LS group.
      

  • ZS Tuncer, MR Bernstein, et al (Harvard Med School, Boston
    Outcome of Pregnancies Occurring Before Completion of Human Chorionic Gonadotropin Follow-up in Patients with Persistent Gestational Trophoblastic Tumor.
    Gynecol Oncol 73: 345-347, 1999.
      
    A chart review identified 43 women with gestational trophoblastic tumor (GTT) who conceived before standard hCG follow-up was completed during the period from 1973 to 1998. The mean interval from hCG remission to new pregnancy was 6.3 months. Of the remaining 29 patients, 75.9% delivered live infants at term and 10.3% had preterm delivery.
       
    Conclusions : Pregnancies occurring before standard hCG follow-up is completed in women treated for gestational trophoblastic tumor may continue under close observation. Most such pregnancies have favorable outcomes. However, there is a low but important risk of delayed diagnosis of tumor relapse during early pregnancy.
      
    Editorial comments: It appears that the risk of disease is low, but it certainly exists for those who undertake pregnancy sooner than 1 year after therapy for GTT.
      

  • P Harrkki-Siren, J Sjoberg, A Tiitinen (Helsinki Univ)
    Urinary Tract Injuries After Hysterectomy
    Obstet Gynecol 92: 113-118, 1998.
      
    Introduction: In gynecologic surgery, urinary tract injuries are among the most serious complications. About 75% of all ureteral injuries are caused by gynecologic procedures. 
      
    There were 142 urinary tract injuries after hysterectomy that were reportd during a 5-year period, and these were retrospectively analyzed. During this study period, 62379 hysterectomies were performed.
      
    Results : After all hysterectomies, the total incidence of ureteral injury was 1 of 1000 procedures: 13.9 of 1000 after laparoscopic, 0.4 of 1000 after total abdominal, 0.3 of 1000 after supracervical abdominal and 0.2 of 1000 after vaginal hysterectomy. Bladder injury there were 1.3 of 1000 procedures, 65% of reported bladder injuries were fistulas. The incidence was 2.2 of 1000 after laparoscopic hysterectomy; 1 of 1000 after total abdominal, 0 of 1000 after supracervical abdominal, and 0.2 of 1000 after vaginal hysterectomy.
       
    Conclusion: After laparoscopic hysterectomy, the risk of ureteral injury and even bladder injury is higher than with traditional hysterectomies.
        
    Editorial comment: The rates reported from Finland for laparoscopic procedures are much higher perhaps because the technique is comparatively new. As noted in the conclusion, if the patient is a good candidate for a vaginal hysterectomy there is no reason to change the operation to a laparoscopic procedure.
        

  • Ovadia Abulafia, David M Sherer (Department of Obstetrics and Gynecology, State University of New York at Brooklyn and the Department of Obstetrics and Gynecology and Women’s Health, Montefiore)
    Angiogenesis of the ovary
    Am J Obstet Gynecol, Jan.2000, 182(1), Part I, pg. 240-246.
          
    The authors present current data pertaining to angiogenesis of the ovary throughout the follicular and luteal phases of the ovarian cycle, in various ovarian pathologic conditions and in benign and neoplastic diseases. MEDLINE, Current Contents, and Index Medicus were searched for studies published between January 1966 and October 1998. All studies that incorporated human and animal models of angiogenesis of the normal ovarian physiologic state and pathologic conditions including both benign and neoplastic ovarian diseases were reviewed. 
        
    Current literature supports that angiogenesis is an important component of both follicular and luteal phases of the ovarian cycle that correlates well with maturation of secretory endometrium. Angiogenesis also participates in various pathologic processes of the ovary, including follicular cyst formation, polycystic ovary, ovarian hyperstimulation syndrome, and both benign and malignant ovarian neoplasms. In the future a knowledge of specific angiogenic patterns of various pathologic processes may assist in the application of antiangiogenic medications in targeted therapy of benign and neoplastic diseases of the ovary.
        

  • Rodriguez C, Patel AV, et al (American Cancer Society, Atlanta, Ga)
    Estrogen Replacement Therapy and Ovarian Cancer Mortality in a Large Prospective Study of US Women
    JAMA 285: 1460-1465, 2001
       
    Conclusion: Postmenopausal estrogen use lasting 10 years or longer was associated with an increased risk for ovarian cancer mortality. This risk persisted for up to 29 years after discontinuation of estrogen.
      
    Editor’s Comments: The results of this large, prospective study suggest that postmenopausal ERT used for 10 or more years, but not for a shorter duration, may slightly increase the risk for death from ovarian cancer. However, the results are based upon a single questionnaire administered in 1982.
      
    Thus, the body of epidemiologic evidence fails to confirm a link between ERT use and ovarian cancer, despite the findings of this single study.
         

  • Ness RB, and the SHARE Study Group (Univ of Pittsburgh, Pa; et al)
    Risk of Ovarian Cancer in Relation to Estrogen and Progestin Dose and Use Characteristics of Oral Contraceptives
    Am J Epidemiol 152: 233-241, 2000
      
    Introduction: Oral Contraceptives (OCs) are considered to be the most powerful known chemopreventive agents for ovarian cancer. Earlier trials have demonstrated that an OC with 50 mg or more of estrogen diminishes the risk of ovarian cancer. It is not known whether the newer, lower-dose formulations have this same protective effect. Reported are findings of population-based, case-control trial designed to address the impact of dose of OC on its association with ovarian cancer.
       
    Results: Compared with never-users, the adjusted risk of ovarian cancer was decreased by 40% for OC users overall. Longer duration of use provided greater protection, independent of age at initiation.
       
    Conclusion: The protection provided by OC against ovarian cancer seems to be independent of the dose of estrogen or progestin. The diminished risk of ovarian cancer from OC use continues for 30 or more years after discontinuation of the OC and is protective after relatively short durations of exposure (1 to 4 years).
        
    Editor’s Comments: Many case-control and cohort studies have consistently shown that use of OCs reduces the risk of epithelial ovarian cancer. The protective effect persists for decades after the use of OCs has ceased. In this large population-based case-control study, a significant protection against development of ovarian cancer persisted for as long as 30 years after discontinuation of OC use and protection occurred with as little as 1 to 4 years’ total duration of OC use.
       
    With 10 or more years of OC use, there was a 70% reduction in development of ovarian cancer. Most of the earlier studies reported that reduction in ovarian cancer risk occurred with higher OC dose formulations than those currently used.
       
    In this study, a similar amount of protection occurred with the lower-dose OC formulations currently being used. In this study, as well as others, there is no information about the relation of formulations containing only 20 mg of ethinyl estradiol and the subsequent risk of developing ovarian cancer.
        

      

 

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