What’s New in Gynaecological Oncology?
Best Management of Clear-Cell Endometrial and Uterine Papillary Serous Carcinomas Although less common than endometrioid endometrial carcinoma, clear-cell endometrial carcinoma (CCE) and uterine papillary serous carcinoma (UPSC) account for a disproportionate number of endometrial cancer-related deaths. Because of the low incidence of UPSC and CCE histotypes, to date only a limited number of prospective trials exist from which evidence-based management can be developed. Two Society of Gynecologic Oncologists (SGO) reviews try to answer this question. Clinical practice guidelines from the SGO regarding chemotherapy suggest a platinum-based doublet or triplet combination with paclitaxel and/or doxorubicin for CCE2 platinum/taxane-based regimen for UPSC.3
and a Randomised trials directly
comparing these regimens are now underway, many of which within the Gynecologic Oncology Group.
Clear-Cell Endometrial Carcinoma For the SGO review of CCE,2
MEDLINE was searched between 1 January
1966 and 31 December 2008 for all publications in English in which the studied population included women diagnosed with CCE. Qualifying studies had at least 30 patients. CCE histology is diagnosed in fewer than 6 % of all endometrial cancers and its incidence increases with age. Furthermore, CCE histology is morphologically and genetically different from that of the more prevalent endometrioid endometrial cancer, sharing many similarities with clear-cell neoplasms of the ovary and kidney. Comprehensive surgical staging is critical in order to plan appropriate postoperative management. Adjuvant pelvic and/or whole abdominal radiotherapy has not been clearly shown to be beneficial in women diagnosed with CCE. Adjuvant chemotherapy with cisplatin, Taxol® and doxorubicin, either in a doublet or triplet combination, has demonstrated efficacy.
Uterine Papillary Serous Carcinoma For the SGO review of UPSC,3
MEDLINE was searched for all research
articles published in English between 1 January 1966 and 1 May 2009 in which the studied population included women diagnosed with UPSC. Although preference was given to prospective studies, qualifying studies were not limited by design or by the number of subjects, given the paucity of available reports. Women affected by UPSC often presented with postmenopausal bleeding but also presented with abnormal cervical cytology, ascites or a pelvic mass. In some cases, the diagnosis was made by endometrial biopsy, while in other cases it was not made until the time of definitive surgery. Metastatic disease was common and best identified via comprehensive surgical staging. Local and distant recurrences occur frequently, with extra-pelvic relapses reported most commonly. Optimal cytoreduction and adjuvant platinum/taxane-based chemotherapy appeared to improve survival, while adjuvant radiotherapy may have contributed to loco-regional disease control. Women diagnosed with UPSC should undergo comprehensive surgical staging and an attempt at optimal cytoreduction. Platinum/taxane-based adjuvant chemotherapy should be considered in the treatment of both early- and advanced-stage patients.
Predicting Optimal Cytoreduction in Ovarian Cancer Using Serum CA-125 Titre Is the preoperative serum CA-125 titre correlated with optimal/ suboptimal surgical cytoreduction? This is an exciting question, which a meta-analysis4
with ovarian cancer. Using the bi-variate model, the diagnostic performance of CA-125 was assessed at various cut-off levels. An overall odds ratio was obtained using the random effects model. A total of 2,192 patients were included in the analysis. The pooled optimal cytoreduction rate was 53.7% and the mean of pooled median CA-125 levels was 580 U/ml. At the 500U/ml cut-off level, sensitivity and specificity were 68.9 % (95 % CI 62.0–75.1) and 63.2 % (95 % CI 53.7– 71.7), respectively. The positive and negative likelihood ratios were 1.87 (95 % CI 1.40–2.50) and 0.49 (95 % CI 0.37–0.66), respectively. CA-125 titre >500 U/ml showed a strong association with suboptimal cytoreduction, with an odds ratio of 3.69 (95 % CI 2.02–6.73). This analysis indicates that CA-125 titre is a strong risk factor for suboptimal cytoreduction and may be applied in preoperative counselling and treatment planning. However, it also shows that CA-125 titre cannot predict optimal cytoreduction accurately.
Multiple Conisation Procedures Increase the Risk of Preterm Delivery What is the impact of one or two conisations on preterm delivery and perinatal mortality in subsequent pregnancies? A population-based cohort study was conducted at the Aarhus University Hospital in order to evaluate preterm delivery and mortality rates in 721 deliveries after one conisation and in 37 deliveries after two conisations, compared with 390 deliveries after dysplasia and 74,552 deliveries that were not preceded by either conisation or dysplasia.5
The Cox regression model
was used to evaluate preterm delivery rates and perinatal mortality. The main outcome measures were: birthweight; gestational age (<28, <32 and <37 weeks of gestation); and perinatal mortality. The authors found that the risk of preterm delivery increased after one conisation (adjusted HR <37 weeks: 2.8 [95 % CI 2.3–3.5]; adjusted HR <28 weeks: 4.9 [95 % CI 2.5–9.7]) and that this risk further increased after two conisations (adjusted HR <37 weeks: 9.9 [95 % CI 6–17]; adjusted HR <28 weeks: 9.8 [95 % CI 1.4–70]), compared with no conisation. One conisation was associated with an increased perinatal mortality (adjusted HR <28 weeks: 9.9 [95 % CI 4.0–25]). All three methods of conisation [large loop excision of the transformation zone, electroknife and cold knife] increased the risk of preterm delivery. The authors concluded that a single conisation is associated with a 2.8-fold increase in the risk of perinatal death, most likely because of a 4.9-fold increase in extreme preterm delivery. Only 37 patients underwent two conisations and the results showed a tenfold increase in the risk of preterm delivery.
How Often Does Human Papillomavirus Cause Invasive Cervical Cancer?
A better understanding of the worldwide prevalence and distribution stability of human papillomavirus (HPV) genotypes in invasive cervical cancer is crucial to guide the introduction of prophylactic vaccines. A simple, large and elegant study6
was performed by an international
based on 14 international studies attempts to answer. In addition, the authors retrospectively reviewed data of 154 patients
EUROPEAN ONCOLOGY & HAEMATOLOGY
group of researchers based on paraffin-embedded samples of histologically confirmed cases of invasive cervical cancer, collected from 38 countries across Europe, North America, South America, Africa, Asia and Oceania. HPV detection in pathologically confirmed, primary invasive cervical cancer was achieved via polymerase chain reaction (PCR) using SPF10 HPV broad-spectrum primers and was followed by enzyme immunoassay and genotyping using a reverse hybridisation line probe assay. Sequence analysis was performed to characterise HPV-positive samples with unknown HPV types. Data analyses included algorithms of multiple infections to estimate type-specific relative contributions. 22,661 paraffin-embedded
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