Alexander B. Olawaiye

Colon and Rectum

In the sixth edition, Stage II was subdivided into IIA and IIB on the basis of whether the primary tumor was T3N0 or T4N0, respectively, and Stage III was subdivided into IIIA (T1-2N1M0), IIIB (T3-4N1M0), or IIIC (any TN2M0). In the seventh edition, further substaging of Stage II and III has been accomplished, based on survival and relapse data that was not available for the prior edition

Endometrial cancer: A review and current management strategies: Part I

Endometrial carcinoma is the most common gynecologic malignancy. A thorough understanding of the epidemiology, pathophysiology, and management strategies for this cancer allows the obstetrician-gynecologist to identify women at increased risk, contribute toward risk reduction, and facilitate early diagnosis. The Society of Gynecologic Oncologys Clinical Practice Committee has reviewed the literature and created evidence-based practice recommendations for diagnosis and treatment. This article examines: • Risk factors, including genetic predisposition • Diagnostic and metastatic evaluation • Surgical management of early and advanced cancer, including lymphadenectomy in early cancer.

Management of women with uterine papillary serous cancer: A Society of Gynecologic Oncology (SGO) review☆

OBJECTIVE Uterine papillary serous carcinoma (UPSC) is a clinically and pathologically distinct subtype of endometrial cancer. Although less common than its endometrioid carcinoma (EEC) counterpart, UPSC accounts for a disproportionate number of endometrial cancer related deaths. To date, limited prospective trials exist from which evidence-based management can be developed. This review summarizes the available literature concerning UPSC in an effort to provide the clinician with information pertinent to its management. METHODS MEDLINE was searched for all research articles published in English between January 1, 1966 and May 1, 2009 in which the studied population included women diagnosed with UPSC. Although preference was given to prospective studies, studies were not limited by design or by numbers of subjects given the paucity of available reports. RESULTS UPSC is morphologically and genetically different from EEC. Women often present with postmenopausal vaginal bleeding, but may also present with abnormal cervical cytology, ascites, or a pelvic mass. In some cases, the diagnosis may be made with endometrial biopsy, while in other cases it is not made until the time of definitive surgery. Metastatic disease is 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 appear to improve survival, while adjuvant radiotherapy may contribute to loco-regional disease control. CONCLUSIONS 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. Careful long-term surveillance is indicated as many of these women will recur. Prospective clinical trials of women with UPSC are necessary in order to delineate the optimal therapy for women with newly diagnosed and recurrent disease.

Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline

PURPOSE To provide guidance to clinicians regarding the use of neoadjuvant chemotherapy and interval cytoreduction among women with stage IIIC or IV epithelial ovarian cancer. METHODS The Society of Gynecologic Oncology and the American Society of Clinical Oncology convened an Expert Panel and conducted a systematic review of the literature. RESULTS Four phase III clinical trials form the primary evidence base for the recommendations. The published studies suggest that for selected women with stage IIIC or IV epithelial ovarian cancer, neoadjuvant chemotherapy and interval cytoreduction are noninferior to primary cytoreduction and adjuvant chemotherapy with respect to overall and progression-free survival and are associated with less perioperative morbidity and mortality. RECOMMENDATIONS All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to initiation of therapy. The primary clinical evaluation should include a CT of the abdomen and pelvis, and chest imaging (CT preferred). Women with a high perioperative risk profile or a low likelihood of achieving cytoreduction to < 1 cm of residual disease (ideally to no visible disease) should receive neoadjuvant chemotherapy. Women who are fit for primary cytoreductive surgery, and with potentially resectable disease, may receive either neoadjuvant chemotherapy or primary cytoreductive surgery. However, primary cytoreductive surgery is preferred if there is a high likelihood of achieving cytoreduction to < 1 cm (ideally to no visible disease) with acceptable morbidity. Before neoadjuvant chemotherapy is delivered, all patients should have confirmation of an invasive ovarian, fallopian tube, or peritoneal cancer. Additional information is available at www.asco.org/NACT-ovarian-guideline and www.asco.org/guidelineswiki.

Management of women with clear cell endometrial cancer: A Society of Gynecologic Oncology (SGO) review

OBJECTIVE Clear cell endometrial cancer (CCE) is an uncommon but important disease because of its aggressive behavior. Furthermore, prospective, randomized studies are either too difficult or impossible because of the small number of women affected. This review explores the differences between clear cell and endometrioid endometrial cancer. In addition, it uses available evidence to determine the best approach to management. METHODS Medline was searched between January 1, 1966 and December 31, 2008 for all publications in English where the studied population included women diagnosed with CCE. Qualifying studies must have had at least 30 patients. RESULTS Clear cell histology is diagnosed in less than 6% of all endometrial cancers and its incidence increases with age. Diagnosis can be made using the same tests that are used in the diagnosis of other types of endometrial cancer. Clear cell histology is morphologically and genetically different from the more prevalent endometrioid endometrial cancer histology. It shares 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 have not been shown to be clearly beneficial in women diagnosed with clear cell endometrial cancer. Adjuvant chemotherapy with cisplatinum, taxol and doxorubicin either in a doublet or triplet combination has demonstrated efficacy. CONCLUSIONS Women diagnosed with CCE require comprehensive surgical staging. Platinum based adjuvant chemotherapy in a doublet or triplet format in combination with paclitaxel and/or doxorubicin should be considered as part of treatment of these women. Careful long term surveillance following treatment is indicated given the higher rate of recurrence compared to endometrioid endometrial cancer.

Exocrine and Endocrine Pancreas

Pancreatic neuroendocrine tumors (including carcinoid tumors) are now staged by a single pancreatic staging system

MRI-Guided High–Dose-Rate Intracavitary Brachytherapy for Treatment of Cervical Cancer: The University of Pittsburgh Experience

PURPOSE Image-based brachytherapy is increasingly used for gynecologic malignancies. We report early outcomes of magnetic resonance imaging (MRI)-guided brachytherapy. METHODS AND MATERIALS Consecutive patient cases with FIGO stage IB1 to IVA cervical cancer treated at a single institution were retrospectively reviewed. All patients received concurrent cisplatin with external beam radiation therapy along with interdigitated high-dose-rate intracavitary brachytherapy. Computed tomography or MRI was completed after each application, the latter acquired for at least 1 fraction. High-risk clinical target volume (HRCTV) and organs at risk were identified by Groupe Européen de Curiethérapie and European SocieTy for Radiotherapy and Oncology guidelines. Doses were converted to equivalent 2-Gy doses (EQD2) with planned HRCTV doses of 75 to 85 Gy. RESULTS From 2007 to 2013, 128 patients, median 52 years of age, were treated. Predominant characteristics included stage IIB disease (58.6%) with a median tumor size of 5 cm, squamous histology (82.8%), and no radiographic nodal involvement (53.1%). Most patients (67.2%) received intensity modulated radiation therapy (IMRT) at a median dose of 45 Gy, followed by a median brachytherapy dose of 27.5 Gy (range, 25-30 Gy) in 5 fractions. At a median follow up of 24.4 months (range, 2.1-77.2 months), estimated 2-year local control, disease-free survival, and cancer-specific survival rates were 91.6%, 81.8%, and 87.6%, respectively. Predictors of local failure included adenocarcinoma histology (P<.01) and clinical response at 3 months (P<.01). Among the adenocarcinoma subset, receiving HRCTV D90 EQD2 ≥84 Gy was associated with improved local control (2-year local control rate 100% vs 54.5%, P=.03). Grade 3 or greater gastrointestinal or genitourinary late toxicity occurred at a 2-year actuarial rate of 0.9%. CONCLUSIONS This study constitutes one of the largest reported series of MRI-guided brachytherapy in North America, demonstrating excellent local control with acceptable morbidity. Dose escalation may be warranted when feasible for adenocarcinomas to offset the risk of local failure.

Lip and Oral Cavity

T4 lesions have been divided into T4a (moderately advanced local disease) and T4b (very advanced local disease), leading to the stratification of Stage IV into Stage IVA (moderately advanced local/regional disease), Stage IVB (very advanced local/regional disease), and Stage IVC (distant metastatic disease)

Neoadjuvant chemotherapy for newly diagnosed, advanced ovarian cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline ☆

PURPOSE To provide guidance to clinicians regarding the use of neoadjuvant chemotherapy and interval cytoreduction among women with stage IIIC or IV epithelial ovarian cancer. METHODS The Society of Gynecologic Oncology and the American Society of Clinical Oncology convened an Expert Panel and conducted a systematic review of the literature. RESULTS Four phase III clinical trials form the primary evidence base for the recommendations. The published studies suggest that for selected women with stage IIIC or IV epithelial ovarian cancer, neoadjuvant chemotherapy and interval cytoreduction are non-inferior to primary cytoreduction and adjuvant chemotherapy with respect to overall and progression-free survival and are associated with less perioperative morbidity and mortality. RECOMMENDATIONS All women with suspected stage IIIC or IV invasive epithelial ovarian cancer should be evaluated by a gynecologic oncologist prior to initiation of therapy. The primary clinical evaluation should include a CT of the abdomen and pelvis, and chest imaging (CT preferred). Women with a high perioperative risk profile or a low likelihood of achieving cytoreduction to <1cm of residual disease (ideally to no visible disease) should receive neoadjuvant chemotherapy. Women who are fit for primary cytoreductive surgery, and with potentially resectable disease, may receive either neoadjuvant chemotherapy or primary cytoreductive surgery. However, primary cytoreductive surgery is preferred if there is a high likelihood of achieving cytoreduction to <1cm (ideally to no visible disease) with acceptable morbidity. Before neoadjuvant chemotherapy is delivered, all patients should have confirmation of an invasive ovarian, fallopian tube, or peritoneal cancer. Additional information is available at www.asco.org/NACT-ovarian-guideline and www.asco.org/guidelineswiki.

Esophagus and Esophagogastric Junction

Tumor location is simplified, and esophagogastric junction and proximal 5 cm of stomach are included Tis is redefined and T4 is subclassified Regional lymph nodes are redefined. N is subclassified according to the number of regional lymph nodes containing metastasis M is redefined Separate stage groupings for squamous cell carcinoma and adenocarcinoma Stage groupings are reassigned using T, N, M, and G classifications