N. Vavra

Benefit of external irradiation in pathologic stage I endometrial carcinoma: A prospective clinical trial of 605 patients who received postoperative vaginal irradiation and additional pelvic irradiation in the presence of unfavorable prognostic factors

Six hundred and five cases of endometrial carcinoma, pathologic stage I, without definable extrauterine disease were initially treated with total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by high-dose-rate iridium-192 irradiation of the vagina. External irradiation of the pelvis was performed only for patients with poor prognostic factors. Five-year survival was calculated by the product-limit method of Kaplan and Meier. Three hundred and forty-eight patients with tumor invasion of the inner third, of any tumor grade, received postoperative vaginal irradiation only. Twenty-eight patients with grade 1 tumor invasion of the middle third received vaginal irradiation only. One hundred and six patients with grade 2 or 3 tumor and infiltration of the middle third received vaginal and external irradiation of the pelvis. One hundred and twenty-three patients with deep muscle invasion of the external third of the myometrium received vaginal and pelvic irradiation. Differences in survival figures were not significant. Survival of the treatment group with good prognosis who received vaginal irradiation alone (91%) was similar to that of the group with poor prognosis who received additional pelvic irradiation (87.7%). Despite the unfavorable situation of patients with poor prognostic factors, treatment results after additional external irradiation were relatively equal to the results for patients with good prognostic factors who had not received external irradiation. Therefore, the benefit of external irradiation in patients with stage I endometrial carcinoma with unfavorable prognostic factors seems evident.

Radiation management of primary carcinoma of the vagina: Clinical and histopathological variables associated with survival

Data are presented on 434 patients treated at the Gynecologic Radiotherapy Department of the University of Vienna for invasive primary carcinoma of the vagina between 1952 and 1984; data on 110 patients treated in the last few years are more detailed. In stage I, 5-year survival was 76.7%; in stage II, 44.5%; in stage III, 31%; and in stage IV, 18.2%. The overall uncorrected 5-year survival rate was 39.9%. The disease is primarily one of the elderly as 78% were found to be older than 60 years of age. Younger patients had a 5-year survival of 50%; patients between 61 and 75 years of age, 41.2%; and those 76 years of age or older, 34.3%. Patients with presenting symptoms had a cure rate of 36.9%, whereas 61.1% of asymptomatic cases survived. Best results (60%) were obtained when the lesion was in the upper third of the vagina; only 37% of patients with lesions of the middle third and lower third survived more than 5 years. Well-differentiated tumors were associated with a 5-year survival of 62.5%; and poorly differentiated tumors, with a rate of 34.9%. Our results indicate that stage of disease is the most significant prognostic factor, but age of the patient, location of lesion in the vagina, and differentiation of the tumor influence outcome too. The majority of patients were managed by a combination of external pelvic irradiation and local application of radium. In stage I and II patients treated with radium alone, good results were obtained, but no patient with stage III or IV disease survived 5 years when external irradiation was not performed.

Oestrogen and progesterone receptor content as a prognostic factor in advanced epithelial ovarian carcinoma

Summary. Levels of oestrogen receptor (ER) and progesterone receptor (PgR) in ovarian cancer tissue were examined with regard to their prognostic importance for survival in 179 patients with primary epithelial ovarian cancer stage III or IV in relation to: FIGO‐stage, histological type, histological grade, age, ascites, and postoperative residual tumour. Hormone receptor content was determined with the DCC‐method, receptor values higher than 9 fmol/mg protein were considered positive. Response to postoperative chemotherapy was significantly correlated with PgR content (80% responders in the group with PgR positive tumours and only 61% responders in the group with PgR negative tumours). A Cox proportional hazards regression model identified histological grade, residual tumour, age and PgR content as independent prognostic factors for survival in advanced epithelial ovarian carcinoma. PgR content had particularly significant prognostic relevance for patients with postoperative residual tumour mass ≤2 cm in diameter. Within this group of patients, those who are PgR positive have a 2‐years survival probability of 83% compared with only 51% in the Pg R‐negative group.

Does T1, N0-1 vulvar cancer treated by vulvectomy but not lymphadenectomy need inguinofemoral radiation?

PURPOSE The objective of our study was to demonstrate differences in relapse rates, total survival times, and complication rates between inguinofemoral radiation and its absence in cases of invasive vulvar carcinoma without lymph node involvement (FIGO Stages T1, N0-1). METHODS AND MATERIALS From 1974 to 1990, 135 patients with invasive vulvar carcinoma in Stage T1 without clinical evidence of inguinal lymph node involvement underwent simple vulvectomy performed by hot-knife resection without lymphadenectomy. Although 65 patients (Group 1) received postoperative inguinofemoral radiation therapy, 70 patients (Group 2) did not, and none received local vulva irradiation. RESULTS The 5-year survival rates were 93.7% in Group 1 and 91.4% in Group 2 (p = NS). Although clitoris involvement was significantly more prevalent in the irradiation group (p = 0.04), inguinal relapse was found less frequently in Group 1 (4.6% or 3 out of 65 patients) than in group 2 (10% or 7 out of 70 patients) (p = 0.32). The complication rates were, 7.7% in Group 1 and 2.9% in Group 2, 2.7% for vaginal stenosis (two patients in each group), 1.5% for inguinal pain (one patient in Group 1), 1.5% for rectovaginal fistula (one patient in Group 1), 1.5% for vulvar infection (one patient in Group 1). CONCLUSION No statistically significant differences in the relapse rates and survival times were found. Risk factors were equally distributed in both study groups except for clitoris involvement. The 5-year survival rates in both groups were similar to those reported in the literature for radical vulvectomy and inguinal lymph-node dissection (83-96%). Morbidity in our study was low. Although our data showed similar results in both groups, we are not recommending at this time to omit groin radiation in general, but it may be justified in low-risk cases.

Preoperative and postoperative CA-125 serum levels in primary Fallopian tube carcinoma

Levels of CA-125 were determined pre- and postoperatively in 13 patients with Fallopian tube cancer. Values before surgery were significantly higher (Median 1220 IU/ml, 90–5000 IU/ml) compared with postoperative levels (Median 194 IU/ml, 67–880 IU/ml) (P=0.0052). Correlation analysis with FIGO stage and grading failed to show any statistical significance, but a trend for a positive correlation with FIGO stage and preoperative values could be observed. The CA-125 antigen is expressed by Fallopian tube carcinoma and should therefore be used in diagnosis and follow-up.

Prognostic factors related to recurrent endometrial carcinoma following initial surgery

Site of recurrence and histological type are significant prognostic factors for survival in recurrent endometrial carcinoma.

Evaluation of adjuvant therapy after surgery for primary carcinoma of the Fallopian tube

Objective: To evaluate the impact of postoperative therapy (chemotherapy vs. irradiation) on overall survival.Design: A nationwide retrospective analysis.Setting: Hanusch-Krankenhaus, Department of Gynaecology.Subjects: 115 patients with histologically proved primary carcinoma of the Fallopian tube: 49 received six treatment cycles of a cis-platinum regimen (group I), 24 patients were treated by full irradiation using 50 Gray minimum (group II). The two groups had a similar distribution of stage I and II; in the more advanced stages chemotherapy was the predominant method of treatment.Results: The five-year survival rate was 53% for women receiving irradiation as against 27% for those given cis-platinum. If the analysis was restricted to those patients with comparable stage I and stage II lesions, the p-value (0.07) was of borderline significance. There was no advantage in adding abdominal to pelvic irradiation (P=0.62).Conclusions: Stage I and stage II carcinoma is probably better treated postoperatively by radiotherapy than chemotherapy. Chemotherapy may have more therapeutic potential in patients with more advanced lesions.

Primary Fallopian tube carcinoma a retrospective survey of 51 cases

Objective: To evaluate retrospectively the importance of invasion beyond the basement membrane on overall survival in Fallopian tube carcinoma and its influence on the necessity of postoperative adjuvant therapy (stage 0 vs. stage I).Design: In a nationwide analysis the data of 51 patients were evaluated. The participating departments provided the study center with histologic specimens. A re-staging was done according to the FIGO-classification for Fallopian tube carcinomas. Stage 0 patients received no further postoperative therapy, in stage I patients were devided in 2 groups to evaluate the impact of postoperative adjuvant therapy (chemotherapy vs. irradiation).Results: Patients of stage 0 had a significantly better prognosis than patients of stage I (p=0.035). Stage I patients treated by irradiation showed a significantly better prognosis than patients treated by chemotherapy (p=0.017).Conclusion: Tumour penetration through the basement membrane causes prognosis to deteriorate significantly (5-year survival rate about 50% in stage I). Postoperative therapy is thus indicated with stage I disease. Irradiation seems to give better results than chemotherapy.

Goserelin a GnRH‐analogue as third‐line therapy of refractory epithelial ovarian cancer

Between October 1988 and March 1991, 23 ovarian cancer patients with progressive disease whilst receiving second- or third-line polychemotherapy received subcutaneously 3.6 mg Goserelin, a GnRH analogue, at monthly intervals until further tumor progression. Four patients (17.4%) achieved partial response, 7 patients (30.4%) had stable disease and 12 patients (52.2%) showed further tumor progression. Median time to tumor progression was 8.5, 5.3 and 2.1 months, respectively (Mantel test, P = 0.0003). Ten out of 11 patients who showed partial response or no change had grade 2 or grade 3 tumors. We conclude that Goserelin shows evidence of antitumor activity also in grade 2 and grade 3 ovarian carcinoma. It offers a therapeutic alternative to a group of patients, in whom we usually terminate cytotoxic treatment.

RADICAL LYMPHADENECTOMY IN THE PRIMARY CARCINOMA OF THE FALLOPIAN TUBE

SummaryThe primary carcinoma of the Fallopian tube is a highly aggressive tumor which can spread by the lymphatic route. The object of the present study was to evaluate the impact of radical pelvic and para-aortic lymphadenectomy on overall survival. Radical lymphadenectomy was performed on twelve patients in addition to hysterectomy and bilateral adnexectomy (group I). Twenty-eight patients subjected only to hysterectomy and adnexectomy formed the control group (group II). On average 47.6 lymph nodes were excised per patient. As long as the carcinoma was limited to adnexa and uterus (stages I and II), no lymph node metastases were found, only in stages III and IV were lymph node metastases detectable. Even though the median survival time of group I was considerably higher than of group II (43 versus 35 months), there was no statistically significant difference between the two groups (P<0.65). Patients with stage III and stage IV disease had relatively longer median survival times if they had a lymphadenectomy. However, the difference was not statistically significant (P<0.91). We cannot therefore recommend routine radical lymphadenectomy for primary Fallopian tube carcinoma. Whether or not lymph node dissection would lead to better results from rational selection of patient for adjuvant therapy is not known.