Management Of Gynecologic Malignancies Research Articles

Issues in gynecologic radiation oncology

Radiation therapy has a number of established roles in the curative, adjuvant, and palliative management of gynecologic malignancies. Specific indications for use of radiation therapy, concepts of integration of radiation therapy with other modalities, and techniques of radiation therapy, however, continue to evolve. Rather than discuss the use of radiation therapy in specific diseases, this paper reviews recent studies dealing with current issues in gynecologic radiation oncology.

Bedeutung von Sonographie und Computertomographie für die Diagnostik intraperitonealer Tumorausbreitungen

Taking the results of 307 cases with peritoneal carcinomatosis, the diagnostic value of ultrasonography and computerized tomography in the detection of peritoneal spread of gynaecological and gastrointestinal tumors is discussed. Ascites is the most important, though nonspecific, symptom which can be detected with the greatest accuracy. Peritoneal nodular lesions as well as omental and/or mesenteric involvement can easily be missed by both methods. Thus, staging-laparotomy cannot be replaced in the management of gynecologic malignancies.

The value of CT scanning in the management of patients with gynecologic malignancies.

The management of gynecologic malignancies is exceedingly complex, requiring thoughtful coordination of surgery, radiation therapy and chemotherapy. Despite the fact that the natural history and clinical course of these cancers are generally well understood, the scarring caused by surgery and/or radiation, and the marked limitations of pelvic examination make clinical staging and evaluation of limited value and known inaccuracy in following women with ovarian, cervical, uterine, vulvar and vaginal cancers. Understandably, the development of computerized axial tomography (CT), and its ability to visualize the abdomen and pelvis, lead to rapid acceptance of CT scans in defining extent of cancer and following patient response to various therapeutic interventions (Chen et al. 1980; Feigen et al. 1987; Photopoulos et al. 1977). Authors have compared the accuracy of CT findings with physical examination, surgical findings, lymphography, conventional radiography or ultrasound (Clarke-Pearson et al. 1986; Vercamb et al. 1987; Amendola 1981; Kerr-Wilson et al. 1984). However, little has been written on the effect of CT scanning on patient management. If we define and accept the accuracy of CT scanning in detecting pelvic and abdominal disease, can we show a benefit in patient management? Or, does CT scanning provide us with expensive information, or misinformation, which fails to translate into better patient care. Do complex imaging modalities compliment thorough examination and experienced clinical judgement, or only duplicate findings and provide extraneous information? To answer these questions, eighty-one months experience in using CT scanning in managing patients with gynecologic malignancies was reviewed.

The role of surgery in the management of gynecologic malignancies.

Surgery is the primary treatment modality in a selected group of patients with primary carcinomas of the vulva and cervix. Carcinoma of the endometrium may be treated with both irradiation therapy and surgical excision; whereas carcinoma of the ovary requires surgical excision followed by chemotherapy or irradiation. The new frontier in surgical management for gynecologic malignancies is one of an adjuvant role. Surgery combined with chemotherapy or irradiation, or both, offers a wide range of treatment options with the possibility of improved tumor control rates and decrease in damage to normal tissues. A brief update on the role of surgery in the treatment of gynecologic malignancies is presented.

Second-look Laparotomy in the Management of Gynecologic Malignancy

This paper reviews the authors experience with “second-look” laparotomy in the management of epithelial ovarian carcinoma, as well as other gynecologic malignancies. Eighty-four second-look laparotomies performed between June, 1972 and March, 1981 were reviewed. Sixty-three patients had epithelial carcinoma of the ovary. The other malignancies represented include nonepithelial cancer of the ovary, cancer of the uterine fundus, and adenocarcinoma of the fallopian tube. All patients were without objective evidence of intraperitoneal disease just prior to the laparotomy. Of the 63 patients with epithelial carcinoma, 22 were Stage I. All patients were treated with Alkeran alone or Alkeran combined with C-Parvum, Megace, or external pelvic radiation. Nineteen of 22, or 86 per cent, of the operations were negative for tumor. In the three positive cases, one patient had disease confined to the pelvis, one had pelvic disease and positive washings, and one had positive washings only. One patient died of disease 2 years later. The other two patients are without evidence of disease after secondary treatment (external pelvic radiation and combination chemotherapy) 6 months to 2 years after the positive laparotomy. Of the 19 negative laparotomies, there were two recurrences. One patient developed a perineal recurrence 9 months after the laparotomy. It was excised and the patient is without evidence of disease 1.5 years later. The second patient developed recurrence 5 years after a negative “second-look.” Ten of 12 Stage II patients were treated with Alkeran alone or in combination with Provera, or external pelvic radiation. One patient was treated with intraperitoneal P32 alone, and another was treated with combination chemotherapy. Nine of 12 laparotomies, or 75 per cent, were negative for malignancy. Two of 12 patients had residual disease after initial tumor-reductive therapy. Both patients with residual disease had positive laparotomies. In the negative laparotomy group, there were no recurrences with 6 months to 5 years follow-up. Sixteen Stage III and IV patients were treated with Alkeran alone or in combination with Megace, C-Parvum, or external pelvic radiation. Ten patients were treated with combination chemotherapy. One patient was treated with Adriamycin alone. Eight of 27 laparotomies, or 27 per cent, were negative for tumor. Five patients were without residual disease after initial tumor-reductive surgery. Of these five, three were in the negative group. In the negative laparotomy group, there were four recurrences or 50 per cent. One of these recurrences occurred in the pleural space and the other three were intraperitoneal. Of the eight patients in the negative laparotomy group, five were treated with Alkeran and three with combination chemotherapy. There were two patients with recurrent ovarian carcinoma treated with chemotherapy followed by “second-look” operations. Both laparotomies were positive. Presence of residual disease after initial tumor reduction is also important in the ratio of negative to positive “second-look” laparotomies. In this study, if residual disease was present, the chance for a negative “second-look” was 19 per cent. If no residual disease was present, the chance was 84 per cent. Residual disease was also important in recurrence after a negative “second-look” laparotomy. If residual disease was present, three out of five, or 60 per cent, developed recurrences. If no residual disease was present, two out of 28, or 7 per cent, recurred. Two “third-look” laparotomies were performed in the epithelial carcinoma subgroup. Both were positive and both patients died 6 months later. The second largest subgroup in the study was composed of patients with germ cell tumors of the ovary. There were nine patients, four with immature teratomas, four with endodermal sinus tumors, and one with a dysgerminoma. All patients had Stage IA disease except the patient with dysgerminoma who was a Stage III. The only positive laparotomy was the patient with dysgerminoma. In the negative group, there have been no recurrences with follow-up ranging from 6 months to 9 years. Rounding out the ovarian cancers were one patient with a Sertoli-Leydig cell tumor and one patient with a carcinosarcoma. Both patients were Stage I and both had negative laparotomies. Both are free of disease, 1 and 4 years after the laparotomy, respectively. There were eight patients with uterine cancer who underwent second-look laparotomies. Six patients had sarcomas (four carcinosarcomas and two leiomyosarcomas). Five of the six patients had intraperitoneal disease initially and five of six had negative second-look operations. Two patients with adenocarcinoma of the uterus

Second-look laparotomy in the management of gynecologic malignancy

Eighty-four second-look laparotomies performed between June 1972 and March 1981 were reviewed. Sixty-three patients had epithelial carcinoma of the ovary. The other malignancies represented include nonepithelial cancer of the ovary, cancer of the uterine fundus, and adenocarcinoma of the fallopian tube. All patients were without objective evidence of intraperitoneal disease just prior to the laparotomy. In the epithelial ovarian carcinoma group, the outcome of the laparotomy was affected by stage, histologic type, histologic grade, and presence of residual disease after initial tumor-reductive surgery. The type of treatment didn't seem to affect laparotomy outcome. Recurrence after a negative second-look laparotomy was affected by stage and presence of residual disease after initial tumor reduction. The second-look laparotomy remains the most sensitive indicator of persistent disease in epithelial carcinoma of the ovary. Experience with second-look laparotomies in other gynecologic malignancies is increasing.

Advances in the management of gynecologic cancer--radiation therapy.

Much progress has been made in the utilization of radiation therapy techniques in the management of gynecologic malignancies. However, new techniques will continue to emerge for the management of these disease processes. At this time, high LET radiation is particularly exciting, as are the potential possibilities for combined modality therapy. It is the expressed hope that these techniques will lead to imporved results in terms of management. The appropriate management for carcinoma of the uterus is excellent for the early stages, but treatments for later stages of the disease are not settled at this time. The high probability of involvement of periaortic lymph nodes in carcinoma of the cervix warrants a more appropriate look at the treatment techniques to be employed in the management of this disease, if the maximum potential for cure is expected. In carcinoma of the ovary, various factors influencing the ultimate prognosis have now been identified; these must be taken into consideration when planning treatment. If carcinoma is known or thought to have been left in the pelvis only, vigorous postoperative pelvic irradiation is mandatory. There isvidence to suggest, however, that equally good results can be obtained in those series by the utilization of chemotherapy. In view of the frequency of seeding to the peritoneum, whole abdominal irradiation should be considered for Stage IB through Stage III carcinoma of the ovary.

Experience with peritoneal cytology in the management of gynecologic malignancies

A summary of a 21 year experience with peritoneal cytology obtained by cul-de-sac and peritoneal lavage is presented. The interpretation of this type of cytology requires well-trained, experienced cytologists. Vaginal cul-de-sac lavage in asymptomatic patients has not proved effective in the early detection of ovarian cancer. Peritoneal cytology obtained at operation, on the other hand, has promise of considerable value. It was positive in 78 per cent of patients with ovarian cancer. Significantly, malignant tumors with an intact capsule shed malignant cells into the peritoneal cavity in 36 per cent of Stage I a patients. The over-all percentage of positive cytology for Stage I a, b, and c tumors was 45 per cent. There were 39 cases of Stage I endometrial carcinoma, of which 12.8 per cent had positive cytology. In patients with Stage III cervical carcinoma, who were explored as a part of their primary treatment, 14.7 per cent of those with negative nodes and 55.5 per cent of those with positive nodes had postive peritoneal cytology. Evidence is presented to prove that shed cancer cells are viable and capable of continued growth and that some form of adjunctive therapy should be considered.