Pelvic Lymph Research Articles

Рутинные лабораторные показатели в стадировании рака шейки матки. Новые возможности

Aim: to identify and assess novel potentialities of routine lab tests to improve the accuracy of preoperative staging (spread) of high-grade squamous intraepithelial lesions (HSIL) and cervical cancer (CC). Patients and Methods: 410 women aged 18–82 (median age 42 [34; 51] years) with verified HSIL or CC were enrolled. Women were selected through medical records. Test results were monitored during in-person examinations since the formulation of clinical diagnosis and after surgical staging. If no surgical staging was performed, histopathology and disease stage as established by protocol examinations using instrumental and lab tests were considered. Women were subdivided into groups based on disease stage and method of treatment. Several parameters (complete blood count, hemostasis, biochemical markers of iron metabolism) were measured. In HSIL, minimal mandatory instrumental tests included pelvic and regional lymph node ultrasound. In CC stage 1–4, pelvic and abdominal ultrasound, pelvic MRI, abdominal CT with contrast, and (sometimes) PET CT. Results: several routine parameters of peripheral blood (hemoglobin, RBCs, ESR, fibrinogen, soluble fibrin monomer complexes/SFMC, D-dimer, ADP-induced platelet activation) were identified. Changes in the levels of these parameters within/above/below reference ranges illustrate the systemic effect of malignancy on the body and are a significant marker of regional metastasis of CC undiagnosed during a clinical examination. Conclusion: complex assessment of these parameters in CC allows for suspecting metastasis and requires more careful and reasonable examinations to improve the accuracy of prehospital diagnosis and determine management strategy. KEYWORDS: HSIL, cervical cancer, diagnosis, metastases, hematological markers, hemostasis, peripheral blood parameters, disease stage. FOR CITATION: Stuklov N.I., Sushinskaya T.V., Epifanova S.V. et al. Routine laboratory tests for staging of cervical cancer. Novel potentialities. Russian Journal of Woman and Child Health. 2021;4(3):229–237 (in Russ.). DOI: 10.32364/2618-8430-2021-4-3-229-237.

Mesonephric-Like Adenocarcinoma: Two Cases Of A Rare Entity And Review Of Literature

Abstract Introduction/Objective Mesonephric-like adenocarcinoma (MLA) is a rare gynecologic malignancy occurring in the uterus and ovary and is morphologic similar to cervical mesonephric adenocarcinoma. We present two cases of mesonephric-like adenocarcinoma of the ovary. Methods The first case is a 72-year-old female presented with abdominal pain with bloating. Abdominal CT scan showed a 7.4 x 6.3 x 6.1 cm heterogenous right adnexal mass. The second case is a 66-year-old female with history of heavy bleeding and endometriosis, status post total abdominal hysterectomy with bilateral salpingo-oophorectomy 20 years ago. Abdominal CT scan demonstrated a 5.3 cm right pelvic mass and 12.5 cm right pelvic sidewall lymph node. Results Both tumors have characteristic variety of features including ductal, tubular, retiform, papillary, solid and infiltrative morphological patterns. Cytologic atypia is mild to moderate. The histological features can raise a broad differential diagnosis including primary tubo-ovarian carcinomas, sex cord-stromal tumors, and metastatic carcinomas. Immunohistochemical stains demonstrate the ovarian tumor cells are positive for multiple pan-epithelial markers (AE1/AE3); negative for sex cord-stromal markers (inhibin and calretinin); positive for PAX8, GATA3, TTF1, and CD10; and negative for ER, PR, and WT1. In the first case, a small incidental endometrial carcinoma arising from an endometrial polyp was also identified. Morphologically, it is distinct from the ovarian mesonephric-like adenocarcinoma. Conclusion Morphological and immunohistochemical features of the two tumors are consistent with MLA, a very rare ovarian tumor that is thought to arise either from mesonephric remnants in the para-ovarian tissue or by trans- differentiation from a benign or neoplastic Mullerian precursor. These tumors are reported to have a very high frequency of KRAS mutations followed by PIK3CA mutations. Due to their rarity, the clinical behavior of these tumors is unknown.

Robotic Radical Trachelectomy with an Abdominally Placed Vaginal Cerclage

Study Objective To demonstrate a robotic radical trachelectomy where-in a vaginal purse-string suture was placed abdominally in order to contain the cervical tumor. Design A case report. Setting A tertiary referral center. Patients or Participants A 32-year-old gravida 0 presented with stage IB1 squamous cell carcinoma of the cervix. Pelvic MRI demonstrated a tumor the size of 1.5cm where the upper margin of the lesion was >2 cm from the uterine isthmus. PET/CT was without evidence of metastatic disease. Interventions The patient desired future fertility and opted for a robotic radical trachelectomy. The patient was placed in dorsal lithotomy position. No intrauterine manipulator was placed. ICG dye was injected onto cervix for delineation of pelvic sentinel lymph nodes. Bilateral pararectal, paravesical, and obturator spaces were developed after which bilateral pelvic sentinel lymph nodes were removed with negative frozen results. The uterine arteries were skeletonized and separated from their ureteral attachments. The rectovaginal and vesicovaginal spaces were developed. The bilateral paracervix were transected off. 2-0 prolene suture was utilized to place a purse-string suture onto upper vagina. The colpotomy was then performed circumferentially and cervix was amputated about 1 cm below the uterine isthmus. Trachelectomy specimen margins were negative. The upper vagina was then reconstructed to the lower uterine segment. A pediatric foley was placed into the lower uterine segment to minimize the risk of cervical stenosis. Measurements and Main Results Robotic radical trachelectomy was performed without any complications, where-in a uterine manipulator was avoided and a purse-string suture was placed onto upper vagina to minimize tumor manipulation and prevent spillage into peritoneal cavity, respectively. Conclusion We believe that if MIS surgeons adhere to basic oncologic surgical principles, we will be able to provide our patients with proven MIS benefits without compromising oncological safety.

STUDY OF OVARIAN MALIGNANCY IN GYNEONCOLOGY UNIT IN ELSHATBY HOSPITAL IN ALEXANDRIA AS A TERTIARY REFFERAL CENTER

Malignant ovarian neoplasms cause more deaths than any other cancer of the female genital tract and is the seventh most common cancer diagnosed.Staging for ovarian cancer is principally surgical and should include total abdominal hysterectomy with bilateral salpingo-oophorectomy, only unilateral adnexectomy in fertility preservation surgery, at least infra-colic omentectomy, multiple peritoneal biopsies, lymph node sampling including pelvic and para-aortic lymph nodes up to renal veins, peritoneal wash and appendectomy in case of suspicion of mucinous histology.During initial surgery, early stage ovarian cancer patients are often incompletely staged. This oversight can have unfavorable sequelae for the prognosis of such patients, as the completeness of surgical staging is an independent prognostic parameter for survival. The aim of this work was to retrospectively review patients with ovarian malignancy from period 2017-2019 in gyne-oncology department of Elshatby hospital.This retrospective study was conducted on records of women admitted to gyne-oncology department in Elshatby hospital during period from 1/6/2017 to 1/6/2019 diagnosed with ovarian malignancy.

Estimation of secondary cancer risk after radiotherapy in high-risk prostate cancer patients with pelvic irradiation.

We aimed to estimate the risk of secondary cancer after radiotherapy (RT) in high‐risk prostate cancer (HRPC) patients with pelvic irradiation. Computed tomography data of five biopsy‐proven HRPC patients were selected for this study. Two different planning target volumes (PTV1 and PTV2) were contoured for each patient. The PTV1 included the prostate, seminal vesicles, and pelvic lymphatics, while the PTV2 included only the prostate and seminal vesicles. The prescribed dose was 54 Gy for the PTV1 with a sequential boost (24 Gy for the PTV2). Intensity‐modulated RT (IMRT) and volumetric modulated arc therapy (VMAT) techniques were used to generate treatment plans with 6 and 10 MV photon energies with the flattening filter (FF) or flattening filter‐free (FFF) irradiation mode. The excess absolute risks (EARs) were calculated and compared for the bladder, rectum, pelvic bone, and soft tissue based on the linear‐exponential, plateau, full mechanistic, and specific mechanistic sarcoma dose‐response model. According to the models, all treatment plans resulted in similar risks of secondary bladder or rectal cancer and pelvic bone or soft tissue sarcoma except for the estimated risk of the bladder according to the full mechanistic model using IMRT(6MV;FF) technique compared with VMAT techniques with FFF options. The overall estimation of EAR indicated that the radiation‐induced cancer risk due to RT in HRPC was lower for bladder than the rectum. EAR values ranged from 1.47 to 5.82 for bladder and 6.36 to 7.94 for rectum, depending on the dose–response models used. The absolute risks of the secondary pelvic bone and soft tissue sarcoma were small for the plans examined. We theoretically predicted the radiation‐induced secondary cancer risk in HRPC patients with pelvic irradiation. Nevertheless, prospective clinical trials, with larger patient cohorts with a long‐term follow‐up, are needed to validate these model predictions.

Pretreatment tumor-related leukocytosis misleads positron emission tomography-computed tomography during lymph node staging in gynecological malignancies

The accuracy of fluorine-18-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG-PET/CT) can be influenced by the increased glycolytic activity of inflammatory lesions. Here, using clinical data obtained from gynecological cancer patients, tumor samples and animal models, we investigate the impact of pretreatment tumor-related leukocytosis (TRL) on the diagnostic performance of 18F-FDG-PET/CT in detecting pelvic and paraaortic lymph node metastasis. We demonstrate that pretreatment TRL misleads 18F-FDG-PET/CT during lymph node staging in gynecological malignancies. In the mechanistic investigations, we show that the false-positive 18F-FDG-PET/CT result for detecting nodal metastasis can be reproduced in animal models of TRL-positive cancer bearing G-CSF expressing cervical cancer cells. We also show that increased 18F-FDG uptake in non-metastatic nodes can be explained by the MDSC-mediated premetastatic niche formation in which proinflammatory factors, such as S100A8 or S100A9, are abundantly expressed. Together, our results suggest that the MDSC-mediated premetastatic niche created in the lymph node of TRL-positive patients misleads 18F-FDG-PET/CT for detecting nodal metastasis.

Outcomes of External-Beam Radiation Therapy Boost with Conventional Fractionation in Cervical Cancer: A Retrospective Analysis about 133 Cases

Introduction: External-beam radiation therapy boost is a treatment option in cervical cancer when brachytherapy is not feasible. Though less effective than brachytherapy, some encouraging results have been reported from some institutions experiences. We conducted this study to assess outcomes of EBRT boost for our patients at National Institute of Oncology in Rabat. Patients and Methods: We collected data from patients treated for cervical cancer between January 2012 and December 2015. Patients, tumor and treatment characteristics were collected. Overall survival (OS), disease-free survival (DFS) and prognostic factors influencing DFS were assessed. Results: One hundred and thirty-three patients were enrolled. Median age was 52 years. Patient haemoglobin level ranged from 3.9 to 15.5 g/dl [mean: 11.2 g/dl]. Most tumors were classified stage III/IVA (63.2%) according to the FIGO classification. Regional lymph node metastases (pelvic and or para-aortic) were observed in 45.1%. Median total dose to tumor was 69.6 Gy (ranging from 66 to 70 Gy). Overall treatment time was protracted, with a median of 60 days. Most of patients received concurrent chemotherapy (94.7%) and the number of cycle ranged from 2 to 7 (median = 5). The follow-up median was 31.3 months, ranging from 6.2 to 96.8 months. At the first visit, most patients achieved complete response (80.5%). Five years OS and DFS were 47% and 44% respectively. In univariate and multivariate analysis, regional lymph nodes metastasis (presence or absence) and haemoglobin level (≤11 g/dl and >11 g/dl) were the two significant and independent prognostic factors influencing DFS (HR: 1.86; p = 0.01 for the former) (HR: 0.59; p = 0.03 for the latter). Conclusion: Our study showed that EBRT boost in conventional fractionation was an acceptable treatment option for cervical cancer unamenable to brachytherapy, especially in the two subgroups of patients that are those without pelvic and/or para-aortic lymph node metastasis and those with haemoglobin level above 11 g/dl.

Advances in paraaortic lymphadenectomy for endometrial carcinoma

Endometrial carcinoma is one of the most common gynecologic malignancies in developed countries, the incidence of the disease has gradually increased in recent years.The vast majority of endometrial cancers are detected at early stages.Surgery is the principal treatment for endometrial cancer, including total hysterectomy, bilateral salpingooophorectomy, with pelvic and paraaortic lymph node dissection.Lymph node metastasis is the main risk factor for poor prognosis of endometrial carcinoma.However, the value and extent of resection of lymph node are still controversial.In this paper, we reviewed the progress of para-aortic lymphadenectomy for endometrial carcinoma. Key words: Endometrial neoplasms; Lymph node excision; Aorta, abdominal

Controlling heterogeneity within the lymphatic target volume for dose painted treatment of prostate cancer

Introduction: For patients with high risk prostate cancer, conventionally fractionated treatment of the pelvic lymphatics and hypofractionated treatment to the prostate can be delivered simultaneously with dose painting. The purpose of this technical note is to highlight unexpected hot spots within the low dose lymphatic target volume as a clinical problem that we have observed with dose painting, and to describe a simple approach to account for this during treatment planning.Summary: We describe the creation of a control structure that can be incorporated into the optimization objective function. An upper constraint objective can be placed on the control structure such that heterogeneity within the plan is limited to the area near the high dose target volume and better emulates the dosimetry of a conventionally fractionated sequential boost plan.

Successful para‐aortic lymph node dissection for endometrial cancer with horseshoe kidney: A case report and review of the literature

Horseshoe kidney (HSK) is considered to impede para-aortic lymph node dissection. We report the case of a 54-year-old female patient with endometrial cancer and HSK, treated successfully with para-aortic lymph node dissection, and present literature review regarding vascular abnormalities associated with HSK affecting para-aortic lymph node dissection. Three-dimensional computed tomography reconstruction revealed the accessory renal artery, supernumerary renal vein and ventral displacement of the renal pelvis and ureter. Abdominal modified radical hysterectomy, bilateral salpingo-oophorec'tomy, pelvic and para-aortic lymph node dissection and omentectomy were then performed. Lymphadenectomy behind the isthmus of the kidney was performed without separation of the isthmus by lifting the kidneys with vessel tape. There were no intraoperative or postoperative complications. Grasping shifted ureter and complicated vascular network of HSK and securing the operative field without division of the isthmus were key to reducing complications and hemorrhage. This case report can serve as a guide for performing para-aortic lymph node dissection safely and effectively in patients with HSK.

Integration of 68Ga-PSMA-PET/CT in Radiotherapy Planning for Prostate Cancer Patients.

The clinical data of 191 prostate cancer patients treated with definitive intensity-modulated RT were retrospectively analyzed. All patients were initially staged with thoracoabdominal CT and bone scintigraphy, and the second staging was performed using Ga-PSMA-PET/CT. Both stages were evaluated for the decision making of RT and any change in RT target volumes. After staging with Ga-PSMA-PET/CT, 26 patients (13.6%) had risk group changes, 16 patients (8.4%) had an increase in risk group, and 10 patients (5.2%) had a decrease in risk group. Down-staging occurred in 22 patients (11.5%), and upstaging was observed in 30 patients (15.7%). A total of 26 patients (13.6%) had nodal stage changes. After the Ga-PSMA-PET/CT scans, the number of metastatic patient increased to 17 (8.9%), with 4 of them moving from oligo- to polymetastatic disease. An additional irradiation of pelvic lymphatics and metastatic site was performed in 13 patients (6.8%) and 6 patients (3.2%), respectively. The RT was aborted in 4 patients (2.1%) because of parenchymal or distant site metastasis observed in the Ga-PSMA-PET/CT. We found that Ga-PSMA-PET/CT causes considerable migration in stage, risk group, and RT field arrangements, especially in high-risk patients regardless of the GS and baseline prostate-specific antigen values alone. Ga-PSMA-PET/CT seems to have a great influence on RT decision making in prostate cancer patients.

Comparison of definitive cervical cancer management with concurrent chemotherapy and radiation between two centers with variable resources and opportunities for improved treatment delivery.

5534 Background: Cervical cancer remains a global health challenge particularly in low to middle income countries with under resourced healthcare systems. We present the experiences of two centers practicing in variable resource environments to determine predictors of improved radiochemotherapy outcomes. Methods: This retrospective review describes baseline demographic and clinicopathologic characteristics of cervical cancer patients treated with concurrent chemotherapy and radiation between 2014 and 2017 at the National Radiotherapy Oncology and Nuclear Medicine Center (NRONMC) in Korle Bu Teaching Hospital, Accra, Ghana and Moffitt Cancer Center, Tampa, Florida, USA. Results: Ghanaian patients presented at an older median age (56 vs. 49 years, p < 0.001), with predominantly stage IIIB disease (43% vs. 16%, p < 0.001) and squamous cell histology (89% vs. 79%, p < 0.001). Median treatment duration was longer for Ghanaian patients (58 vs. 52 days, p < 0.001). Ghanaian patients were less likely to receive concurrent chemotherapy (68% vs. 100%, p < 0.001) and interstitial brachytherapy implants (0 vs 19%, p < 0.001). No Ghanaian patients received a radiation boost to pelvic or paraortic lymph nodes (p < 0.001). Ghanaian patients had lower local control (64% vs. 93%, p < 0.001) and overall survival (82% vs. 95%, p = 0.02) at 24 months, respectively. For stages IB, IIA, IIB, IIIB, 24 month local control rates for NRONMC vs. Moffitt patients were (60% vs. 93%; p = 0.05), (89% vs. 100%; p = 0.35), (91% vs. 91%; p = 0.89), (53% vs. 91%; p = 0.02) and 24 month OS rates were (85% vs. 100%; p = 0.06), (100% vs. 100%; p = 0.48), (85% vs. 96%; p = 0.2), (73% vs. 91%; p = 0.24), respectively. Treatment duration > 55 days predicted poorer overall survival on multivariable analysis (MVA). Stage ≥III disease predicted poorer local control on MVA. Conclusions: Significant differences were noted in treatment and disease characteristics between the two centers. Feasible improvements for patients treated at NRONMC include removing financial barriers to chemotherapy access, improving radiotherapy delivery capacity to reduce treatment delays, and screening programs to reduce advanced disease presentation.

Phase Ib clinical investigation of intraperitoneal ipilimumab and nivolumab in patients with peritoneal carcinomatosis due to gynecologic malignancy.

TPS5606 Background: The peritoneal cavity is a frequent site of metastasis and recurrence for gynecologic malignancy, including approximately 80% of epithelial ovarian cancer (EOC) that presents with peritoneal involvement. These observations have led to the use of intraperitoneal (IP) route of administration for traditional cytotoxic chemotherapy. IP immunotherapy is a recognized but under explored area of clinical investigation with many potential advantages. Indeed, IP administered antibodies in both animals and human subjects are associated with absent or much lower peripheral blood concentrations. In addition to higher local and lower systemic exposure, other theoretical advantages include preferential binding to intraperitoneal and intratumoral immune cells, and absorption through the draining lymphatics of the peritoneal cavity. These pelvic and peri-aortic lymph nodes represent the most relevant lymphoid organs and as such may be the ideal site for T cell activation and trafficking back to the peritoneal tumor. Methods: The trial (NCT03508570) is a single-institution phase Ib trial to determine the recommended phase II dosing (RP2D) of IP administration of nivolumab in combination with ipilimumab. For the purpose of dose finding, the assessment period for dose limiting toxicity (DLT) is 12 weeks. The trial starts with a safety lead-in to confirm the safety of IP nivolumab before combining it with ipilimumab. A maximum sample size of 12 will be used to find the RP2D for nivolumab, up to 24 patients for the combination, and a planned expansion will be carried out such that at least 12 EOC patients are treated at RP2D of the intraperitoneal combination strategy. The secondary objectives are to describe the pharmacokinetics and toxicities, and to estimate the clinical benefit rate for the expansion cohort. Translational objectives include description of immunologic and biologic changes in serial blood and IP fluid collections as well as pre and on-treatment biopsies. Eligibility criteria include recurrent or progressive biopsy-confirmed platinum resistant EOC or other gynecologic cancer with measurable peritoneal disease, and no exposure to prior treatment with checkpoint inhibition. Enrollment began in January of 2019 with 3 subjects enrolled to date. Accrual update will be provided at the annual meeting. Clinical trial information: NCT03508570.

Survival differences based on tumor size among stage 1B cervical cancer patients in Louisiana using revised FIGO staging system.

e17017 Background: In the recently revised 2018 FIGO cervical cancer staging, stage IB is sub-classified into 3 classes based on tumor size. We aim to determine if larger tumor size confers worse survival outcomes in women with stage IB cervical cancer in Louisiana. Methods: Women with stage IB cervical cancer diagnosed between 2010 and 2016 were identified from the Louisiana Tumor Registry. Patients with positive pelvic or para-aortic lymph nodes and those with less than 30 days follow up were excluded. Subjects were classified into three groups based on tumor size: stage IB1 ( < 2cm), stage IB2 (≥ 2cm and < 4cm), and stage IB3 (≥ 4cm). Cox proportional hazards were used to estimate differences in overall (OS) and cause-specific survival (CSS). Covariates included age, race, insurance, census tract-poverty level, and marital status. Results: 198 patients were included with a median follow up time of 43.8 months. Mean age of patients in this cohort was 46.8 years. The subjects were well distributed between the groups: 79 (39.4%) stage IB1, 60 (30.3%) stage IB2, and 60 (30.3%) stage IB3. White women comprised a larger percentage of earlier stage tumors (79.5% 1B1 vs 68.3% 1B2 vs 53.3% 1B3, p < 0.01); Black women were overrepresented in later stage disease (45.0% IB3, 28.3% IB2, 20.5% IB1, p < 0.01). There were no significant differences between the three groups in age, insurance status, poverty level, or marital status. After adjusting for covariates, patients with stage 1B3 disease had worse survival than those with stage 1B1 disease in both OS [HR 6.01 (1.96,18.50)] and CSS [HR 24.31 (2.97,199.00)]. Patients with stage 1B2 disease had worse survival than those with 1B1 disease but this did not reach statistical significance: OS HR 1.88 (0.52,6.74); CSS HR 6.79 (0.77, 59.99). Kaplan-Meier curves of OS and CSS show significant survival differences between the three groups (p < 0.0001) with best outcomes in stage 1B1 and worst in stage 1B3 patients. Conclusions: This analysis of contemporary stage IB cervical cancer patients in Louisiana confirms that tumor size > 4cm confers worse clinical prognosis. Black women are overrepresented advanced stage IB disease. While patients with tumors 2-4cm did worse than those with tumors < 2cm, this did not reach statistical significance. This could be due to the limited sample size of our cohort.

Revised FIGO staging shows dramatic survival differences in cervical cancer patients with positive lymph nodes in Louisiana.

e17010 Background: With revisions to FIGO cervical cancer staging system in 2018, patients with positive pelvic or para-aortic lymph nodes (LN) are now classified as stage IIIC. Rationale for this change is based on data published in 1990. Methods for work up and treatment of cervical cancer have advanced since then. We aim to determine if updated FIGO staging reflects contemporary survival differences in women with cervical cancer in Louisiana. Methods: Women with FIGO stage I-III cervical cancer diagnosed between 2010 and 2016 were identified from the Louisiana Tumor Registry. Those with < 30 days follow up were excluded. Patients were classified into 3 groups: true stage I & II (LN negative), revised stage IIIC (old stage I or II but positive LN), previous stage III (old FIGO stage IIIA or IIIB). Cox proportional hazards were used to estimate differences in overall and (OS) cause-specific survival (CSS). Covariates of age, race, insurance, census-tract poverty level, and marital status were controlled. Results: 740 patients were included with a median follow up of 40.6 months. Patients in revised stage IIIC group were younger than the others (45.9 yrs vs 47.9 yrs in true stage I&II vs 55yrs in previous stage III, p < 0.0001). True stage I&II patients were more likely to be privately insured (48.9% vs 32.1% revised stage IIIC vs 27.7% previous stage III, p < 0.0001). The groups did not differ by race, poverty level, or marital status. Revised stage IIIC and previous stage III patients had significantly worse survival outcomes compared to true stage I & II in both OS [revised stage IIIC HR 1.93 (1.20-3.11); previous stage III 5.92 (4.27, 8.22)] and CSS [revised stage IIIC HR 2.54 (1.45-4.44); previous stage III HR 7.95 (5.29, 11.94)]. Kaplan-Meier survival curves demonstrate significant differences in both OS and CSS (p < 0.0001) with best outcomes in true stage I&II and worst in previous stage III patients. Conclusions: LN status is an important prognostic indicator for contemporary cervical cancer patients in Louisiana. This analysis provides recent data to support the revised FIGO staging system in upstaging patients with positive LN to stage IIIC as they have significantly worse survival than the true stage I & II patients. Importantly, revised stage IIIC patients who would have previously been stage I & II have strikingly better survival outcomes than women with stage IIIA and IIIB disease. If staging is to be intuitive, the stage III subcategories may need to be redefined.

Patient-reported Outcomes and Late Toxicity After Postprostatectomy Intensity-modulated Radiation Therapy

BackgroundLimited long-term data characterize patient-reported quality of life (QOL) following postprostatectomy intensity-modulated radiation therapy (PPRT), and predictors of decline are poorly defined. ObjectiveTo identify modifiable dosimetric and clinical risk factors impacting QOL and late toxicity following PPRT. Design, setting, and participantsA prospective cohort study of consecutive men with prostate cancer who received PPRT between 2007 and 2015 at a single academic institution. InterventionPatients were prospectively evaluated using the Expanded Prostate Cancer Index Composite (EPIC-26) QOL instrument. Radiation Therapy Oncology Group/Common Toxicity Criteria for Adverse Events toxicity grades were assigned at every follow-up visit. Treatment was delivered to the prostate bed (median 68Gy)±pelvic lymphatics (65%, median 50.4Gy) with daily image guidance. Androgen deprivation therapy was concomitantly administered to 132 (66%) men for a median of 4mo. Outcome measurements and statistical analysisChanges were deemed relevant if they exceeded the minimally clinically important difference (MCID), as calculated by a distribution-based method. Generalized estimating equation models and Cox regression were used for QOL and late toxicity univariate and multivariable analysis. Results and limitationsOverall, 199 men were identified with a median follow-up of 33mo. Overall urinary function (UF), bowel function (BF), sexual function (SF), and urinary irritation/obstruction (UI/UO) scores were never lower than the MCID. Between 8% and 18% of men experienced a small multidomain (1× MCID) decline, and 0–8% experienced a moderate multidomain decline (2× MCID) at a given time point up to 84mo after PPRT. The rates of freedom from grade 2 or higher (Gr2+) genitourinary (GU) and gastrointestinal (GI) toxicity were 94% and 95%, respectively, at 4yr. Factors associated with worse QOL or toxicity included longer time to PPRT (UC and UF), higher BMI (UF, BF, and late GI toxicity), older age (BF, SF, and late GU toxicity); hormone therapy (SF), total dose (late GI toxicity), tobacco history (BF), and higher bladder V70Gy (UC, UF, and late GU toxicity). ConclusionsLong-term QOL and late toxicity are favorable following postprostatectomy radiation therapy. Identifiable clinical and dosimetric risk factors may guide decision making to optimize urinary, sexual, and bowel function. Patient summaryThe following study provides a detailed report of favorable patient-reported quality of life and late side-effect profiles of radiation therapy following surgery for localized prostate cancer. Our findings provide patients guidance on what symptoms to expect if they are planning to undergo radiation therapy in this setting. It also allows physicians to counsel patients appropriately, and modify certain clinical and radiation-related risk factors to optimize quality of life.

Feasibility of Performing Laparoscopic Completion Staging in Incidentally Diagnosed Early-Stage Ovarian Carcinoma Patients

Laparoscopy has been described as a method for surgical reassessment in patients with ovarian cancer since the early 1970s; however, these early reports were received with limited acceptance of laparoscopy as a replacement for laparotomy. The objective of this study was to assess the feasibility of laparoscopy as an option for completion staging in ovarian carcinoma. A retrospective analysis was performed at our institute from January 2015 till June 2016 of patients who were diagnosed with early ovarian carcinoma incidentally following surgery elsewhere. Completion staging was done laparoscopically. 12 patients had undergone completion staging. The average age was 33 years. Initial biopsy following the first surgery was epithelial ovarian carcinoma in nine patients, granulosa cell tumor in two patients and teratoma in one patient. After the first surgery, CA-125 levels were elevated in two patients. The average duration between the two surgeries was 55 days. Five patients showed residual malignancy after completion staging, of which four (33%) patients were upstaged. The average number of pelvic and para-aortic lymph nodes dissected was 16 and 7 respectively, of which none were positive. Two patients underwent fertility-preserving surgery, preserving the contralateral ovary and uterus. None of the patients required conversion to laparotomy. Postoperative recovery was uneventful in all the patients. Average hospital stay was 4.5 days. Adjuvant chemotherapy was given to six patients. Completion staging should be considered for patients diagnosed with early ovarian cancer following surgery for undiagnosed adnexal mass. Laparoscopic staging is feasible in such cases without any increase in morbidity.

The outcome of loco-regional radiotherapy in metastatic castration-resistant prostate cancer patients treated with abiraterone acetate.

316 Background: To evaluate the potential benefit of curative radiotherapy (RT) to primary tumor in metastatic castration resistant prostate cancer (mCRPC) patients treated with abiraterone. Methods: The clinical parameters of 106 mCRPC patients treated with abiraterone in the either pre- or post-chemotherapy setting were retrospectively evaluated. All patients had PSA progression or radiographic progression suitable for metastasis according to the RECIST guidelines with or without PSA progression. Patients were either oligometastatic (≤5 metastases) at diagnosis or became oligometastatic after systemic treatment were analyzed. Local RT to primary tumor and pelvic lymphatics was delivered in 44 patients (41%), while 62 patients (59%) did not have RT to primary tumor. Results: Median follow-up times for patients overall and for those who survived were 14.2 months (range, 2.3–54.9 months) and median OS for entire cohort was 21.9 months. The median OS was significantly higher in patients treated with local RT to primary tumor compared to patients without local RT (p = 0.04). Local RT to prostate and pelvic lymphatics significantly diminished local recurrence rate ( p = 0.003). In univariate analysis, a decline in PSA levels ≥50% of baseline was significant prognostic factor for both OS and PFS in entire cohort and in patients receiving prostate RT. In multivariate analysis, PSA response ≥50 of baseline obtained ≥3 weeks after abiraterone therapy is the only significant prognostic factor for better OS and PFS. Additionally, local RT to prostate is nearly significant prognosticator for improved OS. Patients treated with primary RT to prostate had significantly less progression under abiraterone and longer abiraterone period compared to patients without local prostate RT. Conclusions: Local prostate RT significantly improves OS and local control but not PFS, in mCRPC treated with abiraterone. Patients treated with primary RT to prostate had significantly less progression under abiraterone and longer abiraterone period compared to patients without local prostate RT.

Metacure: Multi-arm multimodality therapy for very high risk localized and low volume metastatic prostatic adenocarcinoma.

TPS349 Background: Therapeutic advances in the management of metastatic castration-resistant prostate cancer (mCRPC) have not been matched in non-castrate states. A key obstacle is the traditional paradigm in which therapies with significant benefit in mCRPC are then studied in patients (pts) with localized, rising PSA or early metastatic disease using time-to-event (TTE) outcomes (e.g. biochemical recurrence, radiographic progression or death). These trials are costly, lengthy and often give inconclusive results that do not change practice nor provide a methodology to rank regimens based on efficacy. A new strategy is needed that gives a rapid efficacy readout and prioritizes approaches for large-scale testing. Methods: Metacure is a multi-arm, multi-stage randomized Phase 2 trial in which novel systemic therapies are studied in the context of a multimodality approach, which includes radical prostatectomy + pelvic and retroperitoneal lymph node dissection, if applicable, stereotactic radiotherapy (RT) to osseous metastases, and an option for adjuvant RT based on risk factors. The arms include combinations of ADT + apalutamide +/- abiraterone acetate and prednisone. Non-castrate prostate cancer pts with high probability of relapse or death from disease ranging from very high risk localized to low-volume metastatic disease are eligible. The primary endpoint is pathologic complete response and minimal residual disease. The secondary endpoint is undetectable PSA with non-castrate levels of testosterone. Both are binary endpoints that circumvent interpretations of the clinical relevance of TTE outcomes, providing a read-out of success or failure in a shorter time frame with fewer pts. The uniform entry criteria and continuous randomization enables ranking and prioritization of the strategies evaluated for further development in large-scale trials so that only the most effective ones move forward. This multicenter trial is managed by the Prostate Cancer Clinical Trials Consortium, funded by Janssen and is currently open and actively accruing. Future plans include opening a cohort of pts with aggressive non-castrate disease harboring DNA damage repair alterations. Clinical trial information: NCT03436654.

Lymphatic cysts after gynecological cancer surgery: risk factors, diagnosis and treatment

Lymphatic cysts, also known as lymphocele, are one of the most common complications after pelvic and paraaortic lymph node dissection in patients with gynecological cancers. Despite the high incidence of this complication, no specific guidelines on the diagnosis and treatment of lymphocele have been developed so far. This article analyzes the incidence of lymphatic cysts, risk factors, and currently available options for their diagnosis and treatment.