Peritoneal Cytologic Examination Research Articles

Role of staging surgery and adjuvant chemotherapy in adult patients with apparent stage I pure immature ovarian teratoma after fertility-sparing surgery

ObjectiveThe standard treatment for young patients with stage I malignant ovarian germ cell tumors, except stage I dysgerminoma and stage IA G1 immature teratoma, is unilateral salpingo-oophorectomy with complete staging...

Depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis.

ObjectiveDiagnostic laparoscopy is recommended for the pretherapeutic staging of gastric cancer to detect any unexpected or unconfirmed intra-abdominal metastasis. The aim of this study was to evaluate the role and indications of diagnostic laparoscopy in the detection of intra-abdominal metastasis.MethodsStandard diagnostic laparoscopy with peritoneal cytology examination was performed prospectively on patients who were clinically diagnosed with primary local advanced gastric cancer (cT≥2M0). We calculated the rate of intra-abdominal metastases identified by diagnostic laparoscopy, and examined the relationship between peritoneal dissemination (P) and cytology results (CY). Split-sample method was applied to find clinical risk factors for intra-abdominal metastasis. Multivariate logistic regression analysis and receiver-operator characteristic (ROC) analysis were performed in training set to find out risk factors of intra-abdominal metastasis, and then validate it in testing set.ResultsOut of 249 cM0 patients, 51 (20.5%) patients with intra-abdominal metastasis were identified by diagnostic laparoscopy, including 20 (8.0%) P1CY1, 17 (6.8%) P0CY1 and 14 (5.6%) P1CY0 patients. In the training set, multivariate logistic regression analysis and ROC analysis showed that the depth of tumor invasion on computer tomography (CT) scan ≥21 mm and tumor-occupied ≥2 portions of stomach are predictive factors of metastasis. In the testing set, when diagnostic laparoscopy was performed on patients who had one or two of these risk factors, the sensitivity and positive predictive value for detecting intra-abdominal metastasis were 90.0% and 32.1%, respectively.ConclusionsAccording to our results, depth of tumor invasion and tumor-occupied portions of stomach are predictive factors of intra-abdominal metastasis.

Recurrence patterns and survival endpoints in women with stage II uterine endometrioid carcinoma: A multi-institution study

ObjectiveThere is paucity of data in regard to prognostic factors and outcome of women with 2009 FIGO stage II disease. The objective of this study was to investigate prognostic factors, recurrence patterns and survival endpoints in this group of patients. MethodsData from four academic institutions were analyzed. 130 women were identified with 2009 FIGO stage II. All patients underwent hysterectomy, oophorectomy and lymph node evaluation with or without pelvic and paraaortic lymph node dissections and peritoneal cytology. The Kaplan–Meier approach and Cox regression analysis were used to estimate recurrence-free (RFS), disease-specific (DSS) and overall survival (OS). ResultsMedian follow-up was 44months. 120 patients (92%) underwent simple hysterectomy, 78% had lymph node dissection and 95% had peritoneal cytology examination. 99 patients (76%) received adjuvant radiation treatment (RT). 5-year RFS, DSS and OS were 77%, 90%, and 72%, respectively. On multivariate analysis of RFS, adjuvant RT, the presence of lymphovascular space invasion (LVSI) and high tumor grades were significant predictors. For DSS, LVSI and high tumor grades were significant predictors while older age and high tumor grade were the only predictors of OS. ConclusionsIn this multi-institutional study, disease-specific survival for women with FIGO stage II uterine endometrioid carcinoma is excellent. High tumor grade, lymphovascular space invasion, adjuvant radiation treatment and old age are important prognostic factors. There was no significant difference in the outcome between patients who received vaginal cuff brachytherapy compared to those who received pelvic external beam radiation treatment.

Adjuvant Radiation Therapy for Patients With Type 2 Endometrial Carcinoma: Impact on Tumor Recurrence and Survival

The optimal adjuvant treatment of type II endometrial carcinoma after hysterectomy remains controversial. The objective of this study is to determine the effect of adjuvant radiation therapy (RT) on recurrence-free survival (RFS), disease-specific survival (DSS) and overall survival (OS) in patients with early stage type II endometrial carcinoma. In this IRB-approved study, our prospectively-maintained database of 1450 patients with endometrial cancer was reviewed. Seventy-nine surgically staged patients with 2009 FIGO stage I-II serous and clear cell carcinoma were treated from 1989-2010. All patients underwent total abdominal hysterectomy, oophorectomy, pelvic and paraortic lymph node evaluation and peritoneal cytology examination. The medical records were reviewed, and patient demographics, pathologic features and treatment-related factors were analyzed. The impact of adjuvant RT, on RFS, DSS and OS was studied. Following univariate analysis, multivariate modeling was done using multiple Cox proportional hazards analysis. Seventy-nine patients were analyzed. The median age of the study cohort was 65 years and median follow-up of 44.1 months. Thirty-nine patients (49%) received adjuvant RT (with pelvic external beam RT in 9 patients, vaginal cuff brachytherapy in 8 patients and a combination in 22 patients). Thirty-four (43%) patients received platinum-based chemotherapy. The 5-year RFS was significantly improved in patients who received RT (84% vs 58%, p=0.002). Similarly, 5-year DSS was significantly improved in patients who received RT (87% vs 58% p=0.023) with a trend towards improved 5-year OS (74% vs 56% p=0.088). On multivariate analysis, lack of angiolymphatic invasion (p<0.001 and p<0.001), adjuvant RT (p<0.001 and p=0.004) and lack of lower uterine segment involvement (p=0.007 and p=0.009) were independent predictors of improved RFS and DSS, respectively. In the current study for surgically staged FIGO I-II patients with type II endometrial carcinoma, adjuvant therapy with RT resulted in a significant improvement in recurrence-free and disease-specific survival. These results support the need for a prospective trial evaluating the role or RT in this group of patients.

The impact of race on outcomes of patients with early stage uterine endometrioid carcinoma

ObjectivesThe purpose of the present study was to determine whether racial disparity exists between African American (AA) and non-African American (NAA) patients with uterine endometrioid carcinoma who received similar multidisciplinary management. MethodsWe identified 766 patients with endometrioid adenocarcinoma 2009 FIGO stages I–II who underwent hysterectomy. Patients were divided into two groups; AA and NAA. Recurrence-free survival (RFS), disease specific survival (DSS) and overall survival (OS) for two groups were calculated. ResultsMedian follow-up was 5.1years. 27% were AA and 73% were NAA. All patients underwent hysterectomy and oophorectomy. 80% had peritoneal cytology examination and 69% underwent lymphadenectomy. AA patients were more likely to have higher grade tumors, and higher incidence of lymphovascular space involvement (LVSI). Although the two groups were balanced with regards to surgical staging and adjuvant treatment received, the 5-year RFS and DSS were significantly lower in AA compared to NAA patients (91% vs 84%, p=0.030; 95% vs 88%, p=0.011, respectively). Overall survival was not significantly different between the two groups. On multivariate analysis, after adjusting for other prognostic factors, race (AA vs NAA) was not a significant predictor of outcome. Grade 3 tumors and the presence of LVSI were the only two independent predictors of RFS and DSS with p≤0.001 and p≤0.001, respectively. ConclusionIn this large hospital-based study, AA race was associated with a higher incidence of adverse pathological features and worse recurrence-free and disease-specific survival. However, on multivariate analysis race was not an independent prognostic factor. Further studies are needed to elucidate possible underlying molecular mechanisms for these poorer outcomes.

Clinicopathological analysis and prognostic significance of peritoneal cytology in Chinese patients with advanced gastric cancer

The influence of peritoneal cytology on survival of patients with gastric cancer has not been consistent. This study was to identify risk factors for positive peritoneal cytology and to evaluate the predictive value of positive cytology among Chinese patients with advanced gastric cancer. The study included 139 patients with gastric cancer macroscopically invading the serosa, who underwent gastrectomy and intra-operative peritoneal cytological examination. In these patients, the relationship between cytological positivity and various clinicopathological features was analysed, and survival analysis was performed to identify independent prognostic factors of significance. Thirty-eight (27.3%) of 139 patients had positive peritoneal cytology. Although tumour size, lymphovascular invasion, depth of tumour invasion, lymph node metastasis and peritoneal metastasis were correlated with positive cytology, multivariate analysis revealed the depth of tumour invasion and peritoneal metastasis as the independent features affecting the cytology. Patients with a positive cytology result were confirmed to have a greater risk for recurrence in the pattern of peritoneal carcinomatosis and a significant inferior prognosis. Multivariate analysis indicated that positive peritoneal cytology was an independent prognostic factor among the curatively resected patients with advanced gastric cancer and was the prognostic factor most predictive of death for these patients (risk ratio = 2.74). Positive peritoneal cytology correlated with advanced features of gastric cancer. It is an independent poor prognostic factor, and it may serve as a guide for adjuvant therapeutic options to improve the survival of gastric cancer.

Diagnostic value of preoperative RT-PCR-based screening method to detect carcinoembryonic antigen-expressing free cancer cells in the peritoneal cavity from patients with gastric cancer.

At present the most reliable method for the diagnosis of peritoneal micrometastasis of gastric cancer is peritoneal wash cytology, but the sensitivity of this method is low. The aim of the present study was to verify whether carcinoembryonic antigen (CEA) reverse transcriptase-polymerase chain reaction (RT-PCR) assay can enhance the sensitivity and specificity of conventional cytology, and to determine how this technique can improve the accuracy of peritoneal recurrence. The present study included 230 patients with gastric cancer. Preoperative peritoneal wash was done by a paracentesis, followed by conventional cytology, CEA measurement, and CEA RT-PCR of recovered fluid. The CEA RT-PCR assay yielded 40 (17%) positives, which included none of the 26 patients with benign disease. The incidence of positive cytology and CEA level in wash fluid was 19% and 15%, respectively. Logistic stepwise regression analysis revealed that lymph node status, depth of invasion, venous invasion, and the results of peritoneal cytological examination, and CEA RT-PCR assay were independently related to peritoneal recurrence. The CEA level in the wash fluid was not related to peritoneal recurrence. Peritoneal cytological examination was the most significant predictive factor for peritoneal recurrence with a sensitivity of 46%, specificity of 94% and accuracy of 73%, while the corresponding values of the CEA RT-PCR assay were 31%, 95%, and 73%. Combining cytological examination with CEA RT-PCR assay resulted in a sensitivity rate for peritoneal recurrence of 57%, an 11% improvement over that of cytology alone. The data indicate that the use of a combination of CEA RT-PCR and cytological assay is more likely to identify patients who will develop peritoneal recurrence. This may be useful for the classification of patients for the most suitable therapeutic trials.

Impact of laparoscopic staging in the treatment of pancreatic cancer.

Staging laparoscopy in patients with pancreatic cancer identifies unsuspected metastases, allows treatment selection, and helps predict survival. Inception cohort. Tertiary referral center. A total of 125 consecutive patients with radiographic stage II to III pancreatic ductal adenocarcinoma who underwent staging laparoscopy with peritoneal cytologic examination between July 1994 and November 1998. Seventy-eight proximal tumors and 47 distal tumors were localized. Based on the findings of spiral computed tomography (CT) and laparoscopy, patients were stratified into 3 groups. Group 1 patients had unsuspected metastases found at laparoscopy and were palliatedwithout further operation. Group 2 patients had no demonstrable metastases, but CT indicated unresectability due to vessel invasion. This group underwent external beam radiation with fluorouracil chemotherapy followed in selected cases by intraoperative radiation. Patients in group 3 had no metastases or definitive vessel invasion and were resection candidates. Survival. Staging laparoscopy revealed unsuspected metastases in 39 patients (31.2%), with 9 having positive cytologic test results as the only evidence of metastatic disease (group 1). Fifty-five patients (44.0%) had localized but unresectable carcinoma (group 2), of whom 2 (3.6%) did not tolerate treatment, 20 (36.4%) developed metastatic disease during treatment, and 21 (38.2%) received intraoperative radiation. Of 31 patients with potentially resectable tumors (group 3), resection for cure was performed in 23 (resectability rate, 74.2%). Median survival was 7.5 months for patients with metastatic disease, 10.5 months for those receiving chemoradiation, and 14.5 months for those who underwent tumor resection (P = .01 for group 2 vs. group 1; P<.001 for group 3 vs group 1). Staging laparoscopy, combined with spiral CT, allowed stratification of patients into 3 treatment groups that correlated with treatment opportunity and subsequent survival. Among the 125 patients, laparoscopy obviated 39 unnecessary operations and irradiation in patients with metastatic disease not detectable by CT. Laparoscopic staging can help focus aggressive treatment on patients with pancreatic cancer who might benefit.

Relationship between peritoneal collagen type IV concentrations and the presence of disseminated metastases in gastric cancer.

To predict disseminated microscopic foci or occult micrometastases in the peritoneal cavity in patients with gastric cancer. Randomly selected patients with gastric cancer had peritoneal washings performed at the beginning of laparotomy. Thirty-nine patients with gastric carcinoma and 10 patients with other benign disease as a control group. Inpatients in a surgical department. The concentration of collagen type IV in the irrigated peritoneal fluid was measured radioimmunologically. Intraoperative peritoneal cytologic examination and measurements of carcinoembryonic antigen (CEA) levels were also performed. Results of the quantitative analyses of the collagen type IV concentrations as related to the clinicopathological characteristics and comparison of these results with regard to those of the peritoneal cytologic examination and CEA and collagen type IV levels. There were eight patients with elevated collagen type IV concentrations. They had carcinomas with serosal invasion (pT3 and pT4) and metastatic spread (pN2, M1). Patients with clinically evident peritoneal disseminated metastases had significantly higher collagen type IV concentrations compared with those without metastases. The collagen type IV levels were more sensitive than peritoneal cytologic examination or CEA values in detecting disseminated metastases. There was an early peritoneal recurrence in the form of ovarian metastases in one patient with negative cytologic results and an elevated collagen type IV level. Linear regression analysis showed a statistically significant correlation between the collagen type IV and CEA levels. Quantitative detection of abnormal collagen type IV levels may be useful for predicting the presence of disseminated metastases in patients with gastric cancer.

International federation of gynecology and obstetrics staging of endometrial cancer 1988

In 1988, the International Federation of Gynecology and Obstetrics (FIGO) Cancer Committee changed the staging of endometrial carcinoma from a clinical one to a surgicopathologic one. The emphasis in the new FIGO system was changed to the pathologic findings in the uterus, cervix, adnexa, and pelvic and/or periaortic nodes, and peritoneal cytologic findings. The major changes in this staging system were (1) the use of the depth of myometrial invasion and (2) the identification of tumor cells in peritoneal cytologic examination and of invasion in the retroperitoneal lymph nodes. Preoperative endocervical curettage was no longer necessary. Currently, the high level of operability of patients with endometrial carcinoma makes this staging system a viable one, which will provide information about the need for additional treatment. The use of the grading system for the tumor also was refined to upgrade nuclear changes that were inappropriate for the architectural grade. In serous adenocarcinomas, clear cell adenocarcinomas, and squamous cell carcinomas, nuclear grading took precedence. Adenocarcinomas with squamous differentiation were graded according to the nuclear grade of the glandular component.

Pathology of the uterine body

During the past year, evidence has compiled to suggest that uterine carcinosarcomas are, in fact, metaplastic carcinomas and that mitotic counts are of no value in distinguishing between high- and low-grade endometrial stromal sarcomas in stage I cases. The pathologic and biologic behaviour of uterine müllerian adenosarcomas has been comprehensively reviewed. Prognostic factors have been identified in a large series of surgically staged endometrioid adenocarcinomas of the endometrium, while the sinister nature of the serous papillary and clear cell carcinomas of the endometrium have been confirmed. It has been claimed that a papillary pattern of growth is an independent prognostic factor in endometrial neoplasia and shown that the accuracy of macroscopic estimation of depth of myometrial invasion decreases with increasing tumor grade. The value of peritoneal cytologic examination in early stage endometrial adenocarcinoma has been questioned, as has the value of DNA flow cytometry in endometrial neoplasia. The prognostic significance of steroid receptor status has been confirmed and studies of oncogene amplification are beginning to yield prognostically useful information. Evidence is also beginning to emerge concerning chromosomal abnormalities in many women with endometrial adenocarcinoma.

Peritoneal fluid cytology and prognosis in patients with endometrial carcinoma

Cytologic examination was performed on peritoneal fluid collected from a total of 235 consecutive patients with endometrial carcinoma who underwent laparotomy as the initial treatment at the Cancer Institute Hospital from 1971-1985. The rate of cases positive for cancer cells in the peritoneal cytologic examination was 18.7% for all stages (44 of 235 cases). In stage I endometrial carcinoma, the 5-year and 10-year cumulative survival rates with positive peritoneal cytologic findings were 91.6 and 90.0%, respectively; those in cases with negative cytologic findings were 90.2 and 90.2%, respectively, with no significant difference. The recurrence rate in the same stage was 12.0% for cytologically positive cases versus 9.5% for negative cases. In stages II and III, no significant difference was noted in the survival rate between nine cases with positive peritoneal cytologic findings without macroscopic peritoneal metastasis and 47 comparable cases with negative cytologic findings. Therefore, in endometrial carcinoma, the presence of malignant cells in peritoneal fluid is not a useful prognostic factor.

Prognostic significance of positive peritoneal cytology in endometrial carcinoma

A retrospective review of 280 patients with endometrial carcinoma who had peritoneal cytologic examination done at the time of laparotomy was undertaken. A positive cytologic finding was the only manifestation of extrauterine disease in 16 patients (6%). Four (25%) of these patients had a recurrence. Only 13 (5%) of 237 patients with negative cytologic findings had a recurrence. Positive peritoneal cytology is a marker for potential recurrence.

Prognostic significance of peritoneal cytology in patients with endometrial cancer and preliminary data concerning therapy with intraperitoneal radiopharmaceuticals

One hundred sixty-seven patients with clinical State I carcinoma of the endometrium were treated primarily by operation consisting of total abdominal hysterectomy, bilateral salpingo-oophorectomy, selective pelvic and para-aortic lymphadenectomy, and cytologic testing of peritoneal washings. Twenty-six (15.5%) of the 167 patients had malignant cells identified on cytologic examinations of peritoneal washings. Recurrence developed in 10 of these 26 (34.0%) compared to 14/141 (9.9%) patients with negative cytologic testing. Of the 26 patients, 13 (50%) had disease outside of the uterus at operation and seven have died of disease (54%). Thirteen patients had malignant cells in the peritoneal washings but no disease outside of the uterus and six (46%) of these have died of disseminated intra-abdominal carcinomatosis. On the basis of the poor outcome of those patients who had malignant cells in the peritoneal washings in the 167 patients studied, a plan of treating such patients with intraperitoneal radioactive chromic phosphate suspension (P-32) was instituted. Twenty-three subsequent patients with clinical Stage I carcinoma of the endometrium were found to have malignant cells in the peritoneal fluid. All 23 received intra-abdominal P-32 suspension instillation after operation. There have been three recurrences with two patients dying of disease. All of the three recurrences appeared at sites distant from the abdominal cavity. Peritoneal cytologic examination appears to be an important factor in the prognosis of endometrial cancer and, when the washings are positive for malignant cells, intraperitoneal chronic phosphate therapy appears to be efficacious.

THE PROGNOSTIC VALUE OF PERITONEAL CYTOLOGY IN GYNECOLOGIC MALIGNANT DISEASE

Abstract A study was undertaken to determine if peritoneal cytologic examination at the time of laparotomy could detect nonclinical malignant disease within the peritoneal cavity and thereby be of prognostic value. Between 1961 and 1968, 1,243 cytologic examinations were made of peritoneal specimens obtained from 1,035 patients. Analysis of this material indicates that peritoneal cytologic findings correlate well with prognosis in corpus, ovarian, and cervical malignant lesions. Cytologic examination can detect nonclinical disease spread in early ovarian lesions. In the absence of clinically evident ovarian cancer at the time of “second-look” operation, abnormal cytologic findings may serve as a guide to continuing chemotherapy or changing the mode of therapy. All patients who have gross disease present within the peritoneal cavity at laparotomy do not have malignant cells present in the peritoneal washings. Those patients with normal cytologic findings have a significantly better prognosis than the similar patient with abnormal cytologic findings.

The prognostic value of peritoneal cytology in gynecologic malignant disease

A study was undertaken to determine if peritoneal cytologic examination at the time of laparotomy could detect nonclinical malignant disease within the peritoneal cavity and thereby be of prognostic value. Between 1961 and 1968, 1,243 cytologic examinations were made of peritoneal specimens obtained from 1,035 patients. Analysis of this material indicates that peritoneal cytologic findings correlate well with prognosis in corpus, ovarian, and cervical malignant lesions. Cytologic examination can detect nonclinical disease spread in early ovarian lesions. In the absence of clinically evident ovarian cancer at the time of “second-look” operation, abnormal cytologic findings may serve as a guide to continuing chemotherapy or changing the mode of therapy. All patients who have gross disease present within the peritoneal cavity at laparotomy do not have malignant cells present in the peritoneal washings. Those patients with normal cytologic findings have a significantly better prognosis than the similar patient with abnormal cytologic findings.