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Secondary tumor reductive surgery in persistent or recurrent ovarian cancer
126
SOCIETY OF GYNECOLOGIC
of the colonoscopic findings on management; (b) the prevalence of colorectal neoplasia; and (c) the efficacy of the procedure in staging gynecologic cancers. Symptoms were related to pelvic tumor and only 3 patients had primary gastrointestinal complaints. Forty-six patients had ovarian (13), endometrial(l7), cervical (14), or vaginal (2) carcinomas. There were 2 patients with pelvic lymphoma, 5 with uterine leiomyoma, and 7 with benign ovarian tumors. Twenty-six patients (43%) had neoplastic lesions on colonoscopy. One patient had endometrial carcinoma metastatic to the sigmoid colon, and 4 (7%) had metastatic primary colon adenocarcinoa (2 with metastasis to the ovaries, 1 to the cervix, and 1 to the vagina). Twenty-one patients (35%) had adenomatous polyps (1 to 9 in each) of varying sizes (0.2 to 4 cm) which were removed. Carcinoma in si/u was identified in 3 patients (5%). Colonoscopy helped in altering the management in 8 (13%) and prevented a second surgical procedure in 5 patients. In the latter group, 3 patients with metastatic primary colon carcinoma underwent colon resection during the initial surgery and 2 patients had intraoperative removal of large sessile polyps by colostomy which had been identified by colonoscopy. In conclusion, preoperative colonoscopy appears to be of value in the management of female pelvic tumors. Colorectal neoplasia occurs with increased frequency in patients with gynecologic cancer. The role of presurgical colonoscopy in patients with gynecologic tumors is not yet clear; however, it did not help in staging the gynecologic cancer. 136. High Dose Rate Remote Afterloading Irradiation in the Treatment of Gynecologic Malignancies: A Preliminary Report. G. DEPPE, Y. H. KIM, C. G. ORTON, V. K. MALVIYA, K. AHMAD, J. M. MALONE, JR., AND C. W. CHRISTENSEN,Wayne State University, Detroit, Michigan 48201. High dose rate (HDR) remote afterloading technique was used in 30 patients with gynecologic malignancies to critically evaluate the HDR technique and compare it with the standard low dose rate (LDR) treatment. Sixteen patients with endometrial cancer and six patients with cervical cancer received postoperative vaginal vault radiation. Three patients with Stage III vaginal cancer and five patients with Stage IIIB cervical cancer received brachytherapy using the HDR system. No major complications were observed. The most significant advantage of the HDR system is the ability to secure the applicator in a known geometry without risk of movement of the applicator during therapy. Shorter duration of insertion in an outpatient setting makes HDR a very cost-effective and convenient procedure for both the patient and her physician and improves radiation safety. Additionally, the HDR afterloading system may allow multiple intracavitary treatments for cervical carcinoma, leading to an increased therapeutic advantage. In our early experience, the HDR remotely controlled afterloading system is a good alternative to the conventional LDR system. Controlled clinical trials should be designed to compare both regimens to demonstrate convincing evidence of the superiority of the HDR system. 137. Secondary Tumor Reductive Surgery in Persistent or Recurrent Ovarian Cancer. V. K. MALVIYA, G. DEPPE, AND J. MALONE, JR., Wayne State University, Detroit, Michigan 48201. Recent studies in the literature yield conflicting results about the precise role of secondary tumor reductive surgery (STR) in ovarian cancer. To determine the role of secondary debulking, we studied the records of 74 patients with progressive or stable ovarian cancer who underwent STR. All patients had previously undergone a primary cytoreductive effort. Sixty-six patients received cisplatinum containing combination chemotherapy following surgery, while 8 patients received non-cisplatinum containing chemotherapy or radiation therapy. The presence of persistent or progressive disease after primary surgery was documented prior to STR. Sixty-two of 74 (84%) patients required bowel resection, either as a palliative measure or in an effort to achieve
ONCOLOGISTS-ABSTRACTS optimal cytoreduction (residual tumor <2 cm). However, only 33 of 74 patients (45%) could be optimally cytoreduced. Morbidity, including infection, persistent bowel obstruction, and fistula formation, occurred in 28 patients (38%) and was encountered most frequently in patients requiring bowel resection. One patient died of pulmonary embolism in the immediate postoperative period. The median survival of patients who were optimally cytoreduced was significantly longer than the median survival of those patients who were suboptimally cytoreduced (9 months vs 5 months, P < 0.004). Patients with clinically undetectable ascites had a significantly longer median survival than patients in whom ascites was clinically evident (12 months vs 5 months, P < 0.002). Our data indicate that secondary cytoreduction is justified in patients with incomplete response to primary therapy, but is beneficial only if optimal cytoreduction is achieved. Clinically evident ascites is a poor prognostic factor regardless of optimal cytoreductive surgery. 138. Stage I Carcinoma of the Endometrium-Surgical Staging and Treatment. H. CAGLAR, M. S. PIVER, AND M. M. HRESCHCHYSHYN, University at Buffalo (SUNY), Buffalo, New York. One hundred thirty-eight FIG0 Stage I endometrial cancer patients were surgically staged and treated, and 105 were followed up after 10 months to 11 years. All patients were subjected to TAH, BSO, paraaortic (PA) and pelvic (PE) node biopsies. Thirteen had PE and PA node metastasis with incidence of 7.9 (11) and 7.2% (IO), respectively. 80% (8) with PA and 63% (7) with (PE) metastasis had deep myometrial invasion. Of 10 Gl and G2 with PA and PE mode metastasis, 70% (7) had deep myometrial invasion. None of the G3 had PE, PAmetastasis in the absence of deep invasion, and/or capillary-like space involvement. Forty-eight patients had external radiation, 27 had vaginal cesium, 50 had no adjuvant therapy. Thirteen had chemotherapy alone or with radiation. Three patients with PE node metastasis alone are alive with no evidence of disease 25, 35, and 59 months following external pelvic radiation. Of 10 patients with PA node metastasis, 4 are alive with no evidence of disease at 10, 11, 18, and 62 months; 2 were treated with chemotherapy and 2 with chemotherapy plus radiation. Of 5 patients with adnexal metastasis and neoplasia confined to the pelvis, two are alive with no evidence of disease at 59 and 83 mo. Of 28 patients with G3 or deep invasion or both and neoplasia confined to the corpus, 26 received external radiation; 2 were lost to follow-up and 2 (8.3%) had recurrence and died. Of 76 patients with Gl and G2, less than 50% invasion, 29 were lost to follow-up. Of the 47 evaluable patients, 23 had vaginal cesium and 24 had no therapy. There were no recurrences in either group. The overall recurrence was 12.3% (13) and none survived. 139. Concomitant Cisplatin (DDP) and Radiotherapy (RT) in Locally Advanced Cervical Carcinoma (CX CA). C. D. RUNOWICZ, S. WADLER, L. RODRIGUEZ-RODRIGUEZ,P. LITWIN, K. A. O’HANLAN, G. GOLDERG, C. TOMAINO, AND R. BYRNES, Albert Einstein College of Medicine, The Bronx, New York 10461. Patients (pts) with locally advanced cervical carcinoma (cx ca) have a poor prognosis. The efficacy of radiotherapy (RT) is limited by the presence of large tumor volume and nodal disease. Since concomitant cisplatin (DDP) is a documented radiosensitizer and has activity in squamous cell carcinomas (SCC), a prospective study was designed to evaluate the toxicity and potential synergism of concurrent DDP and RT in locally advanced cx ca. DDP, 20 mg/M’ daily x 5 days every 21 days, was administered concurrently with standard external and intracavitary RT. A median of four courses of DDP was given. Thirty-five pts. were entered from March 1986 to March 1988, 11 were excluded (2 refused further treatment, 3 had disease out of the pelvis, 5 were too early, 1 was lost to follow-up, in remission) leaving 24 evaluable pts. for response. The 3 pts. with disease out of the pelvis were included in toxicity evaluation. The median age was 47 (range
SOCIETY OF GYNECOLOGIC
of the colonoscopic findings on management; (b) the prevalence of colorectal neoplasia; and (c) the efficacy of the procedure in staging gynecologic cancers. Symptoms were related to pelvic tumor and only 3 patients had primary gastrointestinal complaints. Forty-six patients had ovarian (13), endometrial(l7), cervical (14), or vaginal (2) carcinomas. There were 2 patients with pelvic lymphoma, 5 with uterine leiomyoma, and 7 with benign ovarian tumors. Twenty-six patients (43%) had neoplastic lesions on colonoscopy. One patient had endometrial carcinoma metastatic to the sigmoid colon, and 4 (7%) had metastatic primary colon adenocarcinoa (2 with metastasis to the ovaries, 1 to the cervix, and 1 to the vagina). Twenty-one patients (35%) had adenomatous polyps (1 to 9 in each) of varying sizes (0.2 to 4 cm) which were removed. Carcinoma in si/u was identified in 3 patients (5%). Colonoscopy helped in altering the management in 8 (13%) and prevented a second surgical procedure in 5 patients. In the latter group, 3 patients with metastatic primary colon carcinoma underwent colon resection during the initial surgery and 2 patients had intraoperative removal of large sessile polyps by colostomy which had been identified by colonoscopy. In conclusion, preoperative colonoscopy appears to be of value in the management of female pelvic tumors. Colorectal neoplasia occurs with increased frequency in patients with gynecologic cancer. The role of presurgical colonoscopy in patients with gynecologic tumors is not yet clear; however, it did not help in staging the gynecologic cancer. 136. High Dose Rate Remote Afterloading Irradiation in the Treatment of Gynecologic Malignancies: A Preliminary Report. G. DEPPE, Y. H. KIM, C. G. ORTON, V. K. MALVIYA, K. AHMAD, J. M. MALONE, JR., AND C. W. CHRISTENSEN,Wayne State University, Detroit, Michigan 48201. High dose rate (HDR) remote afterloading technique was used in 30 patients with gynecologic malignancies to critically evaluate the HDR technique and compare it with the standard low dose rate (LDR) treatment. Sixteen patients with endometrial cancer and six patients with cervical cancer received postoperative vaginal vault radiation. Three patients with Stage III vaginal cancer and five patients with Stage IIIB cervical cancer received brachytherapy using the HDR system. No major complications were observed. The most significant advantage of the HDR system is the ability to secure the applicator in a known geometry without risk of movement of the applicator during therapy. Shorter duration of insertion in an outpatient setting makes HDR a very cost-effective and convenient procedure for both the patient and her physician and improves radiation safety. Additionally, the HDR afterloading system may allow multiple intracavitary treatments for cervical carcinoma, leading to an increased therapeutic advantage. In our early experience, the HDR remotely controlled afterloading system is a good alternative to the conventional LDR system. Controlled clinical trials should be designed to compare both regimens to demonstrate convincing evidence of the superiority of the HDR system. 137. Secondary Tumor Reductive Surgery in Persistent or Recurrent Ovarian Cancer. V. K. MALVIYA, G. DEPPE, AND J. MALONE, JR., Wayne State University, Detroit, Michigan 48201. Recent studies in the literature yield conflicting results about the precise role of secondary tumor reductive surgery (STR) in ovarian cancer. To determine the role of secondary debulking, we studied the records of 74 patients with progressive or stable ovarian cancer who underwent STR. All patients had previously undergone a primary cytoreductive effort. Sixty-six patients received cisplatinum containing combination chemotherapy following surgery, while 8 patients received non-cisplatinum containing chemotherapy or radiation therapy. The presence of persistent or progressive disease after primary surgery was documented prior to STR. Sixty-two of 74 (84%) patients required bowel resection, either as a palliative measure or in an effort to achieve
ONCOLOGISTS-ABSTRACTS optimal cytoreduction (residual tumor <2 cm). However, only 33 of 74 patients (45%) could be optimally cytoreduced. Morbidity, including infection, persistent bowel obstruction, and fistula formation, occurred in 28 patients (38%) and was encountered most frequently in patients requiring bowel resection. One patient died of pulmonary embolism in the immediate postoperative period. The median survival of patients who were optimally cytoreduced was significantly longer than the median survival of those patients who were suboptimally cytoreduced (9 months vs 5 months, P < 0.004). Patients with clinically undetectable ascites had a significantly longer median survival than patients in whom ascites was clinically evident (12 months vs 5 months, P < 0.002). Our data indicate that secondary cytoreduction is justified in patients with incomplete response to primary therapy, but is beneficial only if optimal cytoreduction is achieved. Clinically evident ascites is a poor prognostic factor regardless of optimal cytoreductive surgery. 138. Stage I Carcinoma of the Endometrium-Surgical Staging and Treatment. H. CAGLAR, M. S. PIVER, AND M. M. HRESCHCHYSHYN, University at Buffalo (SUNY), Buffalo, New York. One hundred thirty-eight FIG0 Stage I endometrial cancer patients were surgically staged and treated, and 105 were followed up after 10 months to 11 years. All patients were subjected to TAH, BSO, paraaortic (PA) and pelvic (PE) node biopsies. Thirteen had PE and PA node metastasis with incidence of 7.9 (11) and 7.2% (IO), respectively. 80% (8) with PA and 63% (7) with (PE) metastasis had deep myometrial invasion. Of 10 Gl and G2 with PA and PE mode metastasis, 70% (7) had deep myometrial invasion. None of the G3 had PE, PAmetastasis in the absence of deep invasion, and/or capillary-like space involvement. Forty-eight patients had external radiation, 27 had vaginal cesium, 50 had no adjuvant therapy. Thirteen had chemotherapy alone or with radiation. Three patients with PE node metastasis alone are alive with no evidence of disease 25, 35, and 59 months following external pelvic radiation. Of 10 patients with PA node metastasis, 4 are alive with no evidence of disease at 10, 11, 18, and 62 months; 2 were treated with chemotherapy and 2 with chemotherapy plus radiation. Of 5 patients with adnexal metastasis and neoplasia confined to the pelvis, two are alive with no evidence of disease at 59 and 83 mo. Of 28 patients with G3 or deep invasion or both and neoplasia confined to the corpus, 26 received external radiation; 2 were lost to follow-up and 2 (8.3%) had recurrence and died. Of 76 patients with Gl and G2, less than 50% invasion, 29 were lost to follow-up. Of the 47 evaluable patients, 23 had vaginal cesium and 24 had no therapy. There were no recurrences in either group. The overall recurrence was 12.3% (13) and none survived. 139. Concomitant Cisplatin (DDP) and Radiotherapy (RT) in Locally Advanced Cervical Carcinoma (CX CA). C. D. RUNOWICZ, S. WADLER, L. RODRIGUEZ-RODRIGUEZ,P. LITWIN, K. A. O’HANLAN, G. GOLDERG, C. TOMAINO, AND R. BYRNES, Albert Einstein College of Medicine, The Bronx, New York 10461. Patients (pts) with locally advanced cervical carcinoma (cx ca) have a poor prognosis. The efficacy of radiotherapy (RT) is limited by the presence of large tumor volume and nodal disease. Since concomitant cisplatin (DDP) is a documented radiosensitizer and has activity in squamous cell carcinomas (SCC), a prospective study was designed to evaluate the toxicity and potential synergism of concurrent DDP and RT in locally advanced cx ca. DDP, 20 mg/M’ daily x 5 days every 21 days, was administered concurrently with standard external and intracavitary RT. A median of four courses of DDP was given. Thirty-five pts. were entered from March 1986 to March 1988, 11 were excluded (2 refused further treatment, 3 had disease out of the pelvis, 5 were too early, 1 was lost to follow-up, in remission) leaving 24 evaluable pts. for response. The 3 pts. with disease out of the pelvis were included in toxicity evaluation. The median age was 47 (range