What is the incidence of isolated paraaortic nodal recurrence in grade 1 endometrial carcinoma?

ObjectivesTo describe the incidence of isolated paraaortic nodal recurrences in patients with a final diagnosis of grade 1 endometrial carcinoma initially treated with surgery.MethodsRecords from a prospectively maintained endometrial carcinoma database were reviewed to identify sites of recurrence. Patients with any papillary serous or clear cell carcinoma, leiomyosarcoma, endometrial stromal sarcoma, squamous carcinoma, or adenosarcoma were excluded. Recurrence sites were classified into 4 main categories: 1) pelvic (including vaginal and other soft tissue pelvic sites); 2) abdominal (including peritoneum, omentum and liver); 3) distant (including lung, brain, supraclavicular, and groins); and 4) isolated paraaortic nodal recurrence (including any nodal recurrence between the midcommon iliac to renal vessels).ResultsBetween 1/93 and 5/06, 1453 patients with endometrial carcinoma met the study inclusion criteria. Final grade distribution included: grade 1 endometrial adenocarcinoma, 310 (21%); grade 2, 578 (40%); grade 3, 481 (33%); and incomplete, 84 (5.8%). In all, 154 patients (11%) had documented recurrences. Recurrence sites for all patients/all grades included: pelvis, 52 (34%); abdomen, 51 (33%); distant, 41 (27%), and isolated paraaortic, 10 (6%). None of the isolated paraaortic recurrences occurred in patients with a final diagnosis of grade 1 carcinoma. Furthermore, 9/10 (90%) isolated paraaortic nodal recurrences were in grade 3 tumors. Only 8 (2.6%) of 310 patients with grade 1 tumors recurred. Sites of recurrence for grade 1 tumors included: abdomen, 3; pelvis, 3; and distant, 2.ConclusionsThis large series of endometrial carcinoma patients initially treated with surgery confirms that isolated paraaortic nodal recurrence in women with a final diagnosis of grade 1 endometrial carcinoma is extremely rare. These rare isolated paraaortic nodal recurrences appear to be limited to high-grade endometrial carcinomas.     

Are nodal metastases in ovarian cancer chemoresistant lesions? Comparative study of initial lymphadenectomy or after chemotherapy

OBJECTIVE: The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3). PATIENTS AND METHODS: The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1). RESULTS: In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates. DISCUSSION AND CONCLUSIONS: The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.     

Does size matter? Tumor size and morphology as predictors of nodal status and recurrence in endometrial cancer

OBJECTIVE: To determine whether tumor size or morphology is predictive of extrauterine disease and/or recurrence risk in endometrial cancer and therefore guide decisions about the necessity of complete surgical staging and adjuvant therapy. METHODS: All women with surgically treated endometrial carcinoma between 1 January 1990 and 1 January 2000 were eligible. 345 patients were eligible for retrospective chart review. Univariate and multivariate logistic regression models were used to determine the predictors of nodal metastasis and recurrence. RESULTS: As tumor size increased, the risk of nodal metastasis increased. However, a risk of nodal metastasis remained even with small lesions less than or equal to 2 cm (6.3% risk). Patients with tumor size greater than 2 cm had a 26.3% incidence of nodal metastasis. In univariate analysis, the odds ratio (OR) for tumor size as a predictor of extrauterine disease was 1.4 (95% CI 1.2-1.6). In multivariate analysis, tumor size was not statistically significant. Only the lesions greater than or equal to 8 cm confer a risk that approaches previously identified well-known predictors. Tumor size was not found to be a statistically significant predictor of recurrence OR 1.3 (1.0-1.8). CONCLUSIONS: Tumor size correlates with extrauterine disease, but it is not an independent prognostic variable. Although the risk of extrauterine disease increases with tumor size, the risk of nodal metastases remains even for those patients with very small tumors, underscoring the need for routine complete surgical staging. Tumor size does not appear to be an independent predictor of recurrence.     

Endometrial cancer: can nodal status be predicted with curettage?

OBJECTIVE: To determine whether histologic or molecular markers assessed in pretreatment curettage specimens predict nodal metastasis in endometrial cancer. METHODS: Phenotypic and molecular variables (ploidy, proliferating cell nuclear antigen, MIB-1, p53, HER-2/neu, and bcl-2) were analyzed in preoperative specimens from 82 patients with endometrial cancer who had lymph nodes dissected. These 82 patients had been selected from a total population of 283 patients with endometrial cancer, using a case-cohort design. Weighted logistic regressions were then used to determine significant predictors of positive lymph nodes, and results were estimated for the total population of 283 patients. RESULTS: Of the overall population, 12% of patients were estimated to have positive lymph nodes. Histologic subtype, p53, and bcl-2 each were significantly correlated (P <0.05) with lymph node status. With application of stepwise logistic regression, p53 was the only independent predictor of lymph node status. In addition, a statistical model predictive of positive lymph nodes was generated which incorporated the risk factors p53, bcl-2, and histologic subtype. CONCLUSION: In pretreatment curettage specimens, the presence of unfavorable levels of p53 or bcl-2 or of nonendometrioid histologic features, or combinations of those, significantly predicted lymph node status, thus facilitating the preoperative identification of patients at risk of lymph node metastases.     

Is it justified to classify patients to Stage IIIC epithelial ovarian cancer based on nodal involvement only?

BACKGROUND: Stage IIIC epithelial ovarian cancer is generally associated with upper abdominal tumor implants of greater than 2 cm and carries a grave prognosis. A subset of patients is upstaged to Stage IIIC because of lymph node metastases, in which prognosis is not well defined. We undertook this study to describe the clinical behavior of occult Stage IIIC. METHODS: All consecutive patients found to have Stage IIIC epithelial ovarian cancer during a 9-year period (1994-2002) were analyzed for surgical procedures, pathology, and disease-free (DFS) and overall survival (OS). RESULTS: Thirty-six patients were upstaged to Stage IIIC by virtue of positive nodes. Nine had small volume upper abdominal disease (IIIA/B before upstaging), 15 had disease limited to the pelvis and 12 had disease confined to the ovaries. 32/36 patients had no gross residual disease at the conclusion of surgery. The 5-year DFS and OS survivals were 52% and 76% respectively, for all patients. We observed no significant difference in outcomes between patients upstaged from IIIA/B versus I-II stage disease. The outcomes were superior to a control group of patients cytoreduced to either no gross RD or RD<1 cm, who had large volume upper abdominal disease at beginning of surgery (p<0.001). CONCLUSIONS: Patients upstaged to Stage IIIC epithelial ovarian cancer for node involvement have an excellent 5-year OS relative to all patients with Stage IIIC disease. These data demonstrate the necessity for stratifying patients classified as having Stage IIIC disease based solely on nodal disease when comparing outcomes. This information is particularly valuable when counseling patients regarding prognosis.     

Consecutive cycles in in vitro fertilization–embryo transfer

Background.?The decline of female fertility with advancing age is well documented. The aim of this study was to compare the ovarian performance after repeated ovarian stimulation cycles in women of different ages.

Methods.?Four hundred patients who started at least three in vitro fertilization (IVF) cycles during the 5-year period between 1998 and 2002 were identified. The patients were divided into four groups: the 25–30 age group (n?=?90), the 31–35 age group (n?=?150), the 36–40 age group (n?=?110) and the 41–45 age group (n?=?50).

Results.?Comparing subsequent cycles versus the first treatment cycle we found a statistically significantly increased number of ampules of recombinant follicle stimulating hormone (rFSH) needed to reach follicles maturation (p?<?0.001). The number of ampules of gonadotropin required was significantly higher (p?<?0.001) in the groups of advanced age compared with the groups of young women. For women in the 36–40 group and in the 41–45 group we found the number of follicles, the number of oocytes and the proportion of grade A embryos, in every cycle, were significantly lower than in the groups of young women. We compared the characteristics of ovarian stimulation and response of a single age group in different consecutive cycles. We found significant differences (p?<?0.05) only in the number of ampules required.

Conclusions.?Maternal age adversely affected ovarian performance. During repeated IVF cycles we also noted an age-independent decline of ovarian response.     

Trends in induced abortions between 1975 and 2000 in a cohort of women born in 1960–64 in four Scandinavian countries

Objectives?To study induced abortion rates, live birth rates, and proportions between the number of induced abortions and live births during a 25-year period in a cohort of Scandinavian women born 1960–1964.

Method?The numbers of abortions and live births in a cohort of women in Denmark, Finland, Norway and Sweden who were 15–19 years old in 1975 were retrieved from official statistics for 1975, 1980, 1985, 1990, 1995 and 2000, when these women had turned 40 to 44 years of age.

Results?Women in each country, who were 15–19 years old in 1975, maintained their original behaviour regarding induced abortion throughout their fertile period. Women in Denmark and Sweden, who had the highest rates of induced abortion in 1975, still had higher rates than women in Norway and Finland in 2000 when aged 40–44.

Conclusion?Behaviour and attitudes established at a young age seem to remain unchanged over time. This finding indicates that guidance and education of youths concerning reproductive matters may be decisive in shaping behaviour for most of the fertile period.     

Publication productivity in IVF in Europe, 1990–2006

The present investigation was conducted to determine how individual European states rank with respect to quantitative productivity in research and publication on IVF. A search in MEDLINE was performed in August 2007 and the number of entries under the MeSH ‘Reproductive Techniques, Assisted’ was registered for each individual year 1990–2006 for 19 European countries. Countries with a total number of >60 publications between 1990 and 2006 were further evaluated. Publication productivity was assessed by three measures: absolute numbers of scientific articles published in MEDLINE, mean number of publications published per year normalized to population size, and mean number of publications published per year normalized to gross domestic product (GDP). The Benelux and Scandinavian countries lead the field, with a median of 26 publications per year per 10⁷ population in Belgium, followed by Finland, The Netherlands, Denmark, and Sweden with 12, 11, 10, and nine publications respectively. This compares with a median of three and two entries from Italy and Germany respectively. After normalizing the publication number to GDP, Belgium leads the field with a median of 10 publications per year per 10¹¹€ GDP, followed by Greece, Sweden, UK and Finland with six, six, five and five publications respectively. The back markers are Switzerland and Germany (one publication each). In conclusion, drastic differences between individual European countries exist in terms of publication activity.