Chapter 093. Gynecologic Malignancies (Part 4)

Patients with stage I disease, no residual tumor, and well or moderately differentiated tumors need no adjuvant therapy after definitive surgery, and 5-year survival exceeds 95%. For all other patients with early disease and those stage I patients with poor prognosis histologic grade, adjuvant platinum-based therapy is warranted. Large prospective randomized trials have demonstrated that adjuvant therapy improves disease-free and overall survival by 8% (82% vs. 74%, p = .008).For patients with advanced (stage III) disease but with limited or no residual disease after definitive cytoreductive surgery (about half of all stage IIIpatients), the primary therapy is platinum-based combination...
Nội dung trích xuất từ tài liệu:
Chapter 093. Gynecologic Malignancies (Part 4) Chapter 093. Gynecologic Malignancies (Part 4) Patients with stage I disease, no residual tumor, and well or moderatelydifferentiated tumors need no adjuvant therapy after definitive surgery, and 5-yearsurvival exceeds 95%. For all other patients with early disease and those stage Ipatients with poor prognosis histologic grade, adjuvant platinum-based therapy iswarranted. Large prospective randomized trials have demonstrated that adjuvanttherapy improves disease-free and overall survival by 8% (82% vs. 74%, p =.008). For patients with advanced (stage III) disease but with limited or noresidual disease after definitive cytoreductive surgery (about half of all stage IIIpatients), the primary therapy is platinum-based combination chemotherapy.Approximately 70% of women respond to initial combination chemotherapy, and40–50% have a complete regression of disease. Unfortunately, only about half ofthese patients are free of disease if surgically restaged. Although a variety ofcombinations are active, a randomized prospective trial of paclitaxel and cisplatincompared to paclitaxel and carboplatin in patients with optimally resectedadvanced disease demonstrated equivalent disease-free and overall survivals butwith significantly reduced toxicity with the carboplatin combination. This regimenof paclitaxel, 175 mg/m2 by 3-h infusion, and carboplatin, dosed to an AUC (areaunder the curve) of 7.5, is the preferred treatment choice for patients withpreviously untreated advanced-stage disease. Three randomized trials using intraperitoneal (IP) chemotherapy havedemonstrated improved disease-free and overall survival compared to theintravenous administration of the same drugs. However, the increased toxicity(neuropathy, nephropathy, and catheter complications) is significant, and onlyabout 40% of patients were able to receive full courses of therapy. Furthermore,the optimal dose and schedule of IP therapy has not been established, nor have anyof the IP regimens been prospectively compared to the standard intravenouscarboplatin-paclitaxel regimen. The ultimate role of IP therapy in the treatment ofadvanced ovarian cancer is unresolved. Patients with advanced disease (stages III and IV) and bulky residual tumorare generally treated with intravenous paclitaxel-platinum combination, and whilethe overall prognosis is poorer, 5-year survival may reach 15–20%. Historically, patients who had an excellent initial response to chemotherapyand no clinical evidence of disease had a second-look laparotomy. The second-look surgical procedure itself does not prolong overall survival, and outside ofclinical trials its routine use is no longer recommended. Maintenance therapy mayextend progression-free survival but has not improved overall survival. Patients with advanced disease whose disease recurs after initial treatmentare usually not curable but may benefit significantly from limited surgery torelieve intestinal obstruction, localized radiation therapy to relieve pressure or painfrom mass lesions or metastasis, or palliative chemotherapy. The selection ofchemotherapy for palliation depends on the initial regimen and evidence of drugresistance. Patients who had a complete regression of disease lasting ≥6 monthsoften respond to reinduction with the same agents; patients relapsing within thefirst 6 months of initial therapy rarely do. Progestational agents, tamoxifen, oraromatase inhibitors produce responses in 5–15% of patients and have minimalside effects. Agents with >15% response rates in patients relapsing after initialcombination chemotherapy include gemcitabine, topotecan, liposomaldoxorubicin, and bevicizumab. Bevicizumab is a monoclonal antibody that targets the vascular endothelialgrowth factor. Initial trials produced a 17% overall response rate in heavilypretreated patients. However, hypertension, thrombosis, and bowel perforationshave been reported in some trials. Patients with tumors of low malignant potential, even with advanced-stagedisease, have longer survivals (80–90%) when managed with surgery alone.Radiation and chemotherapy do not improve outcome. Ovarian Germ Cell Tumors Fewer than 5% of all ovarian tumors are germ cell in origin. They includeteratoma, dysgerminoma, endodermal sinus tumor, and embryonal carcinoma.Germ cell tumors of the ovary generally occur in younger women (75% of ovarianmalignancies in women Dermoid cysts are teratomatous cysts usually lined by epidermis and skinappendages. They often contain hair, and calcified bone or teeth can sometimes beseen on conventional pelvic x-ray. They are almost always curable by surgicalr ...