open access: original paper - Intra-operative frozen section analysis for suspected early-stage ovarian cancer: 11 years of Gateshead Cancer Centre experience - Cross - 2011 - BJOG: An International Journal of Obstetrics & Gynaecology - Wiley Online Library

Intra-operative frozen section analysis for suspected early-stage ovarian cancer: 11 years of Gateshead Cancer Centre experience - Cross - 2011 - BJOG: An International Journal of Obstetrics & Gynaecology - Wiley Online Library

Gynaecological oncology

Intra-operative frozen section analysis for suspected early-stage ovarian cancer: 11 years of Gateshead Cancer Centre experience

1. PA Cross¹, et al

Article first published online: 6 SEP 2011

DOI: 10.1111/j.1471-0528.2011.03129.x

© 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG

Correspondence: re - Intra-operative frozen section analysis for suspected early-stage ovarian cancer - Twigg - 2012 - BJOG: An International Journal of Obstetrics & Gynaecology - Wiley Online Library

Intra-operative frozen section analysis for suspected early-stage ovarian cancer - Twigg - 2012 - BJOG: An International Journal of Obstetrics & Gynaecology

Correspondence

Volume 119, Issue 7, page 896, June 2012

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Sir,

We read with interest the article by Cross et al.¹ on the use of intra-operative frozen section for suspected early ovarian cancer. We would like to commend the authors for their work in providing these data and we recognise the need for mechanisms that can be used to address the National Institute for Health and Clinical Excellence (NICE) Guidelines CG122, which recommend assessment of the para-aortic lymph nodes in women with early ovarian cancer.²

However, there are a number of areas of practice that we feel need to be examined further before frozen section procedures can be used to alter the management of women with suspected early-stage ovarian cancer.

First, we are perplexed that the authors deemed it necessary to undertake para-aortic lymphadenectomy for women with borderline ovarian tumours. These are by nature an unpredictable class of tumour with mostly good outcomes and little in the way of nonsurgical treatment options when there is disseminated disease. Further, they are usually early-stage tumours and so the utility of a para-aortic lymph node dissection is questionable. If the authors had described the rate of disease in lymph nodes and the difference in outcome this provided for the woman with positive nodes their data would lend stronger support for more widespread implementation.

Accepting this and examining the authors data for ‘all comers’ (Table 1) we calculate that 28.8% (415) of women had an appropriate para-aortic lymph node dissection on the basis of the frozen section prediction, which represents the real-world scenario for the gynaecological oncology surgeon waiting in theatre for a frozen section analysis to be phoned back.

If the authors changed their protocol to only using dissection in women with malignancy on frozen section, 63.8% (918) of women would appropriately not undergo a para-aortic dissection. The total number of women correctly triaged by frozen section analysis would be 92.6%. Of the remainder, 7% would not undergo a para-aortic dissection that should and 0.35% would have a dissection they do not need. Such a protocol change compares with the authors’ figures who, when including a policy of para-aortic dissection for borderline tumours on frozen section, overtreated 8% of the women and undertreated 1.3%.

The answer to deciding which strategy one would wish to take up must come down to the differences in outcome for these women, defined by morbidity and mortality comparisons from overtreatment or undertreatment by surgery or chemotherapy, respectively, and any subsequent influence this has on overall survival. Unfortunately the authors do not provide this information, and only allude to data in preparation that indicate their ability to increase the stage of a woman’s disease. However, this figure can be calculated from their data in Table 1 to equate to 82 women (5.7%) who had a frozen section showing borderline disease but whose final paraffin section report showed a malignancy. Until other centres can validate their techniques and such practice can be shown to translate into a survival benefit for women, it is unlikely that their data will change surgical practice in women with early ovarian cancer.

References

• 1
  Cross P, Naik R, Patel A, Nayar A, Hemming J, Williamson S, et al. Intra-operative frozen section analysis for suspected early-stage ovarian cancer: 11 years of Gateshead Cancer Centre experience. BJOG 2012;119:194–201.
  

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• 2
  National Institute for Health and Clinical Excellence. The recognition and initial management of ovarian cancer. [http://www.nice.org.uk/CG122]. Accessed 20 January 2012. 
  • References
  • Cited By

   
  

abstract: Long-term adjustment of early-stage ovarian cancer survivors

Long-term adjustment of early-stage ovarian cancer survivors:

Abstract

The objectives of this study were to describe the quality of life (QOL), consequences of treatment, complementary therapy use, and factors correlating with psychologic state in 58 survivors of early-stage ovarian cancer since little is known about the QOL of early-stage ovarian cancer survivors. Survivors were interviewed using standardized measures to assess physical, psychologic, social, and sexual functioning; impact of cancer on socioeconomic status; and complementary therapy use. Survivors reported good physical QOL scores and few unmet needs. However, menopausal symptoms and negative impact on sexuality were reported. Less than 10% of survivors reported either an interest in sex or were sexually active. Psychologic assessment yielded a subset of 26% of patients with scores suggestive of posttraumatic stress disorder (PTSD) and 40% of survivors scored below the norm on the Mental Health Inventory-17 Survey. One third of patients required treatment for family/personal problems and took antianxiety medications. About 56% of survivors reported fear of cancer recurrence and 59% reported anxiety when their CA125 is tested. Better mental health was significantly related to less fatigue (Functional Assessment of Cancer Therapy [FACT]—fatigue, r = 0.61, P < 0.0001), less pain (European Organisation for Research and Treatment of Cancer [EORTC], r =−0.54, P < 0.0001), fewer stressful life events (Life Event Scale, r =−0.44, P > 0.001), and greater social support (MOS Social Support Survey, r = 0.41, P < 0.01). Early-stage ovarian cancer survivors had few physical complaints and unmet needs, but psychologic distress was evident in a subset of survivors; the majority of survivors reported sexual dysfunction. These results indicate the need for intervention and improved distress screening in the early-stage ovarian cancer population.

open access: Review - Fertility-Sparing Surgery in Early Epithelial Ovarian Cancer: A Viable Option?

Epithelial ovarian cancer (EOC) continues to represent one of the most lethal conditions in women in the western countries. With the shifting of childbearing towards higher age, EOC increasingly affects women with active childbearing wish, resulting in major impacts on treatment management.......

According to the 2007 guidelines of the American College of Obstetrics and Gynecology (ACOG), fertility-sparing surgery for reproductive-age patients with invasive EOC is recommended for highly or moderately differentiated stage IA disease with non-clear-cell histology [14]. In an equivalent manner, the European Society for Medical Oncology (ESMO) referring in 2008 to fertility-sparing techniques in EOC identified patients with unilateral stage I tumor without dense adhesions showing favorable histology (i.e., high or moderate differentiated, non-clear-cell histology) as being the optimal candidates for this procedure [15]. However, the number of published studies concerning fertility-sparing surgery in young EOC patients is rather limited and the evaluated patient’s samples too small to allow unanimous consensus regarding the definition of the selection criteria of the optimal candidate for fertility-sparing surgery in stage I EOC. That leads to a broad variety of national guidelines regarding FSS worldwide, especially in respect to Ic (iatrogenic versus not) and/or poorly differentiated disease and to clear cell histologic subtype [16]. Moreover, under additional consideration of the relatively recently emerging dualistic model theory of EOC pathogenesis, which divides EOC in type I and type II disease [17], patients selection for FSS could theoretically be performed under this perspective and hence indicated for early-stage, type I tumors, even though there is currently no evidence that would support such an approach. Open questions remain if there should be differentiation between iatrogenic Ic disease due to intraoperative tumor rupture versus Ic due to tumor on ovarian surface or malignant cells in peritoneal cytology, whether patients with G3 tumors with no evidence of further metastatic disease in adequate staging are eligible of FSS and whether nonserous or non-endometrioid histologic subtypes should be a priori excluded from any organ-preserving technique.......

Table 1: 
Relevant case series reports in the literature concerning fertility-sparing surgery in epithelial ovarian cancer: oncologic outcome. 

Total patients:  580

Age Ranges:  26–35.9

Cell Type/#'s: 
300 (52%) mucinous
51 (9%) serous
128 (22%) clear cell
65 (11%) endometriod

Mean PFS (mo) or 5 y DFS:  33.3–100% 

5 y OS:  66.7–100%


Death: 18 (3.1%)


Table 2: 
Relevant case series reports in the literature concerning fertility-sparing surgery in epithelial ovarian cancer: reproductive outcome.


Conclusion

After thorough insight of the current literature, FSS in early-stage EOC appears an absolutely viable and safe option for women younger than 40 years who wish to preserve their childbearing potential after careful consideration of histologic subtypes. The optimal indication is referring to stage Ia G1/G2 disease, as well as stage Ic with favorable, that is, non-clear-cell histology. Here there has to be differentiated between iatrogenic—due to intraoperative tumor rupture—versus biologic Ic disease—due to surface involvement or positive Douglas cytology—since the latter is associated with less favorable outcomes after FSS. In case of stage Ic disease and clear cell histology, there is increasing evidence of a poorer relapse-free survival compared to non-clear-cell histology.

For that reason a fertility-sparing approach in this special patients collective should be indicated only after thorough discussion and informed consent of the affected patients with careful balancing of the risks and benefits.

In any case, the treating gynecologic oncologist should be fully aware of his double role in treating the malignant disease as well as in providing oncofertility care to young EOC patients, by considering offering fertility-sparing alternatives when allowed so by tumor stage and histologic differentiation.

National Foundation for Cancer Research Funds Novel Approach to Early Stage Ovarian Cancer - MarketWatch (press release)

National Foundation for Cancer Research Funds Novel Approach to Early ... - MarketWatch (press release):

National Foundation for Cancer Research Funds Novel Approach to Early ... MarketWatch (press release) The new grant, entitled "SQUID Imaging for Detection of Early Stage Ovarian Cancer," will augment Dr. Bast's ongoing program at The University of Texas MD Anderson Cancer Center with this emerging technology. Dr. Bast is a world leader in the early ... and more »

no abstract: Is comprehensive surgical staging needed for thorough evaluation of early stage ovarian carcinoma? (Journal Club article for discussion March 2012

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references original article:

Is comprehensive surgical staging needed for thorough evaluation of early-stage ovarian carcinoma?

• Conclusion

  Patients with epithelial ovarian cancer should continue to undergo comprehensive surgical staging, since it identifies occult metastasis in a significant number of patients.

   Available online 22 August 2011.

A Risk-Adapted Strategy of Adjuvant Paclitaxel/Carboplatin in Early-Stage Ovarian Cancer: Time-Dependent Effect of 4 versus 6 Cycles on Outcome.

Abstract

Objective:
We investigated the efficacy of risk-adapted adjuvant paclitaxel/carboplatin chemotherapy in early-stage ovarian carcinoma.

Methods: Fifty-three patients were treated according to the risk of relapse: patients with stages IA or IB or with grade 1 (low risk) received 4 cycles of paclitaxel and carboplatin; patients with IC/IIA and grade 2 or 3 (high risk) received 6 cycles of chemotherapy. The outcome was compared with that of 95 patients who were all treated with 4 cycles.

Results: Median follow-up was 88, 113 and 42 months for the whole cohort, non-risk-adapted and risk-adapted treatment, respectively.

Five-year relapse-free and disease-specific survival was 86 and 93% for the whole population, 96 and 97% for low-risk and 81 and 91% for high-risk patients.

Risk classification was the only significant prognostic factor for relapse-free (p = 0.011) and disease-specific survival (p = 0.039). Among high-risk patients, the administration of 6 cycles was associated with a significantly lower relapse rate after censoring events, which occurred beyond 2 years (3 vs. 18%; p = 0.013), but this difference was diminished at 5 years (23 vs. 25%; p = 0.797).

Conclusions: Six cycles of chemotherapy reduced the risk of relapse within 2 years, but the benefit from two additional cycles beyond this time is questionable.

Association between miR-200c and the survival of patients with stage I epithelial ovarian cancer: a retrospective study of two independent tumour tissue collections : The Lancet Oncology

Interpretation

miR-200c has potential as a predictor of survival, and is a biomarker of relapse, in stage I EOC.

Prognostic Factors for Stage I Ovarian Carcinoma

All patients who died of disease were stage IC

Survival after recurrence in early-stage high-risk epithelial ovarian cancer: A Gynecologic Oncology Group study

Abstract

Objective

This study aimed to evaluate the clinical outcome of recurrent early-stage high-risk epithelial ovarian cancer patients.

Markman: Intraperitoneal chemotherapy in the management of ovarian cancer: focus on carboplatin

article: http://www.dovepress.com/intraperitoneal-chemotherapy-in-the-management-of-ovarian-cancer-focus-peer-reviewed-article

open text pdf file: http://www.dovepress.com/getfile.php?fileID=4267

Worth noting:

Finally, as it is known that patients with “high risk”
early stage ovarian cancer have a 30% to 50% chance of
experiencing recurrence of the disease process, and those
recurrences are largely within the peritoneal cavity, it is
perhaps reasonable to consider delivering some, or perhaps
all, of a planned adjuvant chemotherapy approach via the
intraperitoneal route.