Gynecologic MalignanciesGynecologic Malignancies

Dr. David Edelmann

Sharett Institute of Oncology

Hadassah Medical Organization

Ovarian cancer

Eudometrial cancer

Cervical cancer

No. new cases/ year

220003100013500 (55000 C.I.S)

No. deaths/

year

1330057004400

U.S.A. Data (1993)

55 Year SurvivalYear Survival

All stages

Ovarian Ca

30%

Eudometrial Ca

67%

Cervical Ca

67%

Stage I90%75%85%

Stage II)orIIIA(35%58%55%

Stage III)IIIB only(20%30%30%

Stage IV)IIIC or IV (5-10%

10%0-15%

Most Gynecologic Malignancies are

Highly CT and RT Responsive

Ovarian Cancer (O.C.)Ovarian Cancer (O.C.)

Epithelial O.C. – 90% (85% Invasive

15% Borderline)

Non-epithelial – 10%

Germ cell tumor

Sex-cord stromal tumor

TreatmentTreatment

A. Surgery is the standard first step modality.

It includes:

1. Surgical staging

2. Cytoreductive (debulking) surgery.

An attempt for optimal debulking (removal of all tumor nodules >

1cm).

Rationale:

5 year survival according to residual tumor at the end of cytoreductive surgery.

a. Microscopic dis. Only - 50-75%

b. Optimal dis. - 30-40%

c. Suboptimal dis. - 5%

A trend for a new approach – Neoadj. CT or interventional debulking surgery followed by further CT. EORTC randomized trial.

B. Postoperative treatment: (Epithelial O.C.)

1. Early stage (I-II)

a. IA-IB (G1)-F.U. only; G2- controversial.

b. All other – Several options:

I. Whole abdomen and pelvis irradiation (optimal debulking). Entire peritoneal cavity 2000-3000 cGy (100-125cGy fractions) with boost to the pelvis to a total dose of 5000 cGy (180 cGy

fractions).

Disadvantage:

substantial morbidity – 15-40% with severe myelsuppression:

diarrhea – 78%

bowel obstruction – 14%

fistulae

retroperitoneal fibrosis, proctitis, enteritis, cystitis, hepatitis, nephritis.

II. I.P. radiocolloids (32P) identical results

with 5ys – 80%

III. CT with melphalan

which cause ANLL after 12 cycles in 10% of the pts.

IV. Combination CT – plat. Based – CPx4-6

More effective and less leukemogenic then melphalan.

2. Advanced stage (III-IV)Standard postop. CT:A plat. compound with an A.A.:Cisplatin =>75mg/m2/ cycleequallyor effectiveCarboplatin=> 350mg/m2/cyclewith cyclophosphamideCT is delivered on day 1 every 3-4 weeks for 6 cycles.

R.R. can be assessed more precisely in pts. with a suboptimally debulked tumor.

Response and outcome in pts. with advanced (optimal + suboptimal ) O.C. following plat.- based comb. CT:R.R. - 60-80%cCR - 30-60%pCR - 10-30%Median survival- 20-30 mo

The new standard The new standard CT for subopt. Stage IIIC and CT for subopt. Stage IIIC and stage IV dis. stage IV dis. NEJ Med. 334(1): 1-6, 1996 (GOG) phase III TP NEJ Med. 334(1): 1-6, 1996 (GOG) phase III TP vs. CP- 386 pts 216 with measurable disvs. CP- 386 pts 216 with measurable dis . .

R.R.cCRpCRMedian PFI

(m)

Median survival (m)

CP60%31%20%1324

TP73%51%26%1838

P0.010.010.08<0.001<0.001

CCC (37) 96% 77% 27% 25