Age Disparities in End of Life Symptom Management Among Patients with Epithelial Ovarian Cancer.

OBJECTIVE: To evaluate the symptoms of women with epithelial ovarian cancer (EOC) during their last admission before death and analyze invasive palliative management administered in relation to symptom control and survival. MATERIALS & METHODS: A retrospective review of Israeli patients with EOC, primary peritoneal cancer (PPC) and tubal cancer, admitted to our department prior to death between 2008-2018. Basic palliative treatment was defined as administration of IV fluids, analgesics, oxygen, antiemetics, antibiotics and/or blood transfusions. Procedures regarded as invasive included: peritoneal or pleural fluid drainage; placement of an indwelling catheter, administration of total parenteral nutrition (TPN), chemotherapy and ventilation. RESULTS: 82 patients were included. Most suffered from weakness and fatigue, gastrointestinal complaints, pain and shortness of breath. 34 patients (41.5%) required only basic palliative treatment to alleviate their symptoms; however, in 48 patients (58.5%) invasive interventions were needed. Patients treated with invasive procedures were younger at death by almost 9 years (mean age of 65.73 ± 9.5 vs. 74.78 ± 9.8; p = 0.001). There were significantly more women with platinum sensitive disease in the invasive interventions group compared to the basic palliative care (60.42% vs. 32.35%; p = 0.012). No survival difference was found between the groups from diagnosis to death, relapse to death, last chemotherapy to death and last admission to death. CONCLUSIONS: EOC patients suffer from high disease burden and multiple symptoms before death. We found that physicians tend to use more invasive care in dying younger patients. However, this aggressive treatment does not prolong survival. Futile treatments influencing quality of life should be avoided.

Anatomic Asymmetry in Sentinel Lymph Node Detection in Endometrial Cancer.

STUDY OBJECTIVE: To determine whether the concomitant use of indocyanine green (ICG) with technetium-99m-filtered sulfur colloid (Tc99m-FSC) improves bilateral sentinel lymph node (SLN) detection rate in endometrial cancer and whether anatomic concordance of pelvic lymph nodes exists and can be used to predict SLN location in cases of unilateral mapping failure. DESIGN: Retrospective cohort study. SETTING: Tertiary academic medical center in Holon, Israel. PATIENTS: Patients diagnosed with endometrial cancer, who underwent SLN mapping with Tc99m-FSC, ICG, or both, at our center between 2014 and 2019. INTERVENTIONS: A total of 111 patients were included in the study. SLN mapping using Tc99m-FSC was performed in 101 (91.9%) patients, and ICG injection was given to 64 (57.6%) patients of whom 55 (49.5%) received both. We compared SLN detection rates (unilateral and bilateral) and anatomic symmetry for each method alone and for a combination of the 2. MEASUREMENTS AND MAIN RESULTS: The overall detection rate for unilateral SLNs was 96.4%; 96.9% with ICG, 93.1% with gamma-probe, and 98.2% by combining both methods. The total bilateral detection rate was 72.1%, with ICG performing better as a single tracer than Tc99m-FSC (75% vs 63.4%, respectively). In 55 women in whom both tracers were used, the bilateral detection rate was significantly higher compared with Tc99m-FSC alone. Symmetric pelvic anatomic concordance of SLN was found in only 35 of 80 patients with bilateral SLN detection (43.8%). CONCLUSION: The combination of preoperative radioisotope injection and intraoperative ICG administration may yield the best bilateral SLN detection rate. In cases of unilateral mapping failure, one cannot rely on the anatomic location of the ipsilateral SLN detected to harvest the complementary node because the symmetric concordance is poor.

The Association of an Elevated Thrombocyte Count with Clinicopathological Prognostic Factors and Survival in Patients with Uterine Carcinosarcoma.

BACKGROUND: Uterine carcinosarcoma (UCS) is a rare tumor with a poor prognosis. An elevated thrombocyte count and thrombocytosis were found to be associated with poor prognosis in several gynecological tumors. Data regarding an elevated thrombocyte count and thrombocytosis, particularly in UCS, are scarce. OBJECTIVES: To assess the frequency of a preoperative elevated thrombocyte count and of thrombocytosis in UCS patients and their association with clinicopathological prognostic factors and survival. METHODS: The preoperative thrombocyte count of 29 consecutive verified USC patients diagnosed in our medical center from January 2000 to July 2015 was recorded, and clinicopathological data of these patients were abstracted from hospital files. RESULTS: Thrombocytosis was found in two patients (6.8 %) and both died of the disease. An elevated thrombocyte count was found in nine patients (31.0%). The percentage of patients with the poor prognostic factors who had a preoperative elevated thrombocyte count was not statistically different from those without these risk factors. The cumulative survival of patients with an elevated count was 22.1 months and that of those without an elevated count was 31.1 months. This difference was statistically not significant (P = 0.85). There was also no difference between the groups regarding the progression free survival. CONCLUSIONS: No association between an elevated thrombocyte count and prognosis was found. Larger studies are needed to clarify this issue.

Gemcitabine-Induced Subacute Cutaneous Lupus Erythematosus: A Case Report.

Subacute cutaneous lupus erythematosus (SCLE) is a rare eruption related to several pharmacological and chemotherapy agents. We present a 63-year-old female with recurrent epithelial ovarian cancer who developed SCLE after administration of gemcitabine. Following discontinuation of gemcitabine and after oral steroid treatment, all skin lesions disappeared. In view of the extensive use of gemcitabine in recurrent ovarian cancer, it is important to be aware of the possibility of SCLE occurrence in these patients.

The Significance of Normal Pretreatment Levels of CA125 (<35 U/mL) in Epithelial Ovarian Carcinoma.

OBJECTIVE: To assess the association between normal CA125 levels at diagnosis of epithelial ovarian carcinoma (EOC) with prognostic factors and with outcome. METHODS: The study group consisted of histologically confirmed EOC patients with normal pretreatment CA125 levels, and the controls consisted of EOC patients with elevated (≥35 U/mL) pretreatment CA125 levels, diagnosed and treated between 1995 and 2112. Study and control group patients fulfilled the following criteria: 1) their pretreatment CA125 levels were assessed; 2) they had full standard primary treatment, i.e. cytoreductive surgery and cisplatin-based chemotherapy; and 3) they were followed every 2-4 months during the first two years and every 4-6 months thereafter. RESULTS: Of 114 EOC patients who fulfilled the inclusion criteria, 22 (19.3%) had normal pretreatment CA125 levels. The control group consisted of the remaining 92 patients with ≥35 U/mL serum CA125 levels pretreatment. The proportion of patients with early-stage and low-grade disease, with optimal cytoreduction, and with platin-sensitive tumors was significantly higher in the study group than in the control group. The progression-free survival (PFS) and overall survival (OS) were significantly higher in the study group than in the control group on univariate analysis but not on multivariate analysis. CONCLUSION: It seems that a normal CA125 level at diagnosis in EOC may also be of prognostic significance for the individual patient.

CA125 expression in the tissue of uterine leiomyosarcoma.

UNLABELLED: Background: Elevated serum levels of the epithelial marker CA125 are occasionally observed in leiomyosarcoma (LMS) patients. OBJECTIVES: To assess the immunohistochemical expression of this marker in the tissue of LMS. METHODS: The consecutive unselected records of all patients with LMS diagnosed during the period 1995-2012 were located and abstracted. After verification of the diagnosis, 4 µm unstained slides were prepared from each case for immunohistochemical staining for CA125. Sections of ovarian carcinoma known to express CA125 were used as positive controls. RESULTS: We located 17 LMS patients from the period under study. Bleeding was the presenting symptom in 9 patients; the diagnosis was established prior to treatment in 11 patients. The tumor was in an advanced stage in 6 patients, and in 7 unstaged patients it was grossly confined to the uterus. Ten patients died within 14 months after the diagnosis. Serum CA125 levels prior to treatment were assessed in only 8 patients and were above normal limits (> 35 U/ml) in 3 of them. Two of the three with elevated serum levels were in stage III, and the third was an unstaged apparent stage I patient. None of the LMS tissue specimens demonstrated immunohistochemical expression of CA125. CONCLUSIONS: CA125 was not immunohistochemically expressed in the tissue of any LMS tumors examined by us. The origin of elevated serum CA125 in some of these tumors is therefore not in its tissue and remains unknown.

The significance of the pattern of serum CA125 level ascent to above the normal range in epithelial ovarian, primary peritoneal and tubal carcinoma patients.

OBJECTIVE: A rise of the CA125 marker above the normal range during follow-up of ovarian, primary peritoneal and tubal carcinoma patients with a complete clinical response after initial treatment signifies recurrence. We assessed whether the pattern of CA125 ascent to above the normal range at recurrence is associated with outcome. METHODS: The records of all recurrent ovarian primary peritoneal and tubal carcinoma patients diagnosed during 1998-2007 were abstracted. Included were patients who fulfilled the following criteria: CA125 levels were ≥35 U/mL at diagnosis and at recurrence, they had full primary treatment with a complete clinical and radiographic response, were followed-up according to schedule, and had at least two CA125 results within the normal range during follow-up. Two patterns of CA125 ascent to above the normal range were compared: a gradual rise and an abrupt rise. RESULTS: 52 patients with recurrent disease who met the inclusion criteria were identified. The median progression free and overall survival were significantly longer in patients with a gradual than in those with an abrupt rise (22.96 vs 14.07; P=0.0014; and 44.37 vs. median not yet reach, respectively). Multivariate analysis showed that the pattern of CA125 ascent is an independent predictor of progression free and overall survival. CONCLUSIONS: Our data seem to indicate that at recurrence the pattern of ascent of serum CA125 levels to above the normal range in patients in complete clinical remission is of prognostic value.

Neoadjuvant chemotherapy in ovarian, primary peritoneal and tubal carcinoma: can imaging results prior to interval debulking predict survival?

OBJECTIVE: To assess whether there is an association between improvement of computed tomography imaging results prior to interval debulking with survival in patients treated by neoadjuvant chemotherapy. METHODS: The clinical and outcome data of all advanced ovarian, primary peritoneal and tubal carcinoma patients who after diagnosis had neoadjuvant chemotherapy and underwent interval debulking during the period 2000-2010, were abstracted. Results of computed tomography imaging at diagnosis and prior to interval debulking were compared. Two parameters were assessed: the change of the size and number of abnormal findings and the change in the amount of ascites. CA-125 level response was also calculated. An assessment of progression free survival and of survival by the Kaplan-Meier method was made according to the change in computed tomography imaging results and according to response of CA-125 levels. RESULTS: The median progression free survival and the median survival of the 37 study group patients were 7.9 and 49.2 months respectively. No significant difference in progression free survival and survival was observed between patients with marked improvement in the computed tomography results and those with less desirable results (7.93 vs. 7.23 months respectively, p=0.89; 45.8% vs. 52.5% months respectively, p=0.95). There were also no statistically significant difference according to CA-125 level response. CONCLUSION: It seems that neither improvement in imaging results nor CA-125 level response can predict the survival of ovarian carcinoma patients prior to interval debulking after neoadjuvant chemotherapy.

Risk factor proportions in Israeli patients with cervical intraepithelial neoplasia 3 and invasive squamous cell carcinoma.

OBJECTIVE: To assess whether there is a difference in the proportion of known risk factors in Israeli women with cervical intraepithelial neoplasia (CIN) 3 compared with those with cervical squamous cell carcinoma (SCC) to explain the incidence discrepancy between the 2 entities. MATERIALS AND METHODS: At admission, patients with histologically confirmed CIN 3 and SCC diagnosed between 1996 and 2006 filled out a prestructured questionnaire containing queries regarding the following variables: age, place of birth, origin (place of birth of parents), level of education, age at coitarche, number of partners, marital status, age at first pregnancy, number of pregnancies, number of children, type of contraception used, and smoking. A comparison of the proportion of these risk factors in patients with CIN 3 and SCC was performed. RESULTS: No statistically significant difference between 41 CIN 3 and 69 SCC patients was found with regard to any of the risk factors assessed. CONCLUSION: The discrepancy between the frequency of CIN 3 and SCC in Israeli women cannot be explained by a difference in the proportion of the known risk factors.

Endometrial carcinoma after endometrial resection for dysfunctional uterine bleeding.

BACKGROUND: Endometrial destruction is an accepted conservative surgical approach for women with dysfunctional uterine bleeding. However, this procedure cannot guarantee complete removal of the entire endometrium. The possibility exists that endometrial carcinoma may develop even years after such procedure. CASE: We report on a case of endometrial carcinoma, which was diagnosed 3 years after hysteroscopic resection of the endometrium for dysfunctional uterine bleeding in a patient with no risk factors. CONCLUSION: Endometrial carcinoma after hysteroscopic endometrial ablation is still a possibility even when strict selection criteria are applied.