Chapter 093. Gynecologic Malignancies (Part 3) pot

Chapter 093. Gynecologic Malignancies (Part 3) Table 93-1 Staging and Survival in Gynecologic Malignancies St age Ovarian 5 -Year Surviv al, % Endome trial 5 -Year Surviv al, % Cervi x 5 -Year Surviv al, % 0 — — Carcin oma in situ 1 00 I Confined 9 Confine 8 Confin 8 to ovary 0 d tocorpus 9 ed to uterus 5 II Confined to pelvis 7 0 Involves corpus and cervix 8 0 Invade s beyond uterus but not to pelvic wall 6 5 III Intraabdo minal spread 1 5–20 Extends outside the uterus but not outside the true pelvis 3 0 Exten ds to pe lvic wall and/or lower third of vagina, or hydronephros is 3 5 IV Spread outside abdomen 1 –5 Extends outside the true pelvis or involves the bladder or rectum 9 Invade s mucosa of bladder or rectum or extends beyond the 7 true pelvis Prognosis in ovarian cancer is dependent not only on stage but on the extent of residual disease and histologic grade. Patients presenting with advanced disease but left without significant residual disease after surgery have a median survival of 39 months, compared to 17 months for those with suboptimal tumor resection. If initial surgery does not produce minimal residual disease, a second cytoreductive surgery has been used after the first three cycles of chemotherapy; in one trial it was associated with a 6-month improvement in median duration of survival. Another randomized trial where more aggressive debulking surgery was initially carried out was unable to confirm this benefit. Prognosis of epithelial tumors is also highly influenced by histologic grade but less so by histologic type. Although grading systems differ among pathologists, all grading systems show a better prognosis for well- or moderately differentiated tumors than for poorly differentiated histologies. Estimated 5-year survivals for patients by tumor grade are: well-differentiated, 88%; moderately differentiated, 58%; poorly differentiated, 27%. The prognostic significance of pre- and postoperative CA-125 levels is uncertain. CA-125 levels generally reflect volume of disease, and high levels usually indicate unresectability and a poorer survival. Postoperative levels, if elevated, usually indicate residual disease. The rate of decline of CA-125 levels during initial therapy or the absolute level after one to three cycles of chemotherapy correlates with prognosis but is not sufficiently accurate to guide individual treatment decisions. Even when the CA-125 level falls to normal after surgery or chemotherapy, "second-look" laparotomy identifies residual disease in 60% of women. Genetic and biologic factors may influence prognosis. Increased tumor levels of p53 are associated with a poorer prognosis in advanced disease. Epidermal growth factor receptors in ovarian cancer are associated with a decrease in disease-free survival, but the increased expression of HER-2/neu has given conflicting prognostic results. HER-2/neu is overexpressed in 20% of ovarian cancers, and responses have been seen to trastuzumab in this subset of patients. Ovarian Cancer: Treatment The selection of therapy for patients with epithelial ovarian cancer depends on the stage, extent of residual tumor, and histologic grade. In general, patients are considered in three separate treatment groups: (1) those with early (stages I and II) ovarian cancer and microscopic or no residual disease, (2) patients with advanced (stage III) disease but minimal residual tumor (<1 cm) after initial surgery, and (3) patients with bulky residual tumor and advanced (stage III or IV) disease. . Chapter 093. Gynecologic Malignancies (Part 3) Table 93-1 Staging and Survival in Gynecologic Malignancies St age Ovarian 5 -Year Surviv al,. advanced (stage III) disease but minimal residual tumor (<1 cm) after initial surgery, and (3) patients with bulky residual tumor and advanced (stage III or IV) disease.