Chapter 093. Gynecologic Malignancies (Part 3)

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Table 93-1 Staging and Survival in Gynecologic Malignancies St age Ovarian -Year 5 trial Endome 5 -Year x Surviv al, % Cervi -Year 5 Surviv al, % Surviv al, % 0 — — Carcin oma in situ 00 1 I Confined 9 Confine 8 Confin 8 to ovary 0 d tocorpus 9 ed to uterus 5 II Confined to pelvis 0 7 corpus cervix Involves and 0 8 s Invade beyond 5 6 uterus but not to pelvic wall III Intraabdo minal spread 5–20 1 Extends outside the 0 3 Exten 3 ds to pelvic 5 wall and/or uterus but not outside the true pelvis lower third of vagina, or hydronephros is IV Spread outside abdomen –5 1 Extends outside the true pelvis involves bladder rectum or the or 9 Invade ...

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Chapter 093. Gynecologic Malignancies (Part 3) Table 93-1 Staging and Survival in Gynecologic Malignancies St Ovarian 5 Endome 5 Cervi 5 age -Year trial -Year x -Year Surviv Surviv Surviv al, % al, % al, % 0 — — Carcin 1 oma in situ 00 I Confined 9 Confine 8 Confin 8
to ovary 0 d tocorpus 9 ed to uterus 5 II Confined 7 Involves 8 Invade 6 to pelvis 0 corpus and 0 s beyond 5 cervix uterus but not to pelvic wall III Intraabdo 1 Extends 3 Exten 3 minal spread 5–20 outside the 0 ds to pelvic 5 uterus but not wall and/or outside the true lower third of pelvis vagina, or hydronephros is IV Spread 1 Extends 9 Invade 7 outside abdomen –5 outside the true s mucosa of pelvis or bladder or involves the rectum or bladder or extends rectum beyond the
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 (