2007, Vol 5, No 3
Risk factors in gynaecological oncology
GIN ONKOL 2007, 5 (3), p. 119-124
ABSTRACT

The paper presents a general overview of risk factors in gynaecological oncology based on a review of recent literature, highlighting their role in preventive medicine. Since mid-twentieth century the role of risk factors is being increasingly appreciated, particularly those directly associated with the risk of developing certain diseases, including female genital malignancies. Several risk factors have been defined, e.g. genetic, biologic, socioeconomic, cultural, geographic, iatrogenic and environmental and their list is ever increasing. This has made possible the definition of high-risk groups of women, who require close medical monitoring in order to detect neoplastic disease at an earliest possible stage. Risk factors usually precede the process of carcinogenesis, although both may be synchronous. Risk factors have various prognostic values: one risk factor may be present in several different neoplasms and several different risk factors may be associated with a single tumour. A frequent phenomenon is oncological synergy. Most female genital neoplasms are multifactorial diseases.

Keywords: risk factor, prophylaxis, oncological gynaecology, multifactorial disease, cumulative risk
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Recurrence after surgical excision and radiotherapy in cervical cancer stage IB/IIA
GIN ONKOL 2007, 5 (3), p. 125-139
ABSTRACT

Aim of paper: Analysis of clinical course of tumour recurrence in patients undergoing surgical excision and radiotherapy for FIGO stage IB/IIA cervical cancer and retrospective evaluation of selected clinical-pathological tumour features in the group of patients, who developed a recurrence, with particular emphasis on recurrence-associated risk factors based on the GOG (Gynaecologic Oncology Group) scale. Material and method: Retrospective analysis encompassed 107 women treated at the Świętokrzyskie Centrum Onkologii (Holycross Cancer Centre) since 2000 thru 2004. Results: Three-year symptom-free survival was obtained in 92 out of 107 women (85%). Recurrence occurred in 16 out of 107 patients (15%), thereof 9 out of 84 women (10%) originally had no lymph-node metastases and 7 out of 23 women (21%) had confirmed lymph node involvement. Recurrences were associated with lateral metastases (5 cases), distant metastases (7 cases) and lateral and distant metastases (4 cases). Recurrence-associated mortality rate was 81% (13 out of 16 patients). Currently, 3 women are alive, 2 thereof having signs of recurrence. Mean recurrence-free survival was 19.6 months and mean symptom-free survival was 8.5 months. Retrospective analysis based on the GOG scale predicted high risk of recurrence (over GOG score 120) in 14 out of 16 women (88%), who did recur and a moderate risk (GOG score 70-120) in the remaining 2 patients (12%). Conclusions: High risk of recurrence predicted by the GOG score has been confirmed in the group of women with cervical cancer FIGO stage IB/IIA undergoing combined treatment (surgery and radiotherapy) independent of invasion of regional lymph nodes. An essential risk factor for tumour recurrence is presence of tumour cells in pericervical and perivaginal tissues.

Keywords: cervical cancer, surgical treatment, recurrence, recurrence risk evaluation based on GOG score, clinical course
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Recurrent platinum-resistant and platinum-sensitive advanced epithelial ovarian cancer: an update
GIN ONKOL 2007, 5 (3), p. 140-150
ABSTRACT

Ovarian cancer continues to be the most lethal malignancy in women. Standard treatment in advanced ovarian cancer is primary optimal cytoreduction with extensive tumour excision combined with platinum- and taxanoid-based chemotherapy. The cornerstone of treatment is surgical reduction of tumour burden. Usually, surgical cytoreduction precedes or follows neoadjuvant therapy, i.e. after several courses of chemotherapy. The key issue in the treatment of ovarian cancer is correct determination of clinical stage of tumour. Nevertheless, still we lack reliable data based on metaanalyses, which might define optimal management of patients presenting with a recurrence of ovarian cancer. Recurrent ovarian cancer is a pathologic process or a chronic disease. We review results of clinical studies aiming at improvement of effectiveness while reducing toxicity of drugs used in systemic treatment of advanced epithelial ovarian cancer. Apart of well-known preparations, e.g. cisplatin, paclitaxel, topotecan and liposomal doxorubicin, great hopes are associated with novel compounds, e.g. gemcitabine, docetaxel, etoposide, irinotecan, vinorelbine and bevacizumab, particularly in platinum-resistant form of recurrent ovarian cancer. Further studies on novel therapeutic protocols focus on different management strategies, e.g. serial administration of drugs, or evaluation of effectiveness of a single drug used as monotherapy. Currently, the most important therapeutic aim is to improve survival of patients with recurrent ovarian cancer while preserving an acceptable quality of life.

Keywords: ovarian cancer, late-stage disease, chemotherapy, recurrent ovarian cancer, therapy
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Radiotherapy as sole treatment of endometrial cancer. Analysis of treatment outcome
GIN ONKOL 2007, 5 (3), p. 151-158
ABSTRACT

Radiotherapy was used as a stand-alone therapeutic modality in 155 patients with endometrial cancer, treated at the Cracow Branch of the Center of Oncology since 1988 thru 1999. In these patients surgical excision was impossible due to far-advanced cancer (clinical stages III and IV) (n=50), severe comorbidity and poor performance status (n=105). In this patient population, 50 persons in clinical stage I received intracavitary brachytherapy, while the remaining 105 patients in clinical stages II, III and IVA received external beam irradiation followed by intracavitary brachytherapy. In the entire group (n=155), cumulative symptom-free 5 year survival rate was 51% (n=79). In relation to tumour grade, 5 year symptom-free survival rate was 70.3% in patients with well differentiated tumour, 43.5% in those with intermediate-grade tumour and only 20% in persons with poorly differentiated cancer. In patients with stage I endometrial cancer, symptom-free 5 year survival rate was 82% (n=41/50); in clinical stage II – 54.5% (30/55), in clinical stages III and IVA – 16% (8/50). Multivariate Cox analysis revealed that independent prognostic factors were clinical stage and tumour grade. Cure rates were 82%, 54.4% and 16% in clinical stages I, II and III/IVA, respectively. Symptom-free 5-year survival rates were 70.3%, 43.5% and 20% in well-differentiated, intermediate- and poorly-differentiated tumours, respectively. Severe late complications of radiotherapy (3rd and 4th degree) developed in 3.5% of patients.

Keywords: endometrial cancer, endometrium, irradiation, radiotherapy, brachytherapy
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Fibrinolysis and inhibitors of coagulation in patients with subclinical renal failure undergoing chemotherapy for advanced cervical cancer
GIN ONKOL 2007, 5 (3), p. 159-177
ABSTRACT

Background: Radiotherapy and chemotherapy increase the likelihood of development of thromboembolic complications. Activation of coagulation and inhibition of fibrinolysis may lead to formation of thrombi in microcirculation of several organs, compromising their function. Appearance of serum coagulation proteins in urine indicates a compromised renal function. Aims of the paper: 1) To assess changes of serum level of coagulation inhibitors and serum fibrinolytic activity in patients with renal failure undergoing treatment for advanced cervical cancer. 2) To develop methods of improving renal function in this clinical setting. Material and method: This was a prospective randomized study, including patients with a diagnosis of FIGO stage IIB-IIIB cervical cancer, with subclinical renal insufficiency. Treatment protocol consisted in radiotherapy (46-65 Gy; box technique), cisplatin (40 mg/m2 QW) in patients with normal serum creatinin level. Renal function was assessed using dynamic scintigraphy to determine glomerular filtration rate (GFR). Serum hemostatic system was assessed by determining levels of D-dimers, PAP, PAI-I, tPA, FDP and C protein. The same parameters were concomitantly assessed in urine. Only patients with GFR below normal range limit were included in the study. Lower limit of age-adjusted normal range was considered 100%. Half of the patients were irradiated without concomitant anticoagulant prophylaxis (group 1). The other half received a standard dose of nadroparin – 2850 IU aXa/0.3 ml. Results: The study revealed a decrease of GFR in the control and in the treatment group not receiving nadroparin. The treatment group receiving nadroparin experienced an increase of GFR. Significant differences were noticed in endpoints between the control group and the treatment group receiving nadroparin, as well as between treatment groups with and without nadroparin (p=0.0001). Lab tests of coagulation system revealed activation of fibrinolysis in patients receiving nadroparin and its further inhibition in the group without nadroparin. Similar alterations were noticed in urine. Conclusions: One of the causes of subclinical renal failure in patients with late-stage cervical cancer may be inhibition of fibrinolysis. Renal insufficiency deteriorates after termination of radiochemotherapy. Unfavorable alterations in the hemostatic system become more pronounced. Administration of low-molecular-weight heparins results in activation of fibrinolysis, unblocking of renal glomeruli and improvement of glomerular filtration.

Keywords: fibrinolysis, coagulation inhibitors, cervical cancer, glomerular filtration rate, anticoagulation prophylaxis
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