(5)I期上皮性卵巣がんにおける妊孕性温存手術の患者選択条件に関する研究(<特集>第62回学術講演会シンポジウム1 婦人科癌における妊孕性温存治療(手術および薬物療法))

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Purpose Fertility-sparing surgery for reproductive-age patients with invasive EOC has been adopted for stage I A and non-clear cell histology grade 1 (G1)/grade 2 (G2) according to the guidelines of the American College of Obstetrics and Gynecology (ACOG, 2007) and for unilateral stage I tumor without dense adhesions showing favorable histology (i.e., non-clear cell histology G1/2) according to the guidelines of the European Society for Medical Oncology (ESMO, 2008). In Japan, fertility-sparing surgery has been recommended for patients with stage I A tumor or unilateral stage I C tumor based only on intraoperative capsule rupture (I C (b)) and favorable histology according to the guidelines of the Japan Society of Gynecologic Oncology (JSGO, 2007). EOC with clear cell or grade 3 (G3) histology and with bilateral ovarian involvement has been excluded from indications for fertility-sparing surgery in all three guidelines. The objective of this study was to assess clinical outcomes and fertility in patients treated conservatively for unilateral, stage I invasive epithelial ovarian cancer (EOC). Patients and Methods Between 1985 and 2004, patients with stage I invasive EOC who underwent fertility-sparing surgery in 30 institutions belonging to the Gynecologic Cancer Study Group of the Japan Clinical Oncology Group or who were referred to these hospitals immediately after fertility-sparing surgery performed elsewhere were enrolled into this study. A multi-institutional retrospective investigation was undertaken to identify patients with unilateral and stage I EOC treated using fertility-sparing surgery. Favorable histology was defined as grade 1 or grade 2 adenocarcinoma, excluding clear cell histology. We defined lethal recurrence (LR) as recurrence showing lesions outside the remaining ovary, as a considerable number of previous reports have suggested that patients with recurrence exclusively within the remaining ovary show much better prognosis following salvage surgery compared with patients displaying other patterns of recurrence. Outcomes for patients were analyzed using overall survival (OS), recurrence-free survival (RFS), and LR-free survival (LRFS). We also investigated reproductive outcomes after fertility-sparing surgery in patients who gave the information. Results A total of 211 patients (stage I A, n=126; stage I C, n=85) were identified from 30 institutions. Median duration of follow-up was 78 months. As a result, 205 patients underwent unilateral salpingo-oophorectomy. The remaining 6 patients underwent unilateral ovarian cystectomy at initial laparotomy, not followed by restaging surgery. As for other surgeries, 105 patients underwent biopsy (wedge resection) from the opposite ovary, 88 patients underwent partial omentectomy, and 55 patients underwent retroperitoneal lymph node dissection or biopsies. 1) Stage I A and favorable histology This subgroup included 108 stage I A patients with favorable histology. Of these, 44 patients (40.7%) received platinum-based adjuvant chemotherapy after surgery, and the 5-year OS, RFS, and LRFS were 100%, 97.8%, and 99.1%, respectively. 2) Stage I C and favorable histology This subgroup included 67 I C patients with favorable histology. Platinum-based adjuvant chemotherapy was administered to 57 patients (85.1%) following surgery. The 5-year OS, RFS, and LRFS were 96.9%, 92.1%, and 95.4%, respectively. As for subgroups of stage I C (I C (b), n=43; I C (a), n=14; I C (1/2), n=10), the 5-year RFS for each subgroup was 92.9%, 91.7% and 90.0%, respectively. 3) Stage I A, I C and clear cell histology This subgroup included 15 stage I A patients with clear cell histology. Of those, 9 patients (60%) were treated with platinum-based adjuvant chemotherapy. The 15 patients showed rates of 100% for each of 5-year OS, RFS, and LRFS. Eleven of 15 stage I C patients (73.3%) were treated with platinum-based adjuvant chemotherapy. These 15 patients showed rates of 93.3%, 66.0% and 72.7% for 5-year OS, RFS and LRFS. 4) Stage I A, I C and G3 Two of the 3 stage I A patients with G3 developed reccurences, and one of the 3 stage I C patients with G3 died of disease 6 months after fertility-sparing surgery. 5) Reproductive outcomes Forty-five of 84 patients (53.6%) who were nulliparous at fertility-sparing surgery and married at the time of investigation gave birth to 56 healthy children. Conclusion The present study confirmed that stage I A EOC patients with favorable histology can be safely treated with fertility-sparing surgery not followed by platinum-based adjuvant chemotherapy. We would thus propose that fertility-sparing surgery be considered for stage I A EOC patients with clear cell histology and for stage I C EOC patients with unilateral ovarian involvement and favorable histology, under conditions of performing complete staging surgery and platinum-based adjuvant chemotherapy (Table 14). Conversely, fertility-sparing surgery cannot be recommended for the following patients: stage I A patients with G3 histology; and stage I C patients with clear cell or G3 histology. Confirming the decision of patient criteria for selection in a phase II trial would be appropriate.
2010-10-01

(5)I期上皮性卵巣がんにおける妊孕性温存手術の患者選択条件に関する研究(<特集>第62回学術講演会シンポジウム1 婦人科癌における妊孕性温存治療(手術および薬物療法))

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(5)I期上皮性卵巣がんにおける妊孕性温存手術の患者選択条件に関する研究(<特集>第62回学術講演会 シンポジウム1 婦人科癌における妊孕性温存治療(手術および薬物療法))

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(5)I期上皮性卵巣がんにおける妊孕性温存手術の患者選択条件に関する研究(<特集>第62回学術講演会シンポジウム1 婦人科癌における妊孕性温存治療(手術および薬物療法))