Devita, Hellman, and Rosenberg's Cancer

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Chapter 23•Gynecologic Cancers 313

ultimately relapse from a clinical complete remission. Even patients with
a surgically confirmed complete remission (negative second look) have
an eventual relapse rate of approximately 50%. Although patients with
optimally debulked stage III disease are a relatively favorable subgroup,
those optimally debulked patients who have a larger presurgical tumor
burden (IIIC) fare worse than those with a lesser presurgical tumor bur-
den (IIIA). One randomized trial has demonstrated that maintenance
paclitaxel improved progression-free survival of women with a clinical
complete response (66% with optimal stage III disease) from 21 to 28
months in a randomized trial, and this option should be discussed with
this patient. However, no survival benefit was observed at the time the
trial was ended and the randomization code was broken, and there is a
significant incidence of neuropathy. No data exist on PET scans in this
situation, and consolidation topotecan has shown no benefit in two ran-
domized trials. Although intraperitoneal therapy is a theoretically attrac-
tive option, cisplatin, the most widely used drug, carries a significant risk
of neurotoxicity, and there are no data showing any survival benefit to its
use in the setting of minimal residual disease.

Answer 23.1.14. The answer is F.
Sex cord–stromal tumors (of which granulosa cell tumors are the most
common subtype) comprise only approximately 5% of all ovarian neo-
plasms. The peak incidence is in women aged more than 50 years,
although a significant proportion occurs in premenopausal women. Gran-
ulosa cell tumors may secrete estrogen and be associated with endome-
trial hyperplasia and endometrial carcinoma. The majority is diagnosed
in stage I, and these patients have 10-year survivals of 75% to 95%. How-
ever, late relapses may be observed. Patients with advanced-stage disease
fare more poorly. Although the rarity of the tumor precludes randomized
trial data, most such patients will be offered chemotherapy, tradition-
ally with bleomycin, etoposide, cisplatin (BEP), or other regimens used in
germ cell tumors.

Answer 23.1.15. The answer is A.
Germ cell tumors almost always occur in young women, with a peak inci-
dence in their early 20s. Some 60% to 70% are stage I at diagnosis. With
the use of platinum-based chemotherapy regimens similar to those used
for men with testicular cancer, even patients with an advanced stage have
a good prognosis. Because most of these tumors occur in young women,
often before they have had children, and because the type of chemotherapy
used will not cause infertility in most young female patients, the surgical
approach is critical; in many patients, the contralateral ovary and uterus
can and should be spared.

Answer 23.1.16. The answer is C.
Recurrent ovarian cancer is not generally curable with transplant
or any other modality, but patients whose disease recurs with a
disease-free interval of more than 1 year have more than a 50% chance of
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