Use of hematologic biomarkers during chemotherapy predicts survival in ovarian cancer patients

OBJECTIVE

The optimal strategy for combining chemotherapy with immunotherapy in ovarian cancer patients is currently under investigation. Increasing evidence indicates that the lymphopenia induced by chemotherapy may promote homeostatic proliferation and thereby enhance antitumor immunity. Furthermore, there has been much discussion and even discord over the effects of anemia and blood transfusion in the perichemnotherapy period. The goals of this retrospective study were to determine the timing of chemotherapy induced lymphopenia and to observe perichemnotherapy hemoglobin levels, and the impact of the timing and depth of lymphopenia and anemia on clinical outcomes of ovarian cancer patients.

MATERIALS AND METHODS

A chart review was performed on 115 patients identified in the electronic medical record from May 2005 until May 2011. Identified patients were only those who received at least six cycles of carboplatin and paclitaxel under the present authors' care for primary peritoneal, ovarian, or fallopian tube carcinoma. Specifically, the authors focused on lymphocyte and hemoglobin nadir and the reconstitution kinetics for this population. For each patient's lymphocyte count, nadir values were abstracted from weekly complete blood counts. They then split the population into two groups based on whether the nadir occurred at or after the nine-week mark (third cycle) for the lymphopenia data; this point was chosen because it was good for prognosis and it corresponds to patients whose trajectories bottom out. The intrachernotherapy hemoglobin levels were observed and an exploratory analysis was performed to attempt to identify a range that significantly effected patient outcomes.

RESULTS

Lymiphocytes: The nadir of absolute lymphocyte concentrations is associated with platinum status and clinical response (Figure 1A). 94/115 patients had a lymphocyte count nadir after the third cycle of chemotherapy. 71/94 (75.5%) were platinum sensitive, 21/94 (22.3%) were resistant, and 2/94 (2.1%) were refractory. Of those that experienced a nadir before three cycles, ten (47.6%) were sensitive, ten (47.6%) were resistant, and one (4.7%) was refractory (p = 0.04). Considering nadir values continuously, both overall survival (OS,p = 0:0068) and progression free survival (PFS,p = 0:0321) were strongly associated with late nadir points. Twenty-one of the 115 patients had a nadir value earlier than the third draw and this was associated with progressive disease, platinum resistance, poor over- all survival, and poor progression free survival. The effect sizes were great [median 0S533 vs. 66 months median PFS, 14 vs. 38 months, early vs. late nadir respectively (Figure 11B)]. Hemzoglobin: A mean Hb less than 12.5 is associated with both overall survival (OS) (HR = 2.11, 95% CI: 1.03-4.33; p= 0:042) and progression free survival (PFS) (HR = 1.91, 95% CI: l.02-3.56; p= 0:041), as were low Hb level at outset of chemotherapy and a decreasing Hb trend over the course of treatment. Furthermore, for each cycle of chemotherapy in which the hemoglobin was recorded at avalue less than 11, hazard increased, with OS (HR = 3.51, 95% CI: 1.63-7.54, p = 0:0Ol3), and PFS (HR = 2.20, 95% CI:1.12-4.33; p = 0:0223). Deeper analysis revealed that outcomes were significantly affected when a pa- tient had three or more cycles with Hb less than 11 with both 05 (HR = 2.34, 95% Cl: 1.37-4.01; Wald-Test p = 0:0020, Log Rank p = 0.00145) and PFS (HR =1.88, 95% CI: 1. 17-3.02; Wald-Test p = 0:009, Log Rank p = 0.00743).

CONCLUSION

The nadir of absolute lymphocyte concentrations is an independent predictor of overall survival and progression free survival. This is an easily measurable biomarker which can be utilized for identifying patients that will be likely to respond to immunomodulation. Furthermore, this evidence showing significant improvement in OS and PFS with two or less cycles with hemoglobin < 11 sheds new light on the need for further studies on growth stimulating factors and blood transfusion during this treatment period.

Docetaxel and nab-paclitaxel are safe alternative options for patients with gynecologic malignancies following hypersensitivity reaction to paclitaxel

Docetaxel and nab-paclitaxel are safe alternatives to paclitaxel after hypersensitivity reaction occurs. There was no significant difference in overall survival between those that had paclitaxel, docetaxel, and nab-paclitaxel.

Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study

BACKGROUND

Folate receptor 1 (FOLR1) is expressed in the majority of ovarian carcinomas (OvCa), making it an attractive target for therapy. However, clinical trials testing anti-FOLR1 therapies in OvCa show mixed results and require better understanding of the prognostic relevance of FOLR1 expression. We conducted a large study evaluating FOLR1 expression with survival in different histological types of OvCa.

METHODS

Tissue microarrays composed of tumour samples from 2801 patients in the Ovarian Tumour Tissue Analysis (OTTA) consortium were assessed for FOLR1 expression by centralised immunohistochemistry. We estimated associations for overall (OS) and progression-free (PFS) survival using adjusted Cox regression models. High-grade serous ovarian carcinomas (HGSC) from The Cancer Genome Atlas (TCGA) were evaluated independently for association between FOLR1 mRNA upregulation and survival.

RESULTS

FOLR1 expression ranged from 76% in HGSC to 11% in mucinous carcinomas in OTTA. For HGSC, the association between FOLR1 expression and OS changed significantly during the years following diagnosis in OTTA (Pinteraction=0.01, N=1422) and TCGA (Pinteraction=0.01, N=485). In OTTA, particularly for FIGO stage I/II tumours, patients with FOLR1-positive HGSC showed increased OS during the first 2 years only (hazard ratio=0.44, 95% confidence interval=0.20-0.96) and patients with FOLR1-positive clear cell carcinomas (CCC) showed decreased PFS independent of follow-up time (HR=1.89, 95% CI=1.10-3.25, N=259). In TCGA, FOLR1 mRNA upregulation in HGSC was also associated with increased OS during the first 2 years following diagnosis irrespective of tumour stage (HR: 0.48, 95% CI: 0.25-0.94).

CONCLUSIONS

FOLR1-positive HGSC tumours were associated with an increased OS in the first 2 years following diagnosis. Patients with FOLR1-negative, poor prognosis HGSC would be unlikely to benefit from anti-FOLR1 therapies. In contrast, a decreased PFS interval was observed for FOLR1-positive CCC. The clinical efficacy of FOLR1-targeted interventions should therefore be evaluated according to histology, stage and time following diagnosis.

Evidence for a time-dependent association between FOLR1 expression and survival from ovarian carcinoma: implications for clinical testing. An Ovarian Tumour Tissue Analysis consortium study

BACKGROUND

Folate receptor 1 (FOLR1) is expressed in the majority of ovarian carcinomas (OvCa), making it an attractive target for therapy. However, clinical trials testing anti-FOLR1 therapies in OvCa show mixed results and require better understanding of the prognostic relevance of FOLR1 expression. We conducted a large study evaluating FOLR1 expression with survival in different histological types of OvCa.

METHODS

Tissue microarrays composed of tumour samples from 2801 patients in the Ovarian Tumour Tissue Analysis (OTTA) consortium were assessed for FOLR1 expression by centralised immunohistochemistry. We estimated associations for overall (OS) and progression-free (PFS) survival using adjusted Cox regression models. High-grade serous ovarian carcinomas (HGSC) from The Cancer Genome Atlas (TCGA) were evaluated independently for association between FOLR1 mRNA upregulation and survival.

RESULTS

FOLR1 expression ranged from 76% in HGSC to 11% in mucinous carcinomas in OTTA. For HGSC, the association between FOLR1 expression and OS changed significantly during the years following diagnosis in OTTA (Pinteraction=0.01, N=1422) and TCGA (Pinteraction=0.01, N=485). In OTTA, particularly for FIGO stage I/II tumours, patients with FOLR1-positive HGSC showed increased OS during the first 2 years only (hazard ratio=0.44, 95% confidence interval=0.20-0.96) and patients with FOLR1-positive clear cell carcinomas (CCC) showed decreased PFS independent of follow-up time (HR=1.89, 95% CI=1.10-3.25, N=259). In TCGA, FOLR1 mRNA upregulation in HGSC was also associated with increased OS during the first 2 years following diagnosis irrespective of tumour stage (HR: 0.48, 95% CI: 0.25-0.94).

CONCLUSIONS

FOLR1-positive HGSC tumours were associated with an increased OS in the first 2 years following diagnosis. Patients with FOLR1-negative, poor prognosis HGSC would be unlikely to benefit from anti-FOLR1 therapies. In contrast, a decreased PFS interval was observed for FOLR1-positive CCC. The clinical efficacy of FOLR1-targeted interventions should therefore be evaluated according to histology, stage and time following diagnosis.

Bevacizumab for the treatment of recurrent ovarian cancer: a retrospective cohort study

OBJECTIVE

To determine response rates (RR), progression-free survival (PFS), overall survival (OS), and toxicity in patients treated with cytotoxic chemotherapy, in combination with bevacizumab compared to cytotoxic chemotherapy alone, in the setting of recurrent ovarian cancer.

MATERIALS AND METHODS

After obtaining Institutional Review Board approval, two cohorts of patients with recurrent ovarian cancer were identified: 1) patients that received cytotoxic chemotherapy with bevacizumab from January 2006 to June 2009; 2) patients that received cytotoxic chemotherapy alone. RR were measured using RECIST criteria or by CA-125 levels using modified Rustin criteria. RR, OS, and PFS were determined using Kaplan-Meier survival analysis.

RESULTS

Thirty-two patients that received bevacizumab in combination with cytotoxic chemotherapy and 32 patients that received cytotoxic chemotherapy alone were identified. The control patients were matched for age, platinum response, histology, surgical outcome, grade, and number of previous chemotherapy regimens. There were no differences between the two cohorts in the rates of venous thromboembolism (VTE) (p = 0.39), bleeding (p = 0.15) or bowel obstruction (p = 0.40). The rate of hypertension in the bevacizumab cohort was greater than in the comparison cohort (p < 0.005). There were no differences in response rates PR/CR vs SD/PD (p = 0.46), OS (p = 0.79) or PFS (p = 0.43).

CONCLUSIONS

With increased toxicity, increased cost of therapy and no improvement in PFS or OS, the role of bevacizumab in patients with recurrent ovarian cancer warrants further investigation.

Adjuvant treatment for uterine leiomyosarcoma

The aims of this study were to evaluate outcomes in women diagnosed with uterine leiomyosarcoma (LMS). A retrospective chart review was conducted. Fifty-eight women with LMS were identified. Of the evaluable 52 patients (six patients were excluded), 73% had Stage I/II disease, and 27% had Stage III/IV disease. Sixty-three percent of patients received chemotherapy (97% doxorubicin-based therapy), eight percent received radiation alone, and 29% received no therapy. For patients with Stage I/II disease, no improvement in OS was demonstrated when adjuvant therapy was administered. There was a significant difference in OS (p = 0.0005) for patients with advanced Stage (III/IV) disease that received adjuvant chemotherapy. OS of the entire group, when adjusted for stage, failed to reveal a significant survival advantage for those receiving chemotherapy-based (p = 0.22). The present findings suggest further research into the role of chemotherapy in early stage disease is needed to better refine optimal treatment.

Evaluation of the outcome benefit conferred by intensive surveillance strategies in women with early-stage endometrial cancer

INTRODUCTION

The optimum follow-up regimen after treatment for early-stage endometrial cancer with curative intent is unknown. The National Comprehensive Cancer Network recommends a physical exam and vaginal cytology every three to six months for two years then at six to 12 month intervals with annual chest X-rays (CXR). However, there is debate as to whether intensive follow-up results in an improvement in outcomes for those with recurrent endometrial cancer.

OBJECTIVE

To determine if intensive surveillance for recurrent cancer in women with early-stage endometrial cancer improves their outcomes.

MATERIALS AND METHODS

The Roswell Park Cancer Institute tumor registry was used to identify patients with Stage I and II endometrial cancer initially diagnosed and treated over an 18-year period, who subsequently recurred. Clinico-pathological variables were abstracted. Patients were divided into two groups, depending on their mode of diagnosis of recurrent cancer: 1) routine screening, or 2) symptomatic. The outcomes between the two groups were compared.

RESULTS

Fifty-two patients met inclusion criteria. Twenty-three patients were diagnosed via routine screening methods and 29 were symptomatic at presentation. Groups were equally represented with respect to age, stage, grade, adjuvant therapy, site of recurrence (local, distant), and time to recurrence (p > 0.05). Median survival time was 79 months for those diagnosed during routine screening and 80 months for symptomatic patients (p > 0.05).

CONCLUSION

Pap smear and CXR appear to be of limited utility as the present study has shown that women diagnosed as a result of intensive surveillance did not have a better outcome than those who presented when symptomatic.

Photodynamic therapy effectively palliates gynecologic malignancies

BACKGROUND

There is a need for novel therapies for women with recurrent gynecologic malignancies. In this paper, the authors report their experience with photodynamic therapy (PDT). PDT involves administering a systemic injection of Photofrin II, a selective tumor photosensitizer hematoporphyrin derivative, followed by exposure of tumor tissue to visible light at 630 nm. The photodynamic destruction of tumor exhibits both cytocidal and vascular effects that may contribute to the tumoricidal effects observed.

MATERIALS AND METHODS

Patients were injected intravenously with two mg/kg Photofrin II. Approximately 48 hours post-injection, the tumor was exposed to red light (wavelength 630 nm +/- 2 nm) from a laser through a flexible 400-um quartz fiber with an attached microlens to produce a spot of uniform intensity and/or diffuser tip fiber to uniformly illuminate the cavity.

RESULTS

Thirty-two patients with recurrent gynecologic malignancies were treated with photodynamic therapy using Photofrin II dye and laser. A total of 45 PDT treatments were given; 25 patients received only one treatment, five patients received two treatments, two patients received three treatments, and one patient received four treatments. There were nine cervical, six vulvar, six vaginal, five ovarian, five endometrial carcinomas, and one recurrent pagets of the anal canal. Nine out of 11 (82%) patients with metastatic cutaneous lesions had a complete response. Five out of 21 patients (24%) with vaginal, cervical or anal recurrences had a complete response to therapy with median response time of 28 months. Toxicity associated with treatment was limited to burning sensation, pain, and edema at treatment site. There were no treatment related deaths.

CONCLUSIONS

PDT is an effective therapy in patients with recurrent gynecologic malignancies and limited treatment options. PDT is an alternative therapy that offers the possibility of complete response in select groups of patient populations. Specifically, it provides palliation for superficial recurrent lesions of skin, cervix, vagina and vulva, in the absence of distant disease.

Pair-Box (PAX8) protein-positive expression is associated with poor disease outcome in women with endometrial cancer

BACKGROUND

The Pax8 transcription factor genes have a role in cell differentiation and cell growth, and silencing of Pax8 in cell cultures results in cell death. The aims of this study were to determine the expression and correlation of Pax8 protein with several clinicopathological variables in patients with endometrial cancer.

METHODS

The following clinical parameters from 229 patients were used for correlation with Pax8 expression; age, histological subtype, myometrial depth of invasion, lymphovascular invasion (LVI), the International Federation of Gynecology and Obstetrics grade, lymph nodes status, and disease status.

RESULTS

A positive association of Pax8(+) expression was found with high tumour grade (P=0.002), LVI+(P=0.0186), and type II tumour subtype (P<0.0001) in univariate analysis. Survival analysis showed an association of Pax8 and 5-year overall survival probability (P=0.01486), 80.04% for patients with Pax8(-) and 55.59% for patients with Pax8(+). There was also an association of Pax8 and 5-year disease-free survival probability (P=0.02028), 72.12% for patients with Pax8(-) vs 49.88% for patients with Pax8(+). Finally, an association of Pax8(+) and shorter recurrence-free survival was also found (P=0.00203), with 74.36% for Pax8(-) and 52.11% for Pax8(+).

CONCLUSION

Overexpression of Pax8 protein by endometrial cancer is associated with poor disease outcomes. Inhibition of Pax8 may be a very attractive targeted therapy for selective patients.

Prognostic factors in stages II/III/IV and stages III/IV endometrioid and serous adenocarcinoma of the endometrium

AIMS

To explore and to compare the outcome of patients diagnosed with stage II/III/IV and stage III/IV endometrioid adenocarcinoma (EAC) with their serous carcinoma (USC) counterparts.

MATERIALS AND METHODS

A total of 107 patients (73 EAC and 34 USC) were evaluated. For statistical analysis, the following baseline variables were considered for their prognostic value: the patient's age at presentation, the tumor size, the depth of myometrial invasion (MI), the lympho-vascular involvement (LVI) and the USC and the EAC subtypes (considered as binary variables). Disease free survival (DFS), death of disease (DOD) and overall survival (OS) were assessed using univariate and multiple Cox proportional hazards models.

RESULTS

In univariate analysis, USC tends to recur more frequently than EAC (p = 0.004), a finding that disappeared in multivariate analysis. Furthermore, tumor histology had no significance in predicting the tumor outcomes. Among all of the prognostic factors and after adjusting for the aforementioned variables, MI ≥50% was the only independent factor in predicting DOD in stages II/III/IV (p = 0.009) and in stages III/IV (p = 0.004). MI was also an independent predictive factor for OS (p = 0.02) and early recurrences in stages III/IV. LVI was the only independent factor in predicting recurrences (p = 0.004) in stages II/III/IV but not in stages III/IV.

CONCLUSION

Based on our study, tumor histology was not a significant factor in predicting disease outcome in stages II/III/IV and II/IV. Despite our limited sample size, we believe that our findings provide meaningful insights into the clinical study of endometrial cancer patients which in turn warrants further investigation.

The use of cod liver oil by patients receiving pegylated liposomal doxorubicin is associated with a lack of severe palmar-plantar erythrodysesthesia

Pegylated liposomal doxorubicin (PLD) is an effective and tolerable agent in the treatment of recurrent and refractory ovarian carcinoma. One of the most common dose-limiting toxicities of PLD is palmar-plantar erythrodysesthesia (PPE). We report a retrospective review of patients who took cod liver oil (CLO) while being treated with PLD at Roswell Park Cancer Institute. None of the patients required dose reduction, treatment interruption or discontinuation secondary to skin toxicity. No patient experienced grade 2 or greater PPE. The mechanism for the development of PLD-induced PPE is unknown. CLO may possibly mitigate it via decreased extravasation of PLD and/or by a blunting of the local inflammatory response. The effects of CLO should be further evaluated in a prospective, randomized trial, and attempts to elucidate the mechanism by which CLO may exert its effects should be pursued.