Cis-platin based combination chemotherapy for advanced ovarian cancer. High overall response rate with curative potential only in women with small tumor burdens

Salvage chemotherapy for ovarian cancer recurrence: weekly cisplatin in combination with epirubicin or etoposide

From December 1986 to April 1990, 40 consecutive ovarian cancer patients who relapsed after response to cisplatin-based chemotherapy regimens were treated with seven courses of weekly cisplatin, in combination with epirubicin or etoposide. The overall response rate obtained with the intensive schedule was 60% and the complete response rate was 25%; median duration of response was 7 months and median survival time, 13.5 months. Responsive cases seem to have longer survival; a prognostic factor for response to salvage treatment and longer survival is the disease-free interval after the first-line chemotherapy. Weekly cisplatin as intensive treatment was very well tolerated and showed acceptable toxicity in both the combination protocols with epirubicin or etoposide.

Outcome of patients with unfavorable optimally cytoreduced ovarian cancer treated with chemotherapy and whole abdominal radiation

There is a subgroup of patients with Stage II or III ovarian cancer whose survival is poor despite optimal cytoreduction of tumor and abdominopelvic radiation. This study examined whether the survival of these patients, who have tumor with unfavorable histopathological characteristics and/or small residual disease, could be improved by giving chemotherapy before radiation. Forty-four out of fifty-one eligible patients, seen between 1981 and 1985, with Stage II or III disease were entered into the study. Following six courses of cisplatin-based chemotherapy, 33 (75%) received abdominopelvic radiotherapy. Survival was compared to that of 48 eligible matched control patients, treated with radiation between 1978 and 1981. The median follow-up is 6.6 years. The median survival was extended from 2.4 to 5.7 years (P = 0.13), and 42.6% of patients receiving combined therapy were free of relapse at 5 years, compared to 21.6% (P = 0.03) in the historical control group, treated with abdominopelvic irradiation alone. Only 2 of 44 patients in the combined group required surgery for bowel obstruction, as did 1 of 48 in the control group. Tolerance and toxicity of the combined approach were acceptable. Although we cannot be certain that the entire benefit we observed was not attributable to the chemotherapy alone, there is evidence that the radiotherapy may have been additive. Chemotherapy followed by abdominopelvic radiotherapy seems a reasonable management policy in these patients.

Carboplatin and cyclophosphamide salvage therapy for ovarian cancer patients relapsing after cisplatin combination chemotherapy

30 ovarian cancer patients with a relapse after prior cisplatin combination chemotherapy were treated in a phase II study with cyclophosphamide 100 mg/m2 orally on days 1-7 and carboplatin 300 mg/m2 intravenously on day 8. Treatment was well tolerated. The major side-effect was thrombocytopenia. 28 patients were evaluable for response. The response was 5 CRs (18%), 4 PRs (14%) 15 SDs (53%) and 4 PDs (14%), for an overall response rate of 32%. The overall progression-free survival lasted from 2 to 23 months, median 8 months. Overall survival ranged from 2 to 35+ months, median 12 months. Patients with a therapy-free interval of more than 1 year showed a higher response rate (46%) than patients with a shorter therapy-free interval (20%). It is concluded that platinum containing second-line chemotherapy, after treatment that already contained cisplatin, is only warranted to palliate symptoms.

Prechemotherapy serum CA125 level as a predictor of survival outcome in epithelial carcinoma of the ovary

A total of 55 patients with epithelial ovarian carcinoma treated with platinum-based chemotherapy were followed for a minimum period of 2 years. Of these 22 patients had a prechemotherapy serum CA125 level of less than 50 ku/l and 33 patients had a serum CA125 level of greater than or equal to 50 ku/l. The 5-year actuarial survival of the two groups were 75% and 10% respectively. Prechemotherapy CA125 level taken 4 weeks after debulking surgery may predict the eventual survival outcome in epithelial ovarian cancer patients who undergo chemotherapy treatment.

Restorative effects of calmodulin antagonists on reduced cisplatin uptake by cisplatin-resistant human ovarian cancer cells

In the present study, we attempted to determine effects of calmodulin antagonists (W-7 and W-5) on cisplatin uptake by human ovarian cancer cells, using KF cells derived from serous cystadenocarcinoma of the ovary and cisplatin-resistant cells (KFr). The degree of cisplatin resistance of the KFr cells was about 3.7-fold higher than that of the parent KF cells, with regard to the concentration of cisplatin required for 50% inhibition of cell proliferation (IC50). When KF and KFr cells were incubated with 10 micrograms/ml cisplatin for 4 hr, cisplatin-content in the KF cells was significantly higher than that in the KFr cells. When KF cells were incubated in the presence of W-7 (but not W-5), cisplatin uptake significantly increased, compared to cells treated with cisplatin alone. On the other hand, when KFr cells were incubated in the presence of 5 micrograms/ml W-7 or W-5, cisplatin uptake was significantly higher than uptake by KFr cells treated with cisplatin alone, being comparable to that by KF cells treated with cisplatin alone. Such an increase in cisplatin uptake seemed to bring about adjuvant effects to cisplatin of KFr cell proliferation in vitro. The KF tumor grown in nude mice took up 24.8 ng/g dry wt of cisplatin 4 hr after intraperitoneal administration. When cisplatin was administered with calmodulin antagonists, cisplatin uptake by the KF and KFr tumors was significantly increased, compared to that after treatment with cisplatin alone. In particular, the cisplatin uptake by the KFr tumor was about 2.5-fold higher than that by the KFr tumor treated with cisplatin alone. These results suggest that coadministration of calmodulin antagonists and cisplatin may be of use in patients with refractory ovarian cancer.

Ovarian cancer

Prevention, early detection, morbidity, and survival issues continue to challenge health professionals involved in the care of women with ovarian cancer. While advances in diagnosis, staging, and treatment have been made, survival rates remain grim. Continuing research in the areas of screening, diagnosis, and treatment is the key to improved survival. The hope of new drug therapy, such as cisplatin-taxol regimens, intraperitoneal therapy, immunotherapy, and bone marrow transplantation, needs further investigation to become reality. As new and potentially more toxic regimens are developed, the nurse must be knowledgeable about the therapies and adverse effects, and maintain a high level of clinical expertise in order to teach the patient, reinforce information, clarify misconceptions, and provide the patient with supportive physical and emotional care.

Long-term survival after chemotherapy with cisplatinum, adriamycin and cyclophosphamide for carcinoma of the ovary

Forty six patients with FIGO Stage II, III, and IV ovarian cancer received treatment with cisplatinum, adriamycin and cyclophosphamide. After a minimum follow-up time of 60 months 13 patients remain free of recurrence. The overall 5-year survival is 39% and the median survival is 39 months. The 5-year survival for Stages II, III, and IV is 64%, 40% and 0% respectively. The 5-year actuarial survival for those who had less than 2 cm residual disease (including those with complete debulking) is 72%, while for those who had greater than 2 cm residual disease (including those who had biopsy only) is 15%. None of the patients have developed any second neoplasm.

Treatment of relapsed carcinoma of the ovary with cisplatin or carboplatin following initial treatment with these compounds

Fifty-four patients with ovarian cancer who achieved a complete or partial remission with cisplatin or carboplatin were rechallenged with the same drug or crossed over to the other platinum compound at relapse. Fifteen of 43 (35%) crossover patients and 1/11 (9%) rechallenged patients responded; the difference was not significant and there was no difference in survival between the two groups. Responders survived significantly longer than nonresponders (P = 0.001) but there was no survival difference between those who responded to a rechallenge and those who responded to crossing over to the other platinum compound. The progression-free interval between the end of initial treatment and relapse was a significant prognostic factor for response to treatment and survival; 17% (6/35) of patients who relapsed before 18 months responded as compared to 53% (10/19) who relapsed after 18 months (P = 0.006) and median survival was 221 and 486 days, respectively, for these two groups (P = 0.026).

A randomized trial comparing whole abdominal radiotherapy with chemotherapy following cisplatinum cytoreduction in epithelial ovarian cancer. West Midlands Ovarian Cancer Group Trial II

The potential role of consolidation therapy has been tested in a randomized trial in ovarian cancer. Patients were randomized to receive either whole abdominal radiotherapy using the moving strip technique (n = 56) or one year of chlorambucil (n = 53) following primary surgery, five courses of cisplatinum 100 mg/m2, and second look laparotomy. Overall survival at two years was 35%. There was no significant difference in survival between the two groups, and in spite of the observation that approximately 50% of the patients were optimally debulked prior to consolidation, no subgroups in either arm could be identified who might benefit from consolidation therapy. Toxicity was considerable in both arms, and almost 50% of patients were unable to complete the planned treatment in both arms. These results suggest that after primary surgery and cisplatinum chemotherapy, there is no indication for consolidation therapy with either radiotherapy or alkylating agents.

A five-drug alternating chemotherapy regimen for patients with advanced epithelial ovarian cancer

Twenty-six patients, 22 previously untreated, with FIGO stage III/IV epithelial ovarian cancer were treated with a five-drug combination regimen consisting of cycles of cisplatinum (60 or 75 mg/m2 IV) and cyclophosphamide (600 or 750 mg/m2 IV) [CP], alternating every 3 weeks with cycles of adriamycin [50 mg/m2 IV], bleomycin [15 mg IV], and chlorambucil [6 mg/m2 orally for 7 days] [ABC]. A total of six cycles, CP x 3 and ABC x 3, were planned. There was a 67% response rate with 7 complete and 5 partial remissions in 18 patients with evaluable disease. Median progression-free interval was 13 months and median survival 24 months for the whole group. The regimen was well tolerated with WHO toxicity greater than 2 in only 5 patients and treatment delay occurring in only 18 of 128 cycles [14%] in 11 patients. The toxicity of combination cytotoxic regimens can be reduced by alternating cycles of therapy. A randomized trial comparing such a regimen with nonalternating therapy would be necessary to determine whether the response rate and duration of response are compromised when the cumulative dose of cisplatinum is reduced.

Current status of epirubicin (Farmorubicin) in the treatment of solid tumours

Epirubicin (Farmorubicin) is a drug of significant interest in the treatment of a variety of solid tumours and a comprehensive review of reported investigations is given. From experimental and clinical studies it appears that in general doxorubicin and epirubicin exhibit no qualitative, but only some quantitative, differences. Thus, the pharmacokinetic and pharmacodynamic characteristics of the two drugs are essentially similar, as are the tumour spectrum and the level of their clinical efficacies. To achieve haematological equitoxicity of the two drugs the dose of epirubicin should be approximately 20% higher than that of doxorubicin, giving rise to a higher cumulative dose of epirubicin. On the other hand, epirubicin is significantly less cardiotoxic than doxorubicin. Thus, the recommended cumulative dose of doxorubicin is 500 mg/m2 and the corresponding figure for epirubicin is 1,000 mg/m2. For either drug a number of questions are still left open, the most important of which include the questions about optimal treatment schedules and the existence of a clinical relevant dose/efficacy relationship.

Predictive factors for long-term survival in patients with advanced ovarian cancer

A total of 107 patients with carcinoma of the ovary were entered in a study combining extensive primary surgery and intensive chemotherapy. Because of evidence supporting the effectiveness of both single agent platinum (P) and the combination of cyclophosphamide and doxorubicin (CA), patients were treated with alternating cycles of CA and CP. Primary surgery to remove the bulk of tumor to less than 2 cm was possible in 45% of the 85 eligible patients, and an additional 17% had similar surgery after two to four cycles of chemotherapy. Fifteen percent of patients progressed on chemotherapy. Of the 68 who were clinically and radiologically without disease at the completion of chemotherapy, 91% had second-look surgery. Forty-eight percent of these women had residual disease. All patients but one are at risk for greater than 60 months, with a median follow-up of 86 months. Overall 5-year survival is 26%, with a median survival of 33 months. Twenty patients survived over 5 years with 11 continuing to be free of disease (13% of all eligible patients). Patients with modified Broder's grade I,II tumors have not yet reached a median survival. Grade, stage, and primary mass size were the only variables with independent prognostic value in a Cox multivariate analysis.

A meta-analysis of prognostic factors in advanced ovarian cancer with median survival and overall survival (measured with the log (relative risk)) as main objectives

We performed a meta-analysis of 38 articles containing 66 treatment groups and 3443 patients in order to evaluate prognostic factors in advanced epithelial ovarian cancer. To evaluate overall survival we designed a method to summarize the overall survival curve into one single figure: the log (relative risk) (LRR). This is the first meta-analysis using overall survival (measured with the LRR) as an objective. We found that the main prognostic factors predicting an improved survival (measured with the LRR) are: chemotherapy including cisplatin as initial treatment, a residual tumour mass of less than 2 cm prior to therapy, FIGO stage II/III and a good performance status. In a multivariate model, the use of cisplatin and the residual tumour were found to be the only factors of prognostic relevance. No relation between median survival and the overall clinical response rate of all patients entered in the denominator, could be demonstrated. Undifferentiated tumours and patients treated with cisplatin regimens had higher response rates to treatment but younger patients and those with endometrioid histology were less likely to respond. A surgical complete remission was encountered more frequently among studies that included a high number of patients with small tumour masses prior to treatment. Trials using cisplatin included more patients with small tumour nodules in their patient material compared to studies not using this drug. The data illustrate the danger of comparing studies with each other. In the trials with a high percentage of patients with small tumour residuals in the study population more toxic deaths were seen. This probably reflects the fact that they had received more intensive treatment. The LRR correlated strongly with the median survival, response and the percentage of surgical complete remissions. We concluded that the introduction of the LRR can be a meaningful addition to the evaluation of the influence of prognostic factors on overall survival.

Phase II study of combination 4'-epidoxorubicin and mitomycin C in recurrent epithelial ovarian cancer

Thirty-three evaluable patients who had epithelial ovarian cancer that had not responded to treatment were entered into a phase II study of combination epirubicin and mitomycin C. Epirubicin (65 mg/m2) and mitomycin C (4 mg/m2) were administered separately, each as an i.v. bolus every 4 weeks. Ten patients (30%) had a complete or partial responses. The median duration of response was 20 weeks (range, 9-53). The regimen was well tolerated. Myelotoxicity occurred in four patients requiring hospitalization for septicaemia. Eleven patients had a blood transfusion. Alopecia was common, and nausea and vomiting, though frequent, usually mild. Cardiological toxicity was observed in one patient only. She developed congestive cardiac failure after an acute myocardial infarction. This regimen is active in advanced ovarian cancer that has not responded to prior treatment and warrants further study combination with other active drugs as a first-line regimen for ovarian cancer.

Randomised trial comparing combinations of cyclophosphamide and cisplatin without or with doxorubicin or 4'-epi-doxorubicin in the treatment of advanced ovarian cancer

Forty-eight patients with FIGO stage III and IV epithelial carcinomas of the ovary were entered in this randomised trial. Radical surgery was performed and no residual tumor with a diameter greater than 2 cm was left behind. Of these patients 62.5% (10/16) had a complete or partial response on cyclophosphamide + cisplatin (CP) 87.5% (14/16) on cyclophosphamide + doxorubicin + cisplatin (CAP) and cyclophosphamide + 4'-epi-doxorubicin + cisplatin (CEP). The median time to progression was 3.5 months on CP, 12.5 months on CAP and 11.0 months on CEP. Patients treated with CAP combination chemotherapy had generally longer progression-free survival (log rank chi 2 = 5.4; P = 0.04). No significant difference was found, however, between patients on CAP and CEP. The median survival times were 12.5 months on CP, 26.5 months on CAP and 14.0 months on CEP. Patients treated with CAP combination chemotherapy had generally longer survival (logrank chi 2 = 9.08; P = 0.0099). No significant difference was found, however, between patients on CAP and CEP in terms of survival. Asymptomatic mild-to-moderate laboratory test toxicity occurred in 6-12% of patients on CP, 6-12% on CAP and no toxicity of this type and grade on CEP. Nausea and vomiting were also less severe and less frequent in the CEP group. Cardiotoxicity was seen in 12.5% (2/16) only in the CAP group.

Adriamycin and cisplatin in the treatment of stage III and IV epithelial ovarian carcinoma

A total of 342 eligible, previously untreated patients with Stage III or IV epithelial ovarian carcinoma were treated with Adriamycin and cisplatin, both at 50 mg/m2, for nine courses. Of the 210 patients who had clinically detectable disease after initial surgery, 85 (41%) had a complete clinical response and 45 (21%) had a partial clinical response. A total of 197 were clinically free of disease at the completion of chemotherapy and 175 of these had a second-look laparotomy; 55 had no macroscopic or microscopic evidence of residual disease after multiple random biopsies were examined histologically (complete surgical/histologic response). The major determinants of complete surgical/histologic response were diameter of largest residual tumor prior to treatment, ECOG performance status, and grade, patients with grade 3 tumors having a higher complete response rate than those with grade 1 or 2 tumors. The major determinants of survival were ECOG performance status and diameter of largest residual tumor prior to treatment. Median survival of the total group was 1.8 years.

Effects of PSK on interleukin-2 production by peripheral lymphocytes of patients with advanced ovarian carcinoma during chemotherapy

The effects of PSK on OKT 4/OKT 8 cell ratio, interleukin-2 (IL-2) production and expression of IL-2 receptor were examined in peripheral blood lymphocytes (PBL) from patients with advanced ovarian cancer during the course of chemotherapy. Preoperative levels of OKT 4/OKT 8 cell ratio and IL-2 production in PBL from patients with advanced ovarian cancer were significantly lower than those in cases of benign ovarian tumor. However, the expression of IL-2 receptor did not show any significant difference between ovarian cancer and benign ovarian tumor patients. When a combination chemotherapy of cisplatin, adriamycin and cyclophosphamide was given, the OKT 4/OKT 8 cell ratio was significantly increased with a significant decrease of the absolute number of the OKT 8 cell subset, while the expression of IL-2 receptor and the absolute number of the OKT 4 cell subset remained unchanged. In contrast, the IL-2 production was markedly depressed after the first course of chemotherapy. When PSK was combined with combination chemotherapy, the degree of inhibition of IL-2 production was reduced (though the effect was not statistically significant). If treatment with PSK was initiated after completion of combination chemotherapy, in addition to a significant elevation of OKT 4/OKT 8 cell ratio the depressed IL-2 production was restored to benign control levels. On the other hand, the expression of IL-2 receptor remained unchanged even if PSK was given after completion of chemotherapy.

Serum CA-125 as a guideline for the timing of a second-look operation and second-line treatment in ovarian cancer

In the assessment of response to treatment of ovarian cancer patients, clinical examination is unreliable in detecting small tumor masses. The second-look laparotomy is therefore an accepted procedure. The optimal timing of second-look laparotomy, however, is uncertain. We therefore examined the usefulness of serial serum CA-125 estimations in the timing of second-look laparotomies in 33 patients suffering from ovarian cancer. Increasing CA-125 concentrations were always followed by relapses or progressive disease, whereas decreasing serum concentrations indicated response to treatment. In future we propose to perform second-look laparotomies when CA-125 levels have declined to a steady plateau and to start a secondary treatment when CA-125 levels start to rise again.

Complications of Tenckhoff catheter implantation in patients with multiple previous intraabdominal procedures for ovarian carcinoma

In patients with minimal residual ovarian carcinoma after aggressive surgical and chemotherapeutic treatment, nephrotoxicity and/or peripheral neuropathy often prohibit continued treatment with intravenous combination cisplatin-based chemotherapy. It is attractive to continue treatment of these patients with intraperitoneal (ip) delivered chemotherapy. From 1981 through 1984 a Tenckhoff catheter was implanted in 59 women for ip chemotherapy after a staging laparoscopy or laparotomy. Minor complications occurred in 8 patients and could be treated conservatively. Ten patients suffered major complications, leading to three (re)laparotomies and catheter extraction in 7 of 10 patients. No patient died of complications, but mean hospitalization time of patients with major complications was 25 days as compared to 11 days for patients without complications. An analysis of nine factors that could lead to postoperative complications failed to reveal a statistically significant risk factor. From this study no profile of a typical high-risk patient emerges.

Treatment of advanced ovarian cancer with sequential combination chemotherapy

Fifty previously untreated patients with advanced or recurrent ovarian cancer (FIGO Stages III and IV) were treated with alternating combination chemotherapy. This consisted of high-dose doxorubicin (70 mg/m2) and cisplatin (100 mg/m2) alternated with CHF (cyclophosphamide, hexamethylmelamine, and 5-fluorouracil). Toxicity (myelosuppression, nephropathy, and neuropathy) was infrequent and mild. Clinical response rates were high (94% response, 62% complete clinical response), but the majority of patients had residual intraabdominal disease at second-look surgery (75%). Thirteen patients (26%) are alive after 4 years of observation (minimum follow-up). Survival was adversely influenced in patients who were older than 70, had Stage IV disease, residual tumor bulk greater than 2 cm, and who failed to achieve complete clinical remission. The median duration of survival (28 months) and percentage of long-term survivors appear similar to that in other platinum-based chemotherapy studies. Although the role of alternating combination chemotherapy in epithelial ovarian cancer remains undefined, it is likely that an alternate approach will be necessary to markedly improve survival rates for patients with this disease.

Chemotherapy for advanced or recurrent gynecologic cancer

Studies of chemotherapy in advanced or recurrent gynecologic cancer have focussed on ovarian, cervical, and endometrial carcinoma. For celomic epithelial carcinomas of the ovary, a large number of cytotoxic agents have been shown to be active. Dramatic improvement in frequency of response with lesser improvement in survival has been noted with the use of cisplatin-based combination chemotherapy as compared to single alkylating agents. More recent studies have evaluated alternative ways to employ cisplatin: higher dose schedules, intraperitoneal administration, and platinum compounds with a potentially better therapeutic index. None has yet been shown superior to a combination of relatively low-dose cisplatin plus an alkylating agent with or without doxorubicin. Cisplatin remains the best studied and most active single agent in patients with squamous cell carcinoma of the cervix. While a number of other agents have demonstrated moderate activity, no combination of drugs has as yet proved superior to single-agent cisplatin. In endometrial carcinoma, progestins and doxorubicin are the most active agents. Tamoxifen, cisplatin, and hexamethylmelamine appear to have moderate activity. No combination has yet been shown to be superior to single agents. Information on chemotherapy for less common gynecologic malignancies is largely anecdotal. Two observations are of note. Cisplatin-based combination chemotherapy is highly active against germ-cell neoplasms of the ovary. Cisplatin also has definite activity against mixed mesodermal sarcoma of the uterus.

Ovarian Cancer: Ten-Year Experience in a Community Hospital

We reviewed 187 patients with epithelial ovarian cancer treated, from 1975 to 1985, at the Division of Radiotherapy and Medical Oncology, Pordenone General Hospital, Italy. It seemed of interest to report an experience carried out in a community hospital in a consecutive unselected series of patients affected by ovarian cancer. Survival time was evaluated from the day of the primary surgical approach to the end of the study (March 1985). The aim of the study was to confirm in our patient population the importance of some already recognised prognostic factors that influence survival (age, stage, histology, grade, type of surgery and residuum). We also analyzed the effect of the treatment variables chemotherapy and radiotherapy on survival. The general pattern of prognostic factors appears to be in agreement with reports in the literature. In our experience, residual disease and stage were the main important prognostic factors; grade and histology had a secondary relevance, and age did not seem to be a prognostic factor in our population. New chemotherapy regimens and/or radiotherapy did not appear to improve survival. In fact, comparison of the results obtained from 1975–1979 and from 1980–1985 (when more aggressive surgery and cisplatin-containing regimens were employed) showed no statistically significant difference in survival rate. Our data suggest that patients at an early stage can receive a satisfactory quality of care in a general hospital with oncology facilities, provided the surgeon and the pathologist are experienced in ovarian cancer. Patients at stage III but completely surgically resected can also be adequately treated. Patients with advanced disease, considering the lack of established efficacious treatments, should be referred to specialized centers, where new drugs or experimental strategies can be tested.

A predictive index of cure versus no cure in advanced ovarian carcinoma patients--replacement of second-look laparotomy as a diagnostic test

Three hundred forty-two Stage III and IV epithelial ovarian carcinoma patients received cytoreductive surgery followed by Adriamycin and cisplatin, 50 mg/m2 each, q 4 weeks for 9 courses. One hundred ninety-seven were clinically NED at completion of treatment and 173 of these 197 had a second-look laparotomy. One hundred twenty had persistent disease. Fifty-three were second-look negative and had no further treatment. Thirty of these latter patients relapsed--all (with one exception) within 2 years. Those not relapsing after negative second-look are considered "cured" (median follow-up 42 months, range 24-68 months) and all others "failures." Stage was a significant predictor of treatment failure--there were no Stage IV "cures." In Stage III patients, age and largest residual tumor diameter post initial surgery were significant predictors of failure. Performance status was marginally significant. In our series, any patient with Stage IV disease or Stage III disease with at least two of the following three poor prognostic factors had a chance of cure of 2.2% (2 "cures" out of 90 patients): age greater than 60 years, macroscopic residual initially, or initial performance status of 2 or 3. Under normal circumstances a second-look procedure to identify persistent disease in this group of patients does not appear justified.

Advanced ovarian cancer: three-year results of a 6-8 month, 2-drug cisplatin-containing regimen

Fifty-two patients with advanced (stage III and IV) ovarian cancer were treated with a regimen of cisplatin (100 mg/m2 over 5 days) and cyclophosphamide (600 mg/m2/day 4). Treatment was repeated every 3-4 weeks for 6-8 months and followed by second look surgery. The median follow up for this single institution study (1980-1984) is 36 months. The median progression-free survival (projected) is 24 months and the median overall survival (projected) is 37 months in this group of patients with unfavorable pretreatment characteristics: median age: 61, median performance status (ECOG) 2, poorly-differentiated tumors: 60%, extensive residual tumors (greater than 2 cm): 65%. Pretreatment performance status was the only independent predictor for prolonged survival. Pathologically documented complete responses were observed in 23% of all patients and 43% of the patients who underwent second-look surgery (28 patients). Neurotoxicity from this regimen was substantial: it occurred in 65% of cases, was severe in 17% and was often not entirely reversible. The results with this intensive 2-drug cisplatin-containing regimen compare favorably to other more complex regimens in the literature. It is possible that the 'dose intensity' of cis-platinum may be the most important element of current therapeutic regimens in ovarian cancer.

Etoposide (VP-16-213) plus cis-diamminedichloroplatinum as salvage therapy in advanced epithelial ovarian cancer

Twenty-two patients with advanced epithelial ovarian cancer were treated with etoposide and cis-platinum. Each had failed one to three regimens of combination chemotherapy including cis-platinum-based combinations. Prior total cis-platinum doses ranged from 50 to 1600 mg/m2 with a median of 440 mg/m2. One of 18 evaluable patients had a complete response lasting 8 months, 1 had a partial response lasting 3 months, 8 had stable disease for a mean of 5.6 months, and 8 had progressive disease. The 4 unevaluable patients had undetectable clinical disease for a mean of 6.7 months. Bone marrow suppression was seen in 4 of 22 patients; two of whom had serious sequelae. The poor objective response rate (9.1%) seen with this combination in patients heavily pretreated with cis-platinum is similar to that seen for single agent etoposide in patients pretreated with alkylating agents. The difficulty of obtaining a good objective response in the face of prior cis-platinum-based combination chemotherapy failure is again verified.

Randomized trial of the addition of cis-platin (DDP) and/or BCG to cyclophosphamide (CTX) chemotherapy for ovarian carcinoma

A prospective randomized trial has compared cyclophosphamide (CTX) with CTX plus cis-diamminodichloroplatinum (DDP) as the initial chemotherapy for advanced ovarian carcinoma. A secondary randomization compared the addition of BCG treatment to either chemotherapy. The addition of DDP had no measurable impact on survival, but a small survival trend favoring BCG-treated patients was noted (P less than 0.08). Toxicity from BCG treatment was insignificant, but the addition of DDP increased both early nausea and vomiting and later hematologic toxicity. There were three long-term complete remission patients, and these all came from the group of six patients with pretreatment residual disease less than 2 cm. A univariate analysis of pretreatment prognostic factors indicated significantly better prognosis (P less than 0.02) for patients with no palpable tumor, platelet count less than 400,000/mm3, residual tumor less than 2 cm, resting pulse less than 91/min. and LDH less than 250 U/L. The authors conclude that for patients with large (greater than 2 cm) residual disease, there is no compelling evidence that initial combination therapy is superior to aggressive single alkylating agent treatment.

Infusional cisplatin plus cyclophosphamide in advanced ovarian cancer

Twenty-one patients with previously untreated advanced ovarian cancer received a two-drug regimen of cisplatin delivered as a systemic infusion at 20 mg/m2/d for 5 days concomitant with oral cyclophosphamide 150 mg/d in divided doses. Courses were repeated at 3- to 4-week intervals. Responses were observed in 14 of 19 evaluable patients (74%) with three complete responses (one pathologically confirmed at second-look laparotomy) and 11 partial responses. Median time to disease progression in the responders was 12 months (range, 4 to 24 months with four patients maintaining remission at 11, 13, 14, and 19 months). The median survival for the entire group was 12 months (range, 1 to 64 months). A higher-than-expected frequency of nephrotoxicity (38%) and neurotoxicity (24%) was observed, suggesting that infusional cisplatin may lead to cumulative adverse effects and necessitate limiting the number of courses delivered in this fashion. Forty-three percent of patients received less than four courses of therapy related to these two categories of toxicity. The therapeutic effect of infusional cisplatin may be comparable to previous reports of bolus schedules in ovarian cancer when employed in combination with cyclophosphamide but the non-hematologic toxicities are substantial.

Sequential multi-agent chemotherapy and whole abdominal irradiation for stage III ovarian carcinoma

Modern therapy for stage III ovarian carcinoma patients usually involves one or more laparotomies with maximal resection of tumor, and intensive multi-agent chemotherapy. However, with long-term follow-up only 10-15% of patients remain free of disease. In the hope of improving outcome, we have treated 17 women with sequential multimodality therapy, including initial surgical resection (if possible), cyclophosphamide-adriamycin +/- cis-platinum, second-look surgery, and whole abdominal irradiation. Seven patients are currently alive without disease, with median follow-up of 52 months since initiation of radiation and 60 months since initiation of chemotherapy. Disease-free survival correlated with residual tumor at the start of radiotherapy: none (4/4); microscopic, less than or equal to 5 mm (3/4); greater than 5 mm or no surgery (0/9). Survival also correlated with tumor grade: grade 1 (2/2); grade 2 (2/3); grade 3 (3/11). Hematological tolerance of radiotherapy was dependent upon the number of chemotherapy cycles: ten of 11 patients receiving less than or equal to eight cycles completed radiotherapy without excessive delay, compared with only one of five receiving greater than eight cycles. There were no treatment-related deaths and only one patient required laparotomy for bowel obstruction. We conclude that intensive multimodal treatment may be tolerated moderately well if the amount of chemotherapy is limited, and that further studies are justified.

Involvement of the central nervous system by ovarian carcinoma

Ovarian carcinoma rarely metastasizes to the central nervous system (CNS). Of 110 patients with epithelial ovarian carcinoma treated at the Northern Israel Oncology Center between the years 1979 and 1985, only five (4.5%) had CNS involvement. The median age of the patients with 54.5 years. All of them had treatment with cisplatin and Adriamycin (doxorubicin). The median duration from diagnosis to the development of brain involvement was 17 months. The median survival time was 28 months from diagnosis of carcinoma and 2 months from diagnosis of CNS disease. The increased incidence of this kind of metastasis in patients achieving local control of their advanced disease suggests that a change in the pattern of metastatic spread or the prolonged survival permits occult CNS metastases to become apparent. A routine computerized axial tomography (CAT) scan of the brain should therefore be performed on patients with ovarian carcinoma with prolonged survival.

A randomized trial of cyclophosphamide and doxorubicin with or without cisplatin in advanced ovarian carcinoma. A Gynecologic Oncology Group Study

A randomized clinical trial was conducted in women with bulky (suboptimal) Stage III and Stage IV ovarian carcinoma, using doxorubicin (Adriamycin) and cyclophosphamide with or without cisplatin. There were 440 evaluable cases, of which 227 had measurable disease. One hundred twenty of these latter patients were treated with cyclophosphamide and doxorubicin (CA), while 107 received cyclophosphamide, doxorubicin and cisplatin (CAP). The clinical complete response (CR) rate for CA was 26% (31/120) compared with 51% (55/107) for CAP (P = less than 0.0001). Of 23 CRs receiving CA who had a second-look laparotomy, only four were negative; of 39 CRs receiving CAP and a second-look, 13 were negative (not statistically significant). The response duration for patients with measurable disease (median 14.6 versus 8.8 months), progression-free interval for all patients (13.1 versus 7.7 months), and survival for patients with measurable disease (19.7 versus 15.7 months) showed a statistically significant advantage for CAP; however, there was no difference in survival of patients with nonmeasurable disease. Toxicity was more severe with CAP but was tolerable. Thus, the addition of cisplatin improves the chemotherapy of advanced ovarian carcinoma.

Advanced epithelial ovarian cancer: toxicity of whole abdominal irradiation after operation, combination chemotherapy, and reoperation

Thirty-five patients with advanced ovarian cancer have received, as salvage therapy, irradiation consisting of 30 Gy to the entire abdominal contents with partial liver/kidney shielding and boosts to 42 and 51 Gy for the paraaortic/diaphragmatic and pelvic regions, respectively. These patients had received 6 to 25 cycles (median, 11 cycles) of prior combination chemotherapy (included cisplatin in 30), with "second-look" laparotomy performed in 33; 24 (68%) had three or more laparotomies. Acute gastrointestinal toxicity was generally mild. Significant hematologic toxicity (leukocytes less than 2000/mm3; or platelets less than 100,000/mm3) was seen in 19 (54%); platelet suppression occurred in 18 of these 19. Nine patients failed to complete the prescribed course of therapy; in seven, this was secondary to hematologic toxicity. Amount of prior chemotherapy and advanced age correlated with degree of hematologic toxicity. Five patients without evidence of disease (laparotomy confirmed) have developed treatment-related bowel obstruction. No other chronic toxicity of clinical significance has been observed. Seven patients have developed bowel obstruction associated with progressive neoplasm. Irradiation was well tolerated symptomatically, but hematologic toxicity associated with prior chemotherapy prevented its completion in 20% of patients. Clinical manifestations of radiation bowel toxicity have been moderate to date and should be interpreted in the context of the aggressive combined modality program.

Second-look laparotomy in managing epithelial ovarian carcinoma

Fifty-one patients treated for an epithelial ovarian carcinoma underwent a second-look operation (SLO) from August 1979 to December 1984. Previously, an initial laparotomy had been performed for staging and maximum cytoreductive surgery. This was followed by 6 to 12 courses of combination chemotherapy including cisplatin. Findings at SLO and outcome are discussed as regards extent of initial surgery, preoperative assessment and secondary debulking procedure. In this work, the findings at SLO were often predictable, and related to the adequacy of initial surgery and to a clinical complete response. Nevertheless, after incomplete initial cytoreductive surgery, SLO appears the best procedure to assess the status of the peritoneal cavity and the efficacy of chemotherapy. Negative SLO after incomplete initial surgery assessed a complete response rate of 34% induced by the cisplatin-based chemotherapy. Survival rate of patients with a negative SLO was 93% at 3 years, which demonstrated the highly significant value of SLO in prognosis. Conversely, patient survival with positive findings at SLO was very low, whatever resection can be made. As this work and similar studies by others showed that it could improve patient survival, an attempt should be made to a secondary debulk of residual tumor, and it seems interesting to perform further such secondary resections until definite conclusions can be drawn about this procedure.

Chemotherapy and Surgery in the Treatment of Ovarian Cancer Bulky Disease

Thirty-six patients with stage III-IV ovarian cancer, bulky disease, were treated with adriamycin and cyclophosphamide administered in two different dosages. Three or four cycles of chemotherapy were administered before the first surgery to facilitate the surgical debulking. After surgery, 6 additional cycles of chemotherapy were administered, and a second look was performed. Clinical CR+PR was observed in 19/30 (63%) evaluable patients after the first part of chemotherapy, but pathologic CR+PR was confirmed in only 13 (43%) patients. After the second part of chemotherapy and the second surgery, 5/30 (17%) patients had pathologic CR and 3/30 (10%) showed residual disease. The two regimens demonstrated similar activity (67% vs 56% clinical CR+PR) but a very different toxicity. In fact, 50% of patients treated with higher doses showed severe leukopenia and 25% severe thrombocytopenia, and 2/13 died of sepsis. The significant activity of adriamycin plus cyclophosphamide in ovarian cancer was confirmed, and increasing the dosage of the two drugs did not increase their activity but only their toxicity.

Carcinogenic effect of cisplatin (cis-diammine-dichloroplatinum (II), CDDP) in BD IX rats

The potent antitumor agent cis-diammine-dichloroplatinum(II) (CDDP) also has carcinogenic properties. CDDP was administered i.p. to 50 BD IX rats for 3 weeks, 3 X 1 mg/kg body weight per week. All animals were pretreated by hydration before each CDDP application, but only half the animals additionally received mannitol together with the CDDP solution, as a nephroprotective measure. To date, 455 days after the first application, 33 animals have died, 13 of them of malignancies: 12 leukemias and 1 renal fibrosarcoma. So far, no significant differences in the frequency and type of malignancies have been observed between animals which additionally received mannitol and the others which did not. In the control group of 25 animals, which received NaCl solution 0.9% i.p. (3 X 1 ml/kg per week, for 3 weeks) malignancies have not yet occurred. The high tumor incidence determined in this study reveals that the risk of secondary tumor development in patients treated with CDDP should not be disregarded.

Chemotherapy of advanced ovarian adenocarcinoma: a randomized comparison of combination versus sequential therapy using chlorambucil and cisplatin

Three hundred and sixty-nine patients with advanced ovarian adenocarcinoma were treated in a prospective randomized trial comparing combination versus sequential therapy with chlorambucil and cisplatin. Initial tumor response rates were similar but combination chemotherapy was associated with significantly prolonged time to first disease progression (median 28 weeks for chlorambucil and 42 weeks for combination chemotherapy). Second-line treatment with cisplatin in patients failing initial chlorambucil caused tumor response in 16.9%. Overall time to ultimate disease progression was similar between the treatment groups. The surgically documented complete response rate (second-look surgery at approximately equal to 12 months) and the survival was similar in the two treatment arms. Multivariate analysis of prognostic factors for survival in this trial showed that bulk of residual disease at time of starting therapy and the development of myelosuppression during therapy were the most important.

High-dose intracavitary cisplatin with intravenous thiosulfate. Low incidence of serious neurotoxicity

Recent published reports have suggested that cisplatin administered in high doses or in certain combination chemotherapy can cause serious neurotoxicity in a large percentage of patients treated. In several high-dose cisplatin-based intracavitary chemotherapy trials with the simultaneous intravenous administration of sodium thiosulfate, the incidence of clinically relevant neurotoxicity has been extremely low. In addition, several patients with serious preexisting cisplatin-induced neurologic dysfunction were treated without worsening of their clinical condition. It is suggested that thiosulfate might have been responsible for the low incidence of neurotoxicity in this patient population. Further experimental and clinical investigation of the potential of this agent to protect against cisplatin-induced neuropathy appears warranted.

Hexamethylmelamine, methotrexate and 5-fluorouracil (HMF) for progressive ovarian carcinoma during therapy with cis-platinum, cyclophosphamide +/- doxorubicin

Hexamethylmelamine, methotrexate, and 5-fluorouracil (HMF) is a second-line chemotherapy for patients with ovarian carcinoma refractory to platinum-based regimens. Two of 15 patients with tumor progression treated with HMF alone had objective complete responses while one had a 12-month disease-free interval (DFI). Among 8 patients treated with HMF and either intraperitoneal chromic phosphate and/or alternating platinum-based chemotherapy following second-look surgery which documented persistent carcinoma, 3 have experienced disease-free intervals of 19, 27, and 42 months. However, no one has been cured or had a long-term remission after HMF therapy alone.

Recurrent ovarian carcinoma: retreatment utilizing combination chemotherapy including cis-diamminedichloroplatinum in patients previously responding to this agent

Eleven women with advanced ovarian cancer treated postoperatively with combination chemotherapy (cytoxan, hexamethylmelamine, Adriamycin, and cis-platinum) had disease-free intervals of 5 to 46 months (mean: 22 months) and subsequently developed recurrent carcinoma. Each patient was then retreated with combination chemotherapy which included cis-platinum. There was a 72% response rate to retreatment (36% complete, 36% partial). These overall and complete remission rates are comparable to those of platinum-based combination chemotherapy in patients without prior treatment. Those patients who responded to retreatment had a significantly longer mean survival rate than those who did not.

Individual chemosensitivity of in vitro proliferating mammary and ovarian carcinoma cells in comparison to clinical results of chemotherapy

Cell lines established from advanced mammary and ovarian carcinomas were assayed for the inhibition of in vitro proliferation by various antineoplastic drugs. The assays were performed with multiple experimental cultures derived from stock cultures of the tumor cell lines in early passages of the cultivation. As determined by comparison of the 50% inhibition of in vitro growth, differential sensitivity of the individual cell lines was observed. Based on the 2-h plasma level of the drugs as discriminatory threshold between resistance and sensitivity, the in vitro effectiveness of each drug on the individual cell lines was compared with the clinical results of chemotherapy applied to the corresponding patients. In total, positive in vitro/in vivo correlations were observed in 39 of 42 cases. The 17 cell lines evaluated retrospectively were resistant to those drugs which had been tried unsuccessfully during chemotherapy. Among the 25 cases tried prospectively 11 cases showed sensitivity in vitro and in vivo, and furthermore 11 prospective cases were resistant in vitro and in vivo.

Advanced ovarian carcinoma. Factors influencing survival

One hundred ten patients with advanced ovarian carcinoma (Stages IIIA, IIIB, and IV) were evaluated for survival. They received as first treatment one of the following regimens: melphalan (L-PAM) (41 patients), cyclophosphamide plus methotrexate plus 5-fluorouracil (CMF) (16 patients), cyclophosphamide plus doxorubicin plus 5-fluorouracil (CAF) (17 patients), cyclophosphamide plus doxorubicin plus hexamethylmelamine plus cisplatin (CHAD) (13 patients, thiotepa plus methotrexate (TM) with fixed rotation with CAF (TM/CAF) (17 patients), and 6 patients received other chemotherapy as first treatment. There was no significant difference in survival time with the various treatment arms despite differences in response rates. Patients with Stage IIIA had significantly longer survival than those with Stages IIIB and IV (P less than 0.01). Patients with good performance status (PS 0) had significantly better survival than those with poor performance status (PS 3-4) (P less than 0.02). At this time the improved response rates on combination chemotherapy has not given improved survival rates, and disease stage and performance status remain of prime importance in survival prediction.

Ovarian carcinoma. A decade of progress

Significant and dramatic progress has been made in the diagnosis and treatment of women with ovarian carcinoma in the last 10 years, the results of which are now just being reflected in an increase in survival and cure rates. In early staged disease (Stage I and II) significant progress has been made concerning our understanding of the sites of subclinical metastasis when at surgery the tumor is clinically limited to the ovary or pelvis. A prospective study of 100 patients with Stages IA to IIB ovarian cancer who underwent restaging within 4 weeks of initial surgery will report this. Moreover, preliminary results of the first randomized therapeutic trials (melphalan versus observation; melphalan versus chromic phosphate [P-32]) in patients surgically staged and found to be Stage IA to IIB carcinoma will be discussed. For Stages IB to III, the 5-year survival rates comparing whole abdominal radiation by the moving strip technique to open field irradiation will be discussed. For advanced (Stage III and IV) ovarian carcinoma, the new techniques in debulking surgery will be illustrated. Finally, the significant progress in response rates, median duration of survival, disease-free survival, and 5-year survival rates made during the past 10 years will be presented. This will be done by comparing a unique group of 117 patients treated with melphalan alone, all of whom have been followed for 5 years or until death, to patients who received cisplatin combination chemotherapy--cyclophosphamide, hexamethylmelamine, Adriamycin (doxorubicin), and cisplatin (CHAD) or cisplatin, Adriamycin, and cyclophosphamide (PAC)--and have now been followed 3.4+ and 4+ years, respectively. What is clearly evident is that in the last decade there has been significant increase in response rates, median duration of survival, 3.4+-, 4+-, and 5-year survival rates and cure rates with the advent of debulking surgery and platinum-containing combination chemotherapy.

"Second-effort" surgical resection for bulky ovarian cancer

Eighteen women with bulky ovarian cancer at the start of chemotherapy were brought to second laparotomy after 6 months of combination chemotherapy in an effort to resect previously unresectable tumor masses. Only one of 18 had significant resection of bulk tumor such that no gross tumor was remaining, although 8 of 15 had the residual uterus removed and 6 of 10 had resection of residual ovary or ovaries. Failure to resect tumor was due to absence of any gross tumor (33%), presence of myriad small seedlings not amenable to resection (22%), or massive residual tumor (18%). Partial resection was accomplished in 22%, but all relapsed promptly in spite of continued aggressive therapy with drugs and whole abdominal irradiation. It is concluded that 6-month "second-effort" surgical resection is unlikely to benefit many women with bulky ovarian cancer, and that surgical resection must be attempted early in the course of the disease if it is to be effective.

Long-term survival after chemotherapy for advanced epithelial ovarian carcinoma

Four hundred twenty-nine patients were entered into four prospective randomized clinical studies between January 1, 1973, and July 1, 1979. The records of 395 of these were analyzed to determine the proportion of patients surviving 48 months after therapy initiation. Ninety-six patients (24%) were living at 48 months, 89 of whom had second-look laparotomies. Of the 96 living patients, 53 (55%) were clinically free of disease and 43 (45%) had disease. Combination-agent chemotherapy produced a larger proportion of 48-month survivors than single-agent therapy (P = 0.001); 70% of these survivors were clinically free of disease. Patient characteristics, such as age, International Federation of Gynaecology and Obstetrics (FIGO) stage, histologic grade of tumor, and amount of residual tumor present prior to chemotherapy exerted a strong influence on length of survival. Long-term survival was not totally dependent on a complete response to chemotherapy; in fact, persistent treatment with drug regimens induced bone marrow disorders and death due to toxicity in five patients. The continued fall in survival curves after 48 months suggests that current therapy regimens are not dramatically changing long-term survival rates.

Effective high-dose chemotherapy with autologous bone marrow infusion in resistant ovarian cancer

Two patients with persistent minimal ovarian cancer after conventional polychemotherapy were treated with high doses of cyclophosphamide and VP 16-213 followed by autologous bone marrow infusion. Ten months afterward no clinical signs of tumor were apparent. In one patient the complete response was surgically documented. Toxicity included cardiac and pulmonary arrest during marrow infusion in one patient, but was otherwise manageable. This method of late intensification of chemotherapy in patients with persisting ovarian cancer merits further investigation.