Gemcitabine reverses cisplatin resistance: demonstration of activity in platinum- and multidrug-resistant ovarian and peritoneal carcinoma

Heavily pretreated ovarian cancer patients treated by single-agent gemcitabine. A retrospective outcome comparison between platinum-sensitive and platinum-resistant patients

To assess activity and toxicity of gemcitabine treatment in heavily pretreated epithelial ovarian cancer (EOC) patients and compare the outcome between platinum-sensitive and platinum-resistant patients. We conducted a retrospective analysis of 43 women with EOC treated with gemcitabine on Days 1, 8 and 15 every 28 days. Response was evaluated by physical examination and serial CA 125 measurements. The patients (median age 62 years, range 29-87) were previously exposed to a median of 3 (2-8) chemotherapy regimens. A median of 3.5 (1-14) gemcitabine cycles were administered. Eleven (25.6%) patients showed partial response, 19 (44.2%) had stable disease and 13 (30.2%) progressed. Among 22 platinum-sensitive and 21 platinum-resistant patients, the response rate was 45.5% and 4.7% respectively (p = 0.001), and the median time to progression was 5.0 and 2.8 months, respectively (p = 0.0006). The respective median survival was 16.5 and 6.3 months (p = 0.0001). Grade III-IV hematological toxicities included anemia in four (9.3%) patients, thrombocytopenia in four (9.3%) and leucopenia in two (4.7%). The main non-hematological toxicities were grade III fatigue in two patients (4.7%) and nausea and vomiting in two (4.7%). Single agent gemcitabine is an attractive option for heavily pretreated EOC patients. The significant difference between platinum-sensitive and resistant patients' warrants further investigation.

Cisplatin plus gemcitabine in platinum-refractory ovarian or primary peritoneal cancer: A Phase II Study of the Gynecologic Oncology Group

OBJECTIVES

To evaluate the safety and efficacy of cisplatin plus gemcitabine in persistent or recurrent platinum-resistant ovarian and primary peritoneal cancer.

STUDY DESIGN

Eligible, consenting subjects with measurable disease and one prior platinum-based regimen, but no prior gemcitabine, were to receive intravenous cisplatin followed by gemcitabine on days 1 and 8 every 28 days.

RESULTS

Between December 2000 and March 2003, 59 patients were enrolled from 24 institutions; two were ineligible. During the first stage of accrual, 27 subjects received cisplatin 30 mg/m2 and gemcitabine 750 mg/m2. In the second stage, gemcitabine was reduced to 600 mg/m2 because of hematologic toxicity at the higher dose. There were 4 complete and 5 partial responses for an overall response rate of 16% (9/57). Thirty-one women (54%) had stable disease. Median time to progression was 5.4 months. Overall survival was 14.9+ months. Grade 4 toxicities were hematologic, except one cutaneous reaction.

CONCLUSIONS

Cisplatin plus gemcitabine, in the doses and schedule employed, has modest activity in this patient population.

Determination of the mechanism of gemcitabine modulation of cisplatin drug resistance in panel of human endometrial cancer cell lines

OBJECTIVES

The primary objective of this study was to determine the mechanism(s) of cisplatin drug resistance in endometrial cancer cell lines. To evaluate the mechanism that gemcitabine modulates cisplatin drug resistance in endometrial cancer cell lines.

METHODS

Combination treatment was completed in panel of four human endometrial cancer cell lines. Growth inhibition assays were conducted in each cell line evaluating combinations of the Ic25, Ic50, and Ic90 to determine optimal dosing for the combination of gemcitabine plus cisplatin. Evaluation of the correlative biological targets for modulation of platinum drug resistance was completed by the respective immunohistochemistry assays.

RESULTS

Downregulation of glutathione-S-transferase (GST) activity by 11% to 100% was observed with an associated 78.6% to 100% decrease in intracellular glutathione (GSH) concentrations. In the gemcitabine plus cisplatin treatment arm compared to either alone, there was also downregulation of MSH2, p53, and ERCC1 expression. No changes observed in the pro-apoptotic proteins, BAX or BAD, expression, AKT activation, or MDR1/PGP expression regardless of treatment with combination of gemcitabine plus cisplatin or either agent alone.

CONCLUSIONS

There is likely more than one mechanism contributing to the increase synergistic in vitro platinum-resistant cell lines and increase clinical activity that has been observed in patients with platinum-resistant tumors. In this in vitro study, we determined the downregulation of intracellular GST activity and GSH concentration were the predominant mechanisms involved in the modulation of platinum resistance. Downregulation of MSH2, p53 and ERCC1 expression may also contribute to increase cytotoxic activity compared to cisplatin alone.

Role of chemotherapy for patients with recurrent platinum-resistant advanced epithelial ovarian cancer: A cost-effectiveness analysis

BACKGROUND

Current chemotherapy in platinum-resistant ovarian cancer patients has demonstrated minimal to no improvements in survival. Despite the lack of benefit, significant resources are utilized with such therapies. Therefore, the objective in the current study was to assess the cost-effectiveness of salvage chemotherapy for patients with platinum-resistant epithelial ovarian cancer (EOC).

METHODS

A decision analysis model evaluated a hypothetical cohort of 4000 platinum-resistant patients with recurrent EOC. Several chemotherapy strategies were analyzed: 1) best supportive care (BSC); 2) second-line chemotherapy-monotherapy; 3) second-line chemotherapy-combination therapy; 4) third-line chemotherapy after disease progression on second-line monotherapy; and 5) third-line chemotherapy after disease progression on second-line combination therapy. Sensitivity analyses were performed on all pertinent uncertainties.

RESULTS

Using costs alone, BSC was the only definitive cost-effective treatment for platinum-resistant recurrent ovarian cancer patients, and second-line monotherapy was a reasonable cost-effective strategy with an incremental cost-effectiveness ratio (ICER) of 64,104 dollars. The cost-effectiveness ranged from 4,065 dollars per month of overall survival (OS) for BSC to 12,927 dollars for third-line previous combination therapy. Compared with BSC, second-line monotherapy gained an additional 3 months of OS, with a cost-effectiveness of 4,703 dollars per month of OS. Second-line combination therapy and third-line therapies exhibited unfavorable ICER.

CONCLUSIONS

The current decision analysis was intended to be thought-provoking and bring awareness to the high costs of subsequent chemotherapy with limited effectiveness in patients with recurrent platinum-resistant EOC. Although actual patients may receive multiple lines of chemotherapy, from the perspective of costs alone this model using a hypothetical cohort demonstrated that best supportive care was the only cost-effective strategy, with second-line monotherapy appearing to be a reasonable cost-effective strategy given current chemotherapeutic options.

Optimizing gemcitabine regimens in ovarian cancer

Ovarian cancer represents the leading cause of death from gynecologic neoplasms. The chance of response to secondary treatment is currently disappointing; few agents have shown notable activity in recurrent/progressive patients. Among these agents, gemcitabine represents one of the most interesting newer antineoplastic agents, showing significant activity, synergism with cisplatin, and a mild toxicity profile in both platinum-sensitive and platinum-resistant (and also taxane-pretreated) recurrent/progressive patients. Moreover, first-line combination chemotherapy including gemcitabine has shown promising response rates in phase I and II studies. The ongoing phase III, five-arm, randomized Gynecologic Oncology Group Protocol 182/International Collaborative Ovarian Neoplasm 5 study should clarify the clinical impact of the addition of a third drug to the standard paclitaxel plus carboplatin treatment regimen.

Rational drug sequencing of paclitaxel, gemcitabine and carboplatin in patients with untreated stage IV and select stage IIIB non-small cell lung cancer

INTRODUCTION

To conduct a phase II study evaluating the efficacy of rationally sequenced paclitaxel, gemcitabine, and carboplatin in patients with stage IV or select stage IIIB non-small cell lung cancer (NSCLC).

METHODS

Patients with select stages IIIB (pleural effusion) and IV NSCLC with an ECOG performance status of 0-1 and no prior chemotherapy for their disease were eligible to participate. Treatment was delivered as follows: paclitaxel at 70 mg/m2 followed by gemcitabine at 300 mg/m2 on day 1, with carboplatin (AUC 5) on day 2 of a 28-day cycle. Response was assessed after every two cycles of therapy. The primary endpoint of this trial was response rate, with secondary endpoints of time to progression and 1 year overall survival.

RESULTS

Twenty patients were enrolled on protocol, one of whom never received chemotherapy. The median number of cycles delivered was 3 (range 0-8). A partial response rate of 42% (8/19; 95% CI: 20-67%) and a stable disease rate of 11% (2/19; 95% CI: 1-33%) were observed. The median overall survival time was 9.6 months (95% CI: 4.6-16.6), with a 1 year overall survival rate of 42.1% (95% CI: 24.9-71.3%). Eight patients (42%) stopped treatment due to toxicity.

CONCLUSION

Paclitaxel followed by gemcitabine and then carboplatin is an active, albeit complex, regimen in the treatment of patients with advanced NSCLC with insufficient advantage to justify continuation of this regimen.

Study of the effect of standardized chemotherapy order forms on prescribing errors and anti-emetic cost

OBJECTIVES

Many anti-neoplastic medication errors and excessive use of serotonin antagonist anti-emetic agents might be prevented by the use of a standardized chemotherapy order form (SCOF). Several studies showing a reduction in prescribing errors or control of inappropriate anti-emetic use through the use of SCOFs have been reported. No previously published study reported SCOFs were used to reduce both prescribing errors and anti-emetic cost. This study attempts to measure these outcomes in a haematology-oncology pharmacy service.

METHODS

The study consisted of a four-month control period, followed by a four-month test period following dissemination of the standardized order forms. In each period, prescriber errors and anti-emetic use were monitored. During the control period, using clinical studies from the primary literature and anti-emetic guidelines, 64 SCOFs representing the most commonly used chemotherapy regimens in the medical oncology and gynaecology oncology services were developed by the haematology-oncology pharmacy. Differences in prescribing error rate and anti-emetic cost were compared between each period and with the institution's historic prescribing error rate.

RESULTS

During the control period, 1078 orders for oral and parenteral granisetron and ondansetron with combined total acquisition cost of $76 454.64 and a mean cost of $70.92 were dispensed. During the test period, the pharmacy dispensed 1121 orders with an acquisition cost of $73 331.61 and a mean cost of $65.42. A savings of $3123.03 resulted from a reduction of the amount prescribed in the test period. The difference in mean cost per order between the two periods was significant (P <0.037). Fifty-three prescribing errors out of 3592 medication orders were detected in the control period, while 12 errors out of 3585 medication orders were detected during the test period. A significant difference(P <0.0001) was detected between the two periods. There was a significant difference (P <0.0001) between the control period and the institution's historic prescribing error rate and no difference between the test period and the institution's historic prescribing error rate.

CONCLUSION

SCOFs significantly reduced serotonin antagonist anti-emetic cost and prescribing error rate over a four-month period.

Cisplatin plus gemcitabine in previously treated squamous cell carcinoma of the cervix: A phase II study of the Gynecologic Oncology Group

OBJECTIVES

This trial was conducted to evaluate the safety and efficacy of cisplatin plus gemcitabine in previously treated squamous cell carcinoma of the cervix.

SUBJECTS AND METHODS

All women had measurable histologically confirmed squamous cell cervical cancer and a GOG performance status less than or equal to 2. The women were to receive cisplatin at 30 mg/m(2) plus gemcitabine at 800 mg/m(2) day 1 and day 8 every 28 days.

RESULTS

Between February 2001 and May 2002, 32 eligible patients were entered. All women had received prior chemotherapy and 29 had received radiation. Twenty patients received platinum previously twice. The median time from primary treatment to recurrence was 21 months, but the median time from last prior chemotherapy was less than 2 months. A second phase of accrual was not indicated per the established stopping rules. There were 7 (21.9%) partial responses and median response duration was 2.1 months. Twelve additional women (37.5%) had stable disease. Nine women (28.1%) had increasing disease. Median time to progression was 3.5 months. There were no treatment-related deaths. Six women had grade 4 neutropenia, three had grade 4 anemia, and two had grade 4 thrombocytopenia. Grade 4 gastrointestinal toxicity occurred in two women and grade 4 anorexia occurred in one.

CONCLUSIONS

This study suggests modest activity for the gemcitabine plus cisplatin doublet in previously treated squamous cell carcinoma of the cervix. The objective response rate of 22% is comparable to that of other active agents and combinations tested in this setting. Toxicities were primarily hematologic and generally manageable with dose reductions.

Ovarian Cancer Care: A Case Study in Determined Living

BACKGROUND

The balance between quality of life and aggressive treatment fuels strong debate in cancer care. Recently, more attention is focused on blending advanced care, palliative care and hospice treatments in a patient-specific, tailored manner. This case study explores quality of life, the role of psychosocial factors in treatment selection, and the role of medical bias in end-of-life decision-making.

CASE REPORT

The patient was a 55-year-old woman with advanced recurrent epithelial ovarian cancer. The disease course was essentially unremitting with only 5 months of non-progression after initial treatment. Multiple courses of chemotherapy were provided, in addition to a wide range of advanced and aggressive therapies to treat the cancer, as well as prolong life. Hospice care was an active part of treatment over 2 separate time periods, with a 1-year hiatus between admissions into hospice care.

CONCLUSION

This case study provides an example of blending aggressive treatment, palliative care and hospice care to allow a patient to achieve specific life milestones, while attempting to preserve quality of life.

Gynecologic oncology group trials of chemotherapy for metastatic and recurrent cervical cancer

Because only 16% of patients with metastatic cervical cancer are alive 5 years after diagnosis, the Gynecologic Oncology Group (GOG) has carefully designed and conducted many phase II studies to identify promising drugs. Cisplatin has emerged as the most active single agent with overall response rates of 19%. Recent phase III trials have documented response rates of 27% and 39% when cisplatin has been combined with either paclitaxel or topotecan, respectively. The comparison of cisplatin to cisplatin plus topotecan in GOG-179 has yielded the first study to show a statistically significant impact on the overall response rate, median progression-free survival, and median survival, with all outcome measures favoring the two-drug regimen. Despite these encouraging results, however, most of the responses are partial and of short duration. The need for novel combinations and the implementation of active biologic agents is implicit. The accumulated data in this disease setting, as evidenced by the experience of the GOG, are presented in this review.

Phase II study of gemcitabine and cisplatin in locally advanced/metastatic oesophageal cancer

Palliative chemotherapy for inoperable/metastatic oesophageal cancer has limited activity. This study assesses the feasibility and activity of gemcitabine and cisplatin in this group of patients. In total, 42 patients with locally advanced/metastatic squamous or adenocarcinoma of the oesophagus were treated with gemcitabine 1250 mg m⁻² days 1 and 8 and cisplatin 75 mg m⁻² day 1 in a 21-day cycle. Interim safety analysis was carried out after the first 19 patients suggested significant toxicity. The dose of gemcitabine was subsequently reduced to 1000 mg m⁻². Patients were assessed for toxicity and response. The median number of treatment cycles per patient was 4 (range 1–6). Grade 3–4 neutropenia occurred in 37% of cycles; however, there was only one episode of neutropenic fever. Nonhaematological toxicities included fatigue, nausea and vomiting. Among 32 patients eligible for response, there were three complete responses and 16 partial responses (overall response rate of 45%); nine patients had stable disease. Median survival was 11 months. The response rate appears to be greatest in those with squamous carcinoma compared to adenocarcinoma (71 vs 33%, P=0.036). The combination of gemcitabine and cisplatin in this schedule has manageable toxicity and significant activity in patients with locally advanced/metastatic oesophageal cancer and is worthy of further study.

Gemcitabine in epithelial ovarian cancer treatment: current role and future perspectives

Newer agents and combinations are needed in order to improve current results in ovarian cancer treatment. Gemcitabine is a novel agent that has shown consistent activity as a single agent in the treatment of platinum-resistant ovarian cancer and a favorable toxicity profile. Because of its clinical and preclinical synergism with platinum analogs, gemcitabine has been combined with carboplatin as a convincing approach in the treatment of platinum-sensitive recurrent ovarian cancer patients. Further combination of gemcitabine and other agents, including paclitaxel, is also feasible and has been actively studied in order to establish the role of gemcitabine in the management of treated and untreated ovarian cancer patients.

Gemcitabine, cisplatin and methylprednisolone (GEM-P) is an effective salvage regimen in patients with relapsed and refractory lymphoma

There is currently no standard salvage chemotherapy regimen in relapsed and refractory lymphoma. Gemcitabine is a novel nucleoside analogue, which acts synergistically with cisplatin both in vitro and in clinical studies. We evaluated the combination of gemcitabine, cisplatin and methylprednisolone (GEM-P) in 41 heavily pretreated patients with relapsed and refractory Hodgkin's and non-Hodgkin's lymphoma. The best-achieved response rate (RR) was 79% (95% CI 64-91), with a complete RR of 21%. In patients with chemo-resistant disease, the RR was 63%. Myelosuppression was the main toxicity, the incidence of Grade 3 or 4 anaemia, neutropenia and thrombocytopenia was 17.1, 61.0 and 53.7% respectively. Only one patient had neutropenic sepsis and none of the patients suffered from haemorrhage. Grade 3 or 4 nonhaematological toxicity was minimal and stem cell mobilisation was not inhibited. GEM-P is an effective salvage regimen and its use prior to autologous stem cell transplant warrants further investigation.

Gemcitabine reverses platinum resistance in platinum-resistant ovarian and peritoneal carcinoma

Platinum compounds are the key components of chemotherapy for ovarian cancer. Preclinical models in an ovarian cancer cell line (A2780) have demonstrated synergistic activity when gemcitabine is added to cisplatin compared with either single agent alone. Furthermore, the combination leads to increased platinum-adduct retention as a result of decreased DNA repair compared with cisplatin alone. Inhibition of specific exonucleases, such as excision repair cross-complementation group 1 (ERCC1), is integral to the platinum-gemcitabine synergy. In platinum-sensitive recurrent ovarian cancer patients (defined as those patients whose cancer recurs after > 6 months following primary therapy), platinum and gemcitabine have demonstrated an improvement in progression-free survival compared with platinum alone. This is also true for the patients who are only moderately platinum sensitive (defined as those patients who have cancer recurring 6-12 months after primary therapy). Increasing numbers of phase II experiences have demonstrated the activity of the platinum-gemcitabine combination in patients defined as platinum resistant (those with disease progression on therapy or whose disease recurs within 6 months of a platinum-based regimen).

Recent updates in the clinical use of platinum compounds for the treatment of gynecologic cancers

Platinum compounds have long played a role in the treatment of gynecologic cancers. Single-agent cisplatin and carboplatin have shown activity in endometrial cancer, and more recent studies have begun to investigate a variety of new platinum-based combinations. In cervical cancer, chemotherapy is used primarily to treat advanced or recurrent disease. Agents with proven single-agent activity in this setting include cisplatin, ifosfamide, and doxorubicin, and a number of cisplatin-based combination therapies are under clinical investigation. A variety of cisplatin-based combinations have also been used in ovarian cancer chemotherapy, with more recent studies investigating the substitution of carboplatin or oxaliplatin for cisplatin and the addition of paclitaxel. This review will examine recent clinical data on the use of platinum-based chemotherapies for the treatment of these gynecologic cancers.

A phase II study of gemcitabine plus carboplatin in platinum-sensitive, recurrent ovarian carcinoma

OBJECTIVES

Gemcitabine and carboplatin each have demonstrated effectiveness without increased neurotoxicity in pretreated patients with ovarian cancer. We evaluated the efficacy and safety of gemcitabine plus carboplatin in patients with recurrent ovarian cancer in a multicenter phase II study.

METHODS

Women with histologically proven measurable or evaluable epithelial ovarian cancer (any FIGO) who relapsed > or =6 months after discontinuation of first-line, platinum-containing therapy received gemcitabine 1000 mg/m(2) on days 1 and 8 and carboplatin AUC 4 on day 1 (after gemcitabine) every 21 days for up to six cycles.

RESULTS

Of the 40 enrolled/evaluable patients, 6 (15%) had complete response and 19 (47.5%) had partial response (PR), including one patient with PR in nonmeasurable disease (PRNM), for an overall response rate of 62.5% (95% CI, 45.8-77.3%). The median duration of response was 7.8 months (95% CI, 6.7-10.0), the median time to progressive disease was 9.6 months (95% CI, 8.5-11.0), and the median time to treatment failure was 9.3 months (95% CI, 8.2-10.4). The main grade 3/4 toxicities were neutropenia (78% of patients), leukopenia (30%), thrombocytopenia (18%), and anemia (15%); no grade 4 nonhematologic toxicities occurred, and grade 3 nonhematologic toxicities were mild.

CONCLUSIONS

The combination of gemcitabine and carboplatin is active and feasible in platinum-sensitive patients with recurrent ovarian cancer. This regimen is undergoing further evaluation in a large phase III trial.

Evaluation of gemcitabine in previously treated patients with non-squamous cell carcinoma of the cervix: a phase II study of the Gynecologic Oncology Group

PURPOSE

A multicenter study was conducted to evaluate the activity and toxicity of gemcitabine in patients with previously treated non-squamous cell carcinoma of the uterine cervix.

PATIENTS AND METHODS

Eligible patients were required to have measurable disease with a GOG performance status of 0-2 and adequate bone marrow, renal, and hepatic function. Histologic confirmation of the primary diagnosis was mandatory. Patients were required to have received one prior chemotherapy regimen for metastatic, persistent or recurrent disease. The initial dosage of gemcitabine was 800 mg/m(2) weekly times three with 1 week off until progressive disease or adverse side effects prohibited further therapy. Doses were escalated or reduced based on the disease toxicity experiences during the previous cycle.

RESULTS

Twenty-two women were entered into the trial. Three patients did not complete follow-up assessment for tumor response leaving 19 evaluable patients for response. All 22 patients were evaluable for toxicity. A median of two cycles was administered to each patient (range: 1-8). The overall response rate (1 partial response) was 4.5% with 36.4% of patients having stable disease. The median progression-free interval was 2.1 months (range: 0.5-12.7) and the overall survival was 6.5 months (range: 0.6-21.9). One patient had a grade 4 gastrointestinal adverse event (rectovaginal fistula formation attributed to the underlying cancer and not the study agent) complicated by grade 4 metabolic derangement. There were no grade 4 hematologic toxicities or treatment-related deaths.

CONCLUSIONS

Gemcitabine as a single agent had minimal activity in previously treated patients with non-squamous cell carcinoma of the uterine cervix.

Response of combination platinum and gemcitabine chemotherapy for recurrent epithelial ovarian carcinoma

OBJECTIVE

It has been postulated that gemcitabine inhibits DNA repair, and platinum resistance is due to increased DNA repair activity. The addition of gemcitabine to platinum-based agents may have synergistic tumoricidal activity.

METHODS

Retrospective chart review of all patients with recurrent, persistent, or progressive fallopian tube or ovarian carcinoma treated with a platinum-based compound and gemcitabine from 2001 to present was performed.

RESULTS

Twenty-nine patients on second to eight line chemotherapy met inclusion criteria. The median age was 53 years. Twenty-two patients received cisplatin and gemcitabine, and 7 patients received carboplatin and gemcitabine based on results of chemoresistance assays or prior chemorelated toxicities. The intent to treat was with six cycles of gemcitabine (1000 mg/m(2)) and either cisplatin (75 mg/m(2)) or carboplatin (AUC 5) day 1 and gemcitabine only on day 8 of a 21-day cycle. The median number of cycles administered was six. There were 20 grade 3 and 4 toxicities and 63% of patients by cycle 6 needed erythropoietin marrow support and 19% needed GCSF support by cycle 4. Twenty-one patients required discontinuation of day 8 that most commonly occurred at cycle 4. Eleven (38%) had CR, 5 (17%) had PR, 6 (21%) had SD, and 7 (24%) had PD, which is a 55% overall response. Nineteen of 29 patients (66%) showed platinum resistance to initial therapy. Of those, four (21%) had CR, four (21%) had PR, six (32%) had SD, and five (26%) with PD, which demonstrates a 42% overall response rate for this particular subset of patients.

CONCLUSIONS

Adjuvant combination platinum-based agent with gemcitabine is a very effective and well-tolerated treatment for recurrent fallopian tube or ovarian carcinoma; even in those who exhibit initial platinum resistance.

Brain metastases of epithelial ovarian carcinoma responding to cisplatin and gemcitabine combination chemotherapy: a case report and review of the literature

BACKGROUND

Brain represents a rare site of metastasis in patients with epithelial ovarian carcinoma (EOC).

CASE REPORT

We observed a case of multiple brain metastases in an EOC patient after complete response of a pelvic recurrence to platinum/paclitaxel chemotherapy. Complete response of brain metastases was observed after whole brain radiotherapy and subsequent chemotherapy by combination of cisplatin and gemcitabine. Three subsequent recurrences of brain metastases were controlled by re-treatment by the combination of 5-fluorouracil, cisplatin and gemcitabine.

METHODS

Because of limited information on the outcome of EOC brain metastases in reported case series, a pooled analysis of the published reports in patients with EOC brain metastases was performed. Data were extracted from 46 reports that contained sufficient details on 189 individual patients. The survival was analyzed by the Kaplan-Meier method. Univariate and multivariate analyses were performed by the log-rank test and Cox method, respectively.

RESULTS

The most favorable outcome was observed in patients treated by surgery combined with radiotherapy and/or chemotherapy. The survival was significantly better in reports describing only one or two cases, in patients diagnosed after 1992, in patients who received therapy in addition to symptomatic treatment, in patients treated by radiotherapy, chemotherapy and surgery, in patients without extracranial metastases and with single brain metastases. On multivariate analysis, the absence of extracranial metastases, treatment by chemotherapy, surgery and radiotherapy were independent positive predictors of survival.

CONCLUSIONS

EOC brain metastases are responsive to chemotherapy. An aggressive multidisciplinary therapeutic approach including chemotherapy may lead to prolonged survival.

Triplet combination of gemcitabine, carboplatin, and paclitaxel in previously treated, relapsed ovarian and peritoneal carcinoma: an experience in Taiwan

OBJECTIVE

The aim of this phase II study was to evaluate the efficacy and toxicity of gemcitabine, carboplatin, and paclitaxel (GCP) combination as salvage therapy in patients with relapsed ovarian or peritoneal cancer who had previously received platinum-based chemotherapy.

PATIENTS AND METHODS

Patients with progressive ovarian or peritoneal carcinoma who had previously received platinum-based chemotherapy were enrolled. Gemcitabine was administered at 800 mg/m(2) as a 30-min intravenous infusion on days 1 and 8; carboplatin (AUC of 5) and paclitaxel (175 mg/m(2)) were administered as 60-min and 3-h intravenous infusions, respectively, on day 1. Treatment cycles were repeated every 3 weeks for a maximum of nine cycles.

RESULTS

Twenty patients (ovarian carcinoma, 19; peritoneal carcinoma, 1) received this triplet regimen as salvage therapy. All the patients had previously received at least one platinum-based regimen for chemotherapy and 17 of them had received platinum plus paclitaxel. The median number of previous regimens was 2 (range, 1-4), and the median platinum-free interval was 9 months (range, 1-18). A total of 130 cycles were administered with a median of six cycles per patient (range, 3-9). The overall response rate was 75%, including 12 complete responses (60%; 95% confidence interval [CI], 36.1-80.9) and three partial responses (15%; 95% CI, 3.2-37.9). The other five patients showed stable disease (25%; 95% CI, 8.7-49.1). The median duration of the progression-free survival was 6.5 months (range, 3-20). Myelosuppression was the main toxicity, with leukopenia being the most prominent (grade 3/4 toxicity in 35% patients), followed by thrombocytopenia in 20% patients. In addition, 35% patients had grade 3 anemia. All the toxicities were manageable and the patients recovered fully. Among non-hematological toxicities, the only notable one was grades 2 and 3 hepatic toxicity seen in two and one patients, respectively, necessitating a decrease in the paclitaxel dose in two patients.

CONCLUSIONS

GCP combination is an effective salvage chemotherapy in patients with heavily pretreated and relapsed ovarian and peritoneal cancer. The significant side effects of myelosuppression and hepatic toxicity were of moderate severity and manageable.

The role of topotecan for extending the platinum-free interval in recurrent ovarian cancer: an in vitro model

OBJECTIVE

Topotecan, a novel topoisomerase-I inhibitor, is an active agent of second-line chemotherapy for extending the platinum-free interval (PFI) and improving the chances of a response to platinum in recurrent ovarian cancer patients. The aim of this study was to understand the molecular mechanism of topotecan-based second-line chemotherapy through an in vitro cell culture model and to gain clinical insight into sequencing issues for second-line treatment with novel agents versus retreatment with platinum.

STUDY DESIGN

The human ovarian cancer cell line A2780 and the cisplatin resistance cell line A2780-CR were separately seeded in 6-well cell culture plates and then exposed to multiple concentrations of cisplatin plus paclitaxel or topotecan for 7 days. Surviving cells were recovered and cultured in drug-free media for 3 weeks and then replated in a 96-well microtiter plate. The LD(50) for these cells was determined by a cytotoxic MTT assay after exposure to multiple clinically relevant concentrations of cisplatin or topotecan. Surviving cells were cultured in drug-free media for an additional 4 weeks at which time the LD(50) was reassessed for each cell population by a second MTT assay. Using RT-PCR and Northern blot hybridization to measure mRNA expression, the molecular profile of these cells in terms of resistance was evaluated for the multidrug-resistant gene (MDR-1), multidrug-resistant protein (MRP), Topoisomerase-I, and beta-Actin.

RESULTS

The LD(50) to cisplatin was unchanged in A2780-CR cells treated by topotecan. Those A2780-CR cells originally exposed to higher concentrations of cisplatin became more resistant to cisplatin in the MTT assays, while those A2780-CR cell lines treated with a combination of lower cisplatin concentrations and paclitaxel became more sensitive to cisplatin in the MTT assay (P < 0.01). The second MTT assay demonstrated that the LD(50) for cisplatin in every cell line decreased significantly after a 4-week drug-free interval (P < 0.01). There was no difference in the mRNA expression for MRP or topoisomerase-I regardless of cell line, or type or concentration of chemotherapeutic exposure. The mRNA for MDR-1 was uniquely overexpressed in the cisplatin-resistant cell line A2780-CR9 initially treated with low doses of cisplatin and paclitaxel, but was not amplified in A2780 (P < 0.01).

CONCLUSIONS

The acquired resistance to cisplatin in A2780 is potentially due to P-glycoprotein-mediated multidrug resistance. This acquired resistance to cisplatin is an unstable phenotype in that some cell populations become sensitive after a drug-free interval and topotecan treatment. This reversal of resistance, however, does not appear to be simply due to loss of MDR-1 expression. While in vivo confirmation is required, agents with novel mechanisms of action offer a strategy to extend the platinum-free interval and thereby improve survival in patients with recurrent ovarian cancer.

Gemcitabine associated vasculitis leading to necrotizing enterocolitis and death in women undergoing primary treatment for epithelial ovarian/peritoneal cancer

We present two patients who developed necrotizing enterocolitis following their first cycle of chemotherapy for epithelial ovarian/peritoneal cancer. After optimal cytoreductive surgery, both women received gemcitabine as part of a chemotherapy protocol. One patient developed necrotizing enterocolitis, 1 day after chemotherapy and the other 8 days after chemotherapy. The first patient succumbed to the enterocolitis despite aggressive supportive care. The second patient succumbed despite both aggressive supportive care and surgical intervention. Pathologic review for both patients revealed a drug induced vasculitis causing necrotizing enterocolitis.

Biweekly 72-Hour 9-Aminocamptothecin Infusion As Second-Line Therapy for Ovarian Carcinoma: Phase II Study of the New York Gynecologic Oncology Group and the Eastern Cooperative Oncology Group

Purpose

To determine the antitumor activity of the novel topoisomerase I inhibitor 9-aminocamptothecin (9-AC) given over 72 hours every 2 weeks in patients with ovarian carcinoma previously treated with one platinum-containing regimen.

Patients and Methods

Patients with ovarian carcinoma who received one prior platinum-containing regimen were eligible. Patients were stratified based on whether their disease was measurable, or nonmeasurable but assessable. 9-AC 35 μg/m2/h was administered by continuous infusion for 72 hours every 2 weeks via ambulatory pump.

Results

Sixty patients were entered, 32 with measurable and 28 with nonmeasurable but assessable disease. Ten (16.7%) of 60 patients responded (95% CI, 7.2% to 26.1%), with four complete responses and six partial remissions. The response rate for patients with measurable and nonmeasurable but assessable disease was 22% (95% CI, 7.6% to 36.2%) and 10.7% (95% CI, 2.3% to 28.2%), respectively. None of the responders were platinum-resistant. Nineteen patients (32%) had stable disease. The major toxicities were hematologic, with 25% of patients having grade 3 and 35% having grade 4 neutropenia, including five episodes of febrile neutropenia, 17% having grade 3 to 4 thrombocytopenia, and 27% having grade 3 to 4 anemia. Nonhematologic toxicity included grade 3 to 4 nausea (27%) and grade 3 to 4 vomiting (12%).

Conclusion

This phase II multicenter trial of biweekly 72 hour 9-AC infusion as second-line therapy for ovarian cancer demonstrates comparable activity to standard approved agents in patients with both measurable and nonmeasurable but assessable disease. Toxicity consists mainly of moderate but controllable myelosuppression. Further studies combining 9-AC with other agents active in ovarian cancer for use as second-line therapy are warranted.

Chemotherapy for newly diagnosed and relapsed advanced ovarian cancer

OBJECTIVES

To review chemotherapy options for patients with newly diagnosed or relapsed advanced ovarian cancer.

DATA SOURCES

Published literature.

CONCLUSION

Primary chemotherapy for newly diagnosed, advanced ovarian cancer consisting of a platinum compound and a taxane is commonly associated with myelosuppression, nausea/vomiting, alopecia, and sensory/motor neuropathy. For recurrent disease, numerous chemotherapy agents are effective, including rechallenging the patient with a platinum and/or a taxane or using newer agents such as pegylated liposomal doxorubicin, topotecan, and gemcitabine. In platinum-resistant disease, selection is based mainly on the toxicity profile, because palliation and quality of life are important.

IMPLICATIONS FOR NURSING PRACTICE

Oncology nurses play a valuable role in ovarian cancer care by proactively meeting patient information needs.

Platinum retreatment of platinum-resistant ovarian cancer after nonplatinum therapy

OBJECTIVE

The objective was to determine the response rate to platinum retreatment of "platinum-resistant" ovarian cancer after intervening nonplatinum therapy.

METHODS

We retrospectively identified 30 patients with platinum-resistant ovarian cancer who received nonplatinum chemotherapy for recurrent epithelial ovarian cancer prior to additional platinum therapy. All patients were treated between July 1, 1997, and June 30, 2001. Platinum resistance was defined as less than a partial response to platinum therapy or progression within 6 months of the last platinum therapy.

RESULTS

Overall, 7 of 30 patients experienced an objective response to platinum therapy (partial response, 23%; complete response, 0%) based on CT scan (2/21) and/or CA-125 (5/9) criteria. The median time to progression for the group was 17 weeks (range, 4-59 weeks). Several predictive factors were identified. The interval since the last platinum treatment did not appear to be predictive in this group. Only 1 of 16 patients who did not have an objective response to the most recent platinum-based therapy responded to platinum rechallenge. Similarly, no patient who received more than three intervening nonplatinum treatments responded to additional platinum therapy (0/10).

CONCLUSIONS

Our small retrospective series suggest that the platinum-resistant category is heterogenous and includes patients who may respond to retreatment with platinum-based agents. This group includes the patients with prior platinum responses and early progression. However, patients without an objective response to the last prior platinum therapy or more than three intervening treatments are unlikely to respond to subsequent platinum therapy.

Gemcitabine combination chemotherapy of ovarian cancer

OBJECTIVE

Used alone, gemcitabine has shown modest, albeit significant, activity in patients with ovarian cancer. The response rate is usually greater when it is used in combination with other agents, and many combinations of gemcitabine show promise. This review summarizes the results of clinical trials where gemcitabine has been used in combination with other cytotoxic agents for the treatment of ovarian cancer in both newly diagnosed patients and those whose disease recurred despite heavy prior treatment.

METHODS

The results of several clinical trials in which gemcitabine was used in combination with platinum compounds, paclitaxel, or other chemotherapeutic agents as either first-line or salvage therapy of ovarian cancer were reviewed.

RESULTS

Gemcitabine appears to act synergistically when combined with a platinum compound, producing response rates as high as 71% in previously untreated patients. The addition of paclitaxel to this combination was even more effective for first-line therapy. When used in the salvage setting, combinations of gemcitabine with cisplatin or carboplatin and/or other cytotoxic agents were also effective and well tolerated.

CONCLUSIONS

Combinations of gemcitabine with platinum compounds and/or other chemotherapeutic agents have significant activity with acceptable toxicity in patients with ovarian cancer, whether used as first-line therapy or in the salvage setting. The exact dosing and different mechanism of action of gemcitabine make it attractive for these combinations.

Successful administration of carboplatin in patients with clinically documented carboplatin hypersensitivity

OBJECTIVE

The goal of this study was to evaluate the tolerance and effectiveness of carboplatin rechallenge using a prolonged desensitizing carboplatin infusion regimen in patients with clinically documented moderate-severe carboplatin hypersensitivity.

METHOD

Patients admitted for carboplatin infusion were identified by computerized pharmacy records and retrospectively analyzed.

RESULT

Thirty-three patients with recurrent ovarian (N = 27), peritoneal (N = 4), tubal (N = 1), and cervical (N = 1) cancer treated with a prolonged desensitizing carboplatin infusion regimen were identified. The patients had received a median of 10 courses of carboplatin (range 3-33) before developing the moderate-severe hypersensitivity reaction. Two hundred and fifteen courses (median 5, range 1-52) were administered. Twenty-nine patients (88%) were successfully rechallenged while four had a recurrent moderate-severe carboplatin hypersensitivity precluding further administration. Despite initial tolerance of the infusion schedule moderate-severe carboplatin hypersensitivity recurred in 3 additional patients (9%) after two, three, and six subsequent courses. Objective responses to therapy were seen in 22 of 28 evaluable patients (79%).

CONCLUSIONS

A prolonged desensitizing carboplatin infusion regimen is tolerated in the majority of patients with clinically documented moderate-severe carboplatin hypersensitivity. Objective response rates seem acceptable with this schedule.