A systematic overview of chemotherapy effects in ovarian cancer

Lessons learned from a decade of clinical trials of high-dose chemotherapy in ovarian cancer

Ovarian cancer is one of the most chemosensitive solid tumors and therefore a good example to explore high-dose chemotherapy (HDC). Interest in pursuing this treatment arose in the late 1980s following the success of HDC in treating hematological cancers and improvements in supportive care with peripheral blood stem cells. Experience from phase II trials and analysis of Bone Marrow Transplant Registry data led to the launch of several randomized phase III trials in the late 1990 s. Initial enthusiasm for this treatment was in part due to the preliminary positive data emerging from HDC in breast cancer. Five randomized trials of HDC in ovarian cancer have been conducted and all experienced difficulty in recruitment. Their different designs and results are reviewed, as well as some of the lessons that have been learned about HDC in solid tumors in the last decade.

Prospective evaluation of weekly topotecan in recurrent platinum-resistant epithelial ovarian cancer

Topotecan administered on a weekly basis has been reported to possess antineoplastic activities with lower toxicities than the standard 5-day regimen every 3 weeks. We studied the activity of weekly topotecan regimen in recurrent platinum-resistant epithelial ovarian cancer patients. Ovarian cancer patients with documented platinum-resistant recurrences were treated with weekly intravenous topotecan (4 mg/m2) on days 1, 8, and 15 on a 28-day cycle. Prospective data collection included patients' demographics together with disease- and treatment-related toxicities. Responses were evaluated using Response Evaluation Criteria in Solid Tumors (RECIST) and CA125 criteria. Progression-free survival and overall survival time from commencement of weekly treatment were estimated using the Kaplan–Meier method. All P values less than 0.05 were considered to be statistically significant. Twenty-two patients were treated. Weekly topotecan was used most commonly as third-line chemotherapy (range 1–5). A total of 244 weekly treatments were administered, with a median of 12 weekly treatments per patient. Two patients (9%) reported grade 3/4 gastrointestinal and two had grade 3/4 hematologic toxicities respectively. No dose reduction or treatment delay was required. Partial response was observed in two patients (9.1%) and another seven patients (31.8%) showed stable disease. No significant association was observed between best clinical response and patients' initial platinum sensitivity status. The estimated median progression-free survival was 20.9 weeks (95% CI 11.2–30.5) from the start of the weekly regimen. Weekly topotecan is well tolerated in patients with recurrent platinum-resistant ovarian cancer with modest activity.

First-line gemcitabine and carboplatin in advanced ovarian carcinoma: a phase II study

OBJECTIVES

To evaluate tumour response rate and toxicities of gemcitabine and carboplatin in chemonaive subjects with advanced epithelial ovarian cancer.

DESIGN

A phase II study.

SETTING

Gynaecologic oncologic unit.

POPULATION

Twenty chemonaive International Federation of Gynecology and Obstetrics (FIGO) stage IIIc and stage IV subjects with ovarian cancer.

MAIN OUTCOME MEASURES

Tumour response, disease free and overall survival and toxicity.

METHODS

Intravenous gemcitabine 1000 mg/m2 on day 1 and day 8 and carboplatin at area under centre (AUC) = 5 on day 1 were administered three weekly for six cycles. Subjects who received more than three cycles of chemotherapy were eligible for assessment of tumour response, while all the cycles of chemotherapy were assessed for toxicities.

RESULTS

The mean age of the subjects was 57.3 years, and the median follow up was 38.7 months. Of the 18 eligible subjects analysed, 11 (61.1%) showed a complete clinical response, and the overall response rate was 83.3% (15/18). The median overall survival was 29.2 [95% (confidence interval) CI 22.8-35.6] months, and the median progression-free survival was 11.6 (95% CI 4.7-18.5) months. WHO grade 3 anaemia, neutropenia and thrombocytopenia was 7.6, 9.5 and 0%, respectively, on day 8, and 15.5, 12.2 and 15.5%, respectively, on day 15. Two subjects required a total of three hospital admissions for neutropenic sepsis, and two required five hospital admissions for platelet transfusion for severe thrombocytopenia.

CONCLUSION

Chemonaive advanced ovarian cancer showed a high response rate to combined gemcitabine and carboplatin chemotherapy. The subjects developed moderate adverse reactions. Phase III study to evaluate the role of combined gemcitabine and carboplatin as first-line chemotherapy in ovarian cancer is warranted.

1,1-Bis(3'-indolyl)-1-(p-substituted phenyl)methanes inhibit ovarian cancer cell growth through peroxisome proliferator-activated receptor-dependent and independent pathways

1,1-Bis(3'-indolyl)-1-(p-t-butylphenyl)methane (DIM-C-pPhtBu) is a peroxisome proliferator-activated receptor gamma (PPARgamma) agonist, and treatment of SKOV3 ovarian cancer cells with this compound (5 micromol/L) inhibits cell proliferation, whereas up to 15 micromol/L rosiglitazone had no effect on cell growth. DIM-C-pPhtBu also inhibits G0-G1 to S phase cell cycle progression and this is linked, in part, to PPARgamma-dependent induction of the cyclin-dependent kinase inhibitor p21. DIM-C-pPhtBu induces PPARgamma-independent down-regulation of cyclin D1 and we therefore further investigated activation of receptor-independent pathways. DIM-C-pPhtBu also induced apoptosis in SKOV3 cells and this was related to induction of glucose-related protein 78, which is typically up-regulated as part of the unfolded protein response during endoplasmic reticulum (ER) stress. Activation of ER stress was also observed in other ovarian cancer cell lines treated with DIM-C-pPhtBu. In addition, DIM-C-pPhtBu induced CCAAT/enhancer binding protein homologous protein through both ER stress and c-jun NH2-terminal kinase-dependent pathways, and CCAAT/enhancer binding protein homologous protein activated death receptor 5 and the extrinsic pathway of apoptosis. These results show that DIM-C-pPhtBu inhibits growth and induces apoptosis in ovarian cancer cells through both PPARgamma-dependent and PPARgamma-independent pathways, and this complex mechanism of action will be advantageous for future clinical development of these compounds for treatment of ovarian cancer.

Radical surgery-peritonectomy and intraoperative intraperitoneal chemotherapy for the treatment of peritoneal carcinomatosis in recurrent or primary ovarian cancer

BACKGROUND AND OBJECTIVES

Advanced ovarian cancer typically spreads in a diffuse intra-abdominal fashion. This characteristic suggests that combined radical surgery and intraperitoneal chemotherapy may be a useful treatment procedure. The purpose of this study was to review patients submitted to surgical debulking and hyperthermic intraoperative intraperitoneal chemotherapy (HIIC) and to evaluate the potential prognostic survival factors for advanced epithelial ovarian cancer in our center.

METHODS

A series of patients (N = 33) diagnosed of peritoneal carcinomatosis for epithelial ovarian cancer (stage III) from January 1997 to December 2004 submitted to radical surgery-peritonectomy and HIIC with paclitaxel was included in this study; 19 primary ovarian cancer and 14 recurrent ovarian cancer.

RESULTS

Cytoreduction R0 (P = 0.018) and negative lymph nodes (P = 0.005) were covariables for major prognostic survival. Patients with optimal cytoreduction R0 obtained survival rates of 63% at 5 years in recurrent ovarian cancer and 60% in primary ovarian cancer, 71% and 63%, respectively with associated subtotal infra-abdominal peritonectomy, and even better results if negative lymph nodes.

CONCLUSIONS

Radical surgery-peritonectomy with HIIQ has been shown to be a surgical procedure with high tolerability, low morbimortality, enhanced survival, and prolonged disease-free interval in patients with peritoneal carcinomatosis so much for recurrent or primary ovarian cancer.

Phase I/II trial of multicycle high-dose chemotherapy with peripheral blood stem cell support for treatment of advanced ovarian cancer

Ovarian cancer is chemosensitive, but most patients with advanced disease die from tumor progression. As 25% of the patients can be cured by chemotherapy, it is reasonable to evaluate high-dose chemotherapy (HDCT). Forty-eight patients with untreated ovarian cancer were entered in a multicenter phase I/II trial of multicycle HDCT. Median age was 46 (19-59 years); International Federation of Gynecology and Obstetrics-stage was III in 79% and IV in 21%; 31% had residual disease >1 cm after surgery. Two courses of induction/mobilization therapy with cyclophosphamide (250 mg/m2) and paclitaxel (250 mg/m2) were used to collect peripheral blood stem cells. HDCT consisted of two courses of carboplatin (area under curve (AUC) 18-22) and paclitaxel followed by one course of carboplatin and melphalan (140 mg/m2) with or without etoposide (1600 mg/m2). Main toxicity was gastrointestinal. Limiting carboplatin to AUC 20 and eliminating etoposide resulted in manageable toxicity (69% without grade 3/4 toxicity). One patient died from treatment-related pneumonitis. At 8 years median follow-up, median progression-free-survival (PFS) and overall survival (OS) is 13.3 and 37.0 months. Five-years PFS and OS is 18 and 33%. Multicycle HDCT is feasible in a multicenter setting. A European phase III trial based on this regimen is evaluating the efficacy of HDCT.

Prognostic value of FDG-PET in patients with ovarian carcinoma following surgical treatment

OBJECTIVE

[corrected] To determine the prognostic value of FDG-PET after surgical resection in patients with ovarian carcinoma, we compared the results of FDG-PET and serum CA-125 level and prognosis of patients.

METHODS

Eighteen patients underwent a total of 32 FDG-PET examinations following surgery for ovarian carcinoma from October 2001 to December 2002 at our hospital (median follow-up period, 31 months). Age of the patients at the time of the initial FDG-PET examination ranged from 31 to 73 years (mean 52 years) and the period from surgery to the initial FDG-PET examination ranged from 5 to 109 months (mean 30 months). Serum CA-125 levels were determined on the occasion of each FDG-PET examination. Recurrent tumors were treated with surgery in 5 cases, radiotherapy in 2 cases, and chemotherapy in 9 cases.

RESULTS

The initial FDG-PET examinations revealed that 13 cases had positive and 5 cases had negative findings, which included 2 false positive cases. The survival rate for all patients at 1 year and 2 years after the initial examination was 82% and 63%, respectively. Two-year survival rates in patients with positive and negative FDG-PET findings were 51% and 83%, respectively, and the difference was not statistically significant (p = 0.19). Furthermore, 4 patients with normal CA-125 levels and 14 patients with elevated CA-125 levels showed 2-year survival rates of 100% and 51%, respectively, and they were not significantly different (p = 0.11). For all 32 examinations, the 2-year survival rates for patients with normal CA-125 levels (100%) were significantly higher (p = 0.025) than that for patients with elevated CA-125 levels (47%), however there was no significant difference (p = 0.20) between FDG-PET positive cases (53%) and negative cases (83%). CONCLUSION The prognosis of patients with positive FDG-PET findings was less favorable than that of patients with negative findings. However, over the mean extended observation period of about 2.5 years, no significant difference in the prognosis of patients was observed between the two groups. The results of the present study indicate that elevated serum CA-125 levels may be more useful for evaluating the prognosis of ovarian cancer during the post-operative follow-up than FDG-PET findings.

Prospective evaluations of continuous weekly paclitaxel regimen in recurrent platinum-resistant epithelial ovarian cancer

BACKGROUND

Paclitaxel administered on a weekly basis has been reported to possess both anti-angiogenic and apoptotic-inducing effects. We investigated the activity of a weekly continuous paclitaxel regimen in patients with recurrent platinum-resistant ovarian cancer.

METHODS

Patients with recurrent ovarian cancer and documented platinum-resistant disease were treated with weekly intravenous paclitaxel (60-80 mg/m(2)) continuously for up to 24 weeks over an 18-month period. Prospective data collection included: information on patients' demographics together with disease- and treatment-related toxicities. Response was evaluated using radiographic and Ca125 criteria. Chi-square tests were used to test for significant associations between categorical variables. Progression-free survival and overall survival time from commencement of weekly treatment were estimated using the Kaplan-Meier method. All P values less than 0.05 were considered to be statistically significant.

RESULTS

Thirty-four patients were treated on protocol. Five patients (15%) reported grade 3/4 neurotoxicity at the end of 12 weeks. No dose reduction or treatment delay was required. No significant hematologic toxicity was observed. Responses were evaluable in thirty-two patients. Complete response was observed in three patients (9%), and another 14 patients showed a partial response (44%). Seven patients (22%) had disease stabilization. The estimated median progression-free survival and overall survival were 6.10 months (95% CI:3.81-8.39) and 10.43 months (95% CI: 8.49-12.38) respectively from the start of the regimen.

CONCLUSION

Continuous weekly paclitaxel is a well-tolerated and active regimen in patients with recurrent platinum-resistant ovarian cancer.

Epidermoid anal cancer: a review of a population-based series of 308 consecutive patients treated according to prospective protocols

PURPOSE

The primary therapy in epidermoid anal cancer is radiotherapy, generally with chemotherapy. The use of neoadjuvant chemotherapy has been infrequently reported in the literature. This study presents results from a large population-based series and provides comparisons between different treatments.

METHODS AND MATERIALS

Between 1985 and 2000, 308 patients with invasive epidermoid anal cancer were diagnosed in the Stockholm Health Care Region. Treatment was given according to defined protocols. External beam radiotherapy alone or with concomitant bleomycin and neoadjuvant chemotherapy followed by radiotherapy alone were the primary treatments. Radical surgery was reserved for poor responders or recurrences. Data were reviewed with regard to treatment, outcome, and prognostic factors.

RESULTS

Among the 276 patients (90%) treated with curative intent, 264 (96%) received treatment in accordance with the protocols. The overall 5-year survival rate was 68%. Among the 142 patients with locally advanced tumors (T > or =4 cm or N+), patients treated with neoadjuvant platinum-based chemotherapy (n = 91) had significantly better complete response rates compared with patients treated with radiotherapy with or without bleomycin (n = 51) (92% vs. 76%, p < 0.01). A significantly increased overall 5-year survival rate was also found among patients receiving neoadjuvant therapy (63% vs. 44%, p < 0.05).

CONCLUSION

Structured treatment protocols result in favorable outcome on a population level. The results further suggest a significant therapeutic gain from including neoadjuvant chemotherapy in the treatment of locally advanced anal cancer.

Influence of Dosing Schedule on Toxicity and Antitumor Effects of a Combination of Adriamycin and Docetaxel in Mice

PURPOSE

Although the combination of Adriamycin (ADR) and docetaxel (DOC) showed a better cure rate against metastatic breast cancer in a clinical study, severe myelosuppression and cardiotoxicity were dose-limiting factors. The purpose of this study was to establish the most suitable dosing schedule to relieve severe adverse effects and improve the antitumor effects.

EXPERIMENTAL DESIGN

Both ADR and DOC were administered simultaneously in the simultaneous-dosing group (ADR/DOC), whereas in the intermittent-dosing groups (ADR-DOC and DOC-ADR), the second drug was administered 12 h after the first drug. Leukocyte counts and survival were measured to estimate adverse effects. After administration, ADR and DOC concentrations in blood, myelocyte cells, and heart were determined. To clarify the antitumor effect, tumor growth was measured in Ehrlich-cell-bearing mice after the initiation of drug injections.

RESULTS

The simultaneous-dosing group showed severe leukopenia compared with the saline-treated group. However, the toxicity was reduced in the intermittent-dosing groups. The DOC-ADR group showed the best survival rate in the dosing groups. In the pharmacokinetic study, ADR and DOC concentrations in plasma, myelocyte cells, and the heart were markedly higher in the simultaneous-dosing group than the intermittent-dosing groups. These results indicate that pharmacokinetic interactions may contribute to the change in leukopenia induced by concurrent administration of ADR and DOC. The antitumor effect in the DOC-ADR group was the highest in the dosing groups.

CONCLUSIONS

In the present study, the findings suggest that ADR administered 12 h after DOC injection (DOC-ADR group) not only inhibits tumor growth more strongly but also significantly reduces leukopenia compared with results for the simultaneous-dosing (ADR/DOC) group and significantly reduced the number of toxic deaths compared with the other groups.

Whole abdominopelvic radiotherapy (WAPRT) using intensity-modulated arc therapy (IMAT): first clinical experience

PURPOSE

Whole abdominopelvic radiation therapy (WAPRT) is a treatment option in the palliation of patients with relapsed ovarian cancer. With conventional techniques, kidneys and liver are the dose- and homogeneity-limiting organs. We developed a planning strategy for intensity-modulated arc therapy (IMAT) and report on the treatment plans of the first 5 treated patients.

METHODS AND MATERIALS

Five consecutive patients with histologically proven relapsed ovarian cancer were sent to our department for WAPRT. The target volumes and organs at risk (OAR) were delineated on 0.5-cm-thick CT slices. The clinical target volume (CTV) was defined as the total peritoneal cavity. CTV and kidneys were expanded with 0.5 cm. In a preset range of 8 degrees interspaced gantry angles, machine states were generated with an anatomy-based segmentation tool. Machine states of the same class were stratified in arcs. The optimization of IMAT was done in several steps, using a biophysical objective function. These steps included weight optimization of machine states, leaf position optimization adapted to meet the maximal leaf speed constraint, and planner-interactive optimization of the start and stop angles. The final control points (machine states plus associated cumulative monitor unit counts) were calculated using a collapsed cone convolution/superposition algorithm. For comparison, two conventional plans (CONV) were made, one with two fields (CONV2), and one with four fields (CONV4). In these CONV plans, dose to the kidneys was limited by cerrobend blocks. The IMAT and the CONV plans were normalized to a median dose of 33 Gy to the planning target volume (PTV). Monomer/polymer gel dosimetry was used to assess the dosimetric accuracy of the IMAT planning and delivery method.

RESULTS

The median volume of the PTV was 8306 cc. The mean treatment delivery time over 4 patients was 13.8 min. A mean of 444 monitor units was needed for a fraction dose of 150 cGy. The fraction of the PTV volume receiving more than 90% of the prescribed dose (V(90)) was 9% higher for the IMAT plan than for the CONV4 plan (89.9% vs. 82.5%). Outside a build-up region of 0.8 cm and 1 cm away from both kidneys, the inhomogeneity in the PTV was 15.1% for the IMAT plans and 24.9% for the CONV4 plans (for CONV2 plans, this was 34.9%). The median dose to the kidneys in the IMAT plans was lower for all patients. The 95th percentile dose for the kidneys was significantly higher for the IMAT plans than for the CONV4 and CONV2 plans (28.2 Gy vs. 22.2 Gy and 22.6 Gy for left kidney, respectively). No relevant differences were found for liver. The gel-measured dose was within clinical planning constraints.

CONCLUSION

IMAT was shown to be deliverable in an acceptable time slot and to produce dose distributions that are more homogeneous than those obtained with a CONV plan, with at least equal sparing of the OARs.

Population pharmacokinetics of cisplatin after 120-h infusion: application to routine adaptive control with feedback

OBJECTIVE

A Bayesian population pharmacokinetics study of data from routine therapeutic drug monitoring cisplatin during a 5-day infusion of cisplatin.

METHODS

A total of 95 kinetics data sets (58 patients) were available to perform this study. Individual pharmacokinetic parameters, estimated from 20 courses of treatment in 18 patients, were used to calculate the population parameters (cl: 0.175 +/- 0.034 L/h; t(1/2): 327 +/- 91 h). The accuracy of Bayesian forecasting was tested by comparing in 40 other patients the clearance values calculated either from a complete kinetics profile (eight sampling times) or from three early samples and the new population parameters. Finally, drug monitoring efficacy was assessed by comparing the target Cmax values with the Cmax obtained after dose adjustment based upon early Bayesian estimation of the individual pharmacokinetic parameters.

RESULTS

: No significant difference was found between Bayesian and experimental clearances. Besides, dose-individualization proved to successfully adjust Cmax values around their respective target.

CONCLUSION

The new reference pharmacokinetic population parameters lead to accurate estimation of individual pharmacokinetic parameters from a limited number of samples, thus allowing efficient therapeutic drug monitoring during 5-day infusion regimens of cisplatin.

Systemic therapy for gynecological neoplasms: ovary, cervix and endometrium

Early-stage endometrial carcinomas should be treated by total abdominal hysterectomy and bilateral salpingo-oophorectomy. In a small subset of patients, who wish to have children, conservative treatment (hormonal therapy) could be considered. The most effective agents for palliation of advanced disease are doxorubicin plus cisplatin.

Evidence for a graft-versus-tumor effect in refractory ovarian cancer

PURPOSE

A 31-year-old woman suffered a 4th relapse of epithelial ovarian cancer refractory to several cytotoxic drugs including platinum, paclitaxel, and topotecan.

METHODS

Sequential high-dose chemotherapy with autografting (three courses) led to a minor response of short duration. In order to induce a graft-versus-tumor effect, allogeneic hematopoietic stem cell transplantation (HSCT) from an HLA-identical sibling donor, after dose-reduced conditioning, was performed in January 2001.

RESULTS

On day +51 the patient developed acute grade II graft-versus-host disease of the skin and gastrointestinal tract, which was successfully treated by prednisolone. Six months after allogeneic HSCT a complete disappearance of the tumor could be seen. Unfortunately, 14 months later a 5th relapse was diagnosed.

CONCLUSIONS

This case demonstrates, on the one hand, that allogeneic HSCT is able to induce complete remissions (CR) in chemoresistant ovarian cancer. On the other hand, despite achievement of CR after allografting, the chance of cure remains limited for these patients.

Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy

OBJECTIVES

The purpose of this study was to determine the recurrence rate, survival, and pregnancy outcome in patients with Stage IA and Stage IC invasive epithelial ovarian cancer treated with unilateral adnexectomy.

METHODS

A multi-institutional retrospective investigation was undertaken to identify patients with Stage IA and IC epithelial ovarian cancer who were treated with fertility-sparing surgery. All patients with ovarian tumors of borderline malignancy were excluded. Long-term follow-up was obtained through tumor registries and telephone interviews. The time and sites of tumor recurrence, patient survival, and pregnancy outcomes were recorded for every patient.

RESULTS

Fifty two patients with Stage I epithelial ovarian cancer treated from 1965 to 2000 at 8 participating institutions were identified. Forty-two patients had Stage IA disease, and 10 had Stage IC cancers. Cell type was distributed as follows: mucinous, 25; serous, 10; endometrioid, 10; clear cell, 5; and mixed, 2. Histologic differentiation was as follows: grade 1, 38; grade 2, 9; and grade 3, 5. Twenty patients received adjuvant chemotherapy (mean 6 courses, range 3-12 courses). Patients received the following chemotherapeutic agents: cisplatin/taxol or carboplatin/taxol, 11; melphalan, 5; cisplatin and cyclophosphamide, 3; and single-agent cisplatin, 1. Eight patients had second-look laparotomies and all were negative. Duration of follow-up ranged from 6 to 426 months (median 68 months). Five patients developed tumor recurrence 8-78 months after initial surgery. Sites of recurrence were as follows: contralateral ovary, 3; peritoneum, 1; and lung, 1. Nine patients underwent subsequent hysterectomy and contralateral oophorectomy for benign disease. At present, 50 patients are alive without evidence of disease and 2 have died of disease 13 and 97 months after initial treatment. The estimated survival was 98% at 5 years and 93% at 10 years.Twenty-four patients attempted pregnancy and 17 (71%) conceived. These 17 patients had 26 term deliveries (no congenital anomalies noted) and 5 spontaneous abortions.

CONCLUSION

The long-term survival of patients with Stage IA and IC epithelial ovarian cancer treated with unilateral adnexectomy is excellent. Fertility-sparing surgery should be considered as a treatment option in women with Stage I epithelial ovarian cancer who desire further childbearing.