Maximal cytoreductive effort in epithelial ovarian cancer surgery

Prognostic and predictive relevance of CA-125 at primary surgery of ovarian cancer

INTRODUCTION

Despite radical surgery and chemotherapy, most patients with ovarian cancer develop recurrence and die due to progressive disease. To stratify patients for optimal therapy, prognostic and predictive factors are needed. We examined the role of pre- and postoperative CA-125 in this context.

METHODS

A total of 231 patients with primary ovarian cancer who presented for surgery at our institution between 1996 and 2004 were included in this study (25% FIGO stage I/II and 75% FIGO stage III/IV). The prognostic and predictive values of CA-125 serum concentrations before and after surgery as well as their correlation with clinicopathological variables were analyzed.

RESULTS

Median preoperative CA-125 was 61.6 kU/l (9-1,867 kU/l) in stage I/II patients and 533.15 kU/l (10-22,617 kU/l) in stage III/IV patients. Before surgery, 67% of stage I/II patients and 96% of stage III/IV patients had elevated CA-125 (>35 kU/l). There was a significant decrease in CA-125 after surgery in both patient cohorts (61.6-43.4 kU/l, P = 0.001 and 533.15-92.3 kU/l, P < 0.001, respectively). Furthermore, in stage III/IV patients with complete or so-called optimal (<1 cm residual disease) debulking, preoperative CA-125 levels were significantly lower than in patients with residual disease >1 cm (P = 0.01, P = 0.009, respectively). Neither CA-125 concentration before surgery nor its decrease was prognostically relevant for recurrence and survival at any stage. However, in stage III/IV patients, a high postoperative CA-125 was associated with shorter progression-free survival (P = 0.024).

CONCLUSIONS

Although CA-125 serum levels differ significantly before and after surgery in early and advanced-stage ovarian cancer and preoperative CA-125 values correlate with surgical outcome in advanced-stage disease, we could not determine a preoperative cutoff value for prediction of the surgical result. A prognostic relevance was only observed for postoperative CA-125 in stage III/IV patients.

A gene signature-based approach identifies thioridazine as an inhibitor of phosphatidylinositol-3'-kinase (PI3K)/AKT pathway in ovarian cancer cells

OBJECTIVE

Thioridazine, a derivative of phenothiazine, has been reported to have antiproliferative activity on tumor cells. However, the mechanism has not been well defined.

METHODS

Using in-silico gene signature based approach, we have demonstrated that thioridazine could inhibit phosphatidylinositol-3'-kinase (PI3K)/Akt pathway, and thus exert cytotoxicity in ovarian cancer cells.

RESULTS

The Connectivity Map indicated that thioridazine induces gene signature similar to that of Akt inhibition. Moreover, preexisting inhibitors of PI3K/Akt pathway were also found to reveal similar signature. In SKOV-3 cells, immunoblot using p85 antibody showed that thioridazine could inhibit PI3K signal. In addition, thioridazine was found to inhibit p-Akt (Ser 473) in a dose-dependent manner. Furthermore, thioridazine was found to decrease cell viability and induce apoptosis. Exposure to thioridazine induced G(0)/G(1) arrest and down-regulated the cell cycle regulator, Cyclin D1 and CDK4, and up-regulated p21, p16, and p-CDC25A. Finally, additive cytotoxicity was observed when cisplatin and thioridazine were treated simultaneously.

CONCLUSIONS

The current study indicated that in-silico approach, such as Connectivity Map, is a potentially useful method to identify the unknown cellular function among the drugs already in use in clinic. Owing to the property of Akt inhibition and additive cytotoxicity observed with the platinum compound, further research should be focused on this drug.

Interaction between preoperative CA-125 level and survival benefit of neoadjuvant chemotherapy in advanced epithelial ovarian cancer

OBJECTIVE

This study aims to determine whether neoadjuvant chemotherapy (NAC) has survival benefit in selected patients with advanced epithelial ovarian cancer (EOC) who have high risk of suboptimal cytoreduction which is represented by high serum CA-125 level.

METHODS

We retrospectively reviewed records of 314 patients with EOC including 94 patients who received NAC. After stratification by preoperative CA-125 levels, the progression-free survival (PFS) was compared between the NAC group and the primary debulking surgery (PDS) group.

RESULTS

The NAC group had more FIGO stage IV disease (P<0.001) and higher CA-125 levels (P<0.001). Although suboptimal resection rate was higher in the PDS group (50% vs. 18%, P<0.001), however, NAC was not associated with increased PFS in multivariate Cox analysis (P=0.334). Nevertheless, after stratification according to CA-125 levels, NAC showed survival benefit in the subgroup with high CA-125 levels (>2000 U/ml; HR 0.62, P=0.037).

CONCLUSION

Our preliminary data suggests the possible interaction between CA-125 levels and survival benefit of NAC. The randomized trial data about NAC should be stratified by the reproducible and relevant criteria such as preoperative serum CA-125 level to elucidate true survival benefit of NAC in ovarian cancer.