A randomized comparison of cyclophosphamide, Adriamycin, and 5-fluorouracil with triethylenethiophosphoramide and methotrexate, both as sequential and as fixed rotational treatment in patients with advanced ovarian cancer

Dose intensity analysis in advanced ovarian cancer patients

To determine if chemotherapy dose intensity influences treatment outcome in advanced ovarian cancer, all randomised studies of first line chemotherapy, published between 1975 and 1989, were analysed for relationships between planned dose intensity and (a) objective response and (b) median survival. Total dose intensity of each study regimen was calculated and a weighted regression model providing for systemic differences in response or survival among studies was utilised. Hence, treatment arms of different studies were never directly compared. In addition, relative dose intensities of individual drugs within combinations was similarly evaluated. The improvement in objective response rate when adding one unit of total dose intensity ranged between 12% and 16% depending on baseline response rate. The improvement in median survival when adding one unit of total dose intensity ranged between 2 and 4 months. One unit of total dose intensity corresponds to, for example, 20 mg m2 week of cisplatin, or 25 mg m2 week of doxorubicin, or 350 mg m2 week of cyclophosphamide. The analysis of individual drugs suggested that doxorubicin and the platinum compounds were about equally effective, with cyclophosphamide being less effective. The methodological benefits and limitations of the approach used and the implication of the results are discussed.

Prognostic factors for overall survival in patients with advanced ovarian carcinoma

Twenty-one pretreatment variables were investigated for prognostic influence on survival in 301 previously untreated patients with ovarian carcinoma, stage IIB-IV. Patients were randomized to sequential combination chemotherapy: cyclophosphamide, doxorubicin, 5-fluorouracil, followed by cisplatin and hexamethylmelamine, or to the 3-drug combination alternating with the 2-drug combination every other month. Median overall survivals were 25 and 22 months, respectively, P greater than 0.4. Based on the results from a Cox multivariate stepwise analysis a subset of independent significant prognostic factors was found to include: residual tumor size, performance status, alkaline phosphatase, number of metastases, histological differentiation grade and type. A prognostic index was calculated for each patient and three prognostic categories of patients were determined. The 3-yr survival rates for patients with low-, intermediate-, and high-risk scores were 62, 31, and 7%, respectively. Multivariate analysis thus contributes further information about the disease, and a knowledge of the distribution of such factors across different trials is important when comparing treatment outcome.

A randomized study of sequential versus alternating combination chemotherapy in advanced ovarian carcinoma

The concept of using either alternating or sequential combination chemotherapy with non-cross-resistant combinations was tested in a randomized trial including 301 previously untreated patients with advanced epithelial ovarian carcinoma. The sequential schedule consisted of CAF (cyclophosphamide, doxorubicin, 5-fluorouracil) followed by PH (cisplatin, hexamethylmelamine) in nonresponders, CAF- greater than PH (n = 157), and the alternating regimen consisted of CAF/PH (n = 144). With a median observation time of 54 months, no statistically significant differences were found between the pathologically complete response (PCR) rates of 17% and 16%, respectively, nor were there any statistical differences in median disease-free survival for PCR patients (CAF- greater than PH 34+ months and CAF/PH 26+ months), in overall survival (28 and 24 months, respectively), or in time to treatment failure (10 and 11 months). The overall estimated cure rate was 13%. An equal degree of myelosuppression was seen with the two regimens, whereas neuro- and nephrotoxicity were more pronounced when PH was given sequentially to CAF than with the alternating schedule. We conclude that the sequential and the alternated use of doxorubicin- and platinum-based regimens yield equivalent results and that other approaches should be investigated to improve treatment effects.

The feasibility of early administration of combination chemotherapy following cytoreductive surgery and second-look operation in patients with stage III ovarian carcinoma: a pilot study

The purpose of this study is to evaluate the feasibility of early use of modified PAC-1 chemotherapy following debulking surgery and its efficacy by assessing disease status during a second-look operation. Twenty-six consecutive previously untreated patients with stage III ovarian carcinoma were evaluated in a prospective study over the 5-year period March 1981 to August 1986. Initial exploratory laparotomy was performed for staging and maximum cytoreduction. Within 24 hr postoperative modified PAC-1 (M-PAC-1) combination chemotherapy was administered and then repeated every 4 weeks for 11 months which was then followed by second-look operation. Patients were analyzed according to the following pretreatment characteristics: age, FIGO stage, histologic tumor type, extent of initial surgery, size of residual tumor, and findings during second-look. Nineteen patients were evaluable. No evidence of either microscopic or macroscopic disease was noted in 15 patients (79%), whereas the remaining 4 (21%) exhibited persistent disease. Of the remaining 7 patients not undergoing SLO, 4 completed 12 courses of chemotherapy but did not undergo surgery for medical reason (n = 2) or patient refusal (n = 2). Two more patients refused chemotherapy after 9 courses and the seventh patient expired with persistent disease after 8 courses. The early use of combination chemotherapy was well tolerated. Neurological, hematological, and renal toxicity was never severe enough to cause discontinuation of therapy.

Management of apparent single foci of epithelial ovarian cancer

Four patients with proven ovarian cancer were found to have single lesions in the liver parenchyma after completing chemotherapy. They otherwise appeared to be in complete clinical remission. Percutaneous needle biopsy was sometimes misleading and dangerous. Laparoscopy and laparotomy were required for optimum safe diagnosis, staging, and treatment. Definitive resection appeared to be beneficial but usually only as a palliative form of debulking. Subsequent adjuvant combination chemotherapy may sometimes improve the duration of useful remissions. Unusual sites of metastatic ovarian cancer appear to be increasing in frequency. Successful management of late recurrences in the liver is possible, provided the diagnosis is immediately suspected and one utilizes both definitive surgery and chemotherapy.