Second-look and second surgery: second chance or second best?

Transimmunization restores immune surveillance and prevents recurrence in a syngeneic mouse model of ovarian cancer

Ovarian cancer accounts for most deaths from gynecologic malignancies. Although more than 80% of patients respond to first-line standard of care, most of these responders present with recurrence and eventually succumb to carcinomatosis and chemotherapy-resistant disease. To improve patient survival, new modalities must, therefore, target or prevent recurrent disease. Here we describe for the first time a novel syngeneic mouse model of recurrent high-grade serous ovarian cancer (HGSOC), which allows immunotherapeutic interventions in a time course relevant to human carcinomatosis and disease course. Using this model, we demonstrate the efficacy of Transimmunization (TI), a dendritic cell (DC) vaccination strategy that uses autologous and physiologically derived DC loaded with autologous whole tumor antigens. TI has been proven successful in the treatment of human cutaneous T cell lymphoma and we report for the first time its in vivo efficacy against an intra-peritoneal solid tumor. Given as a single therapy, TI is able to elicit an effective anti-tumor immune response and inhibit immune-suppressive crosstalks with sufficient power to curtail tumor progression and establishment of carcinomatosis and recurrent disease. Specifically, TI is able to inhibit the expansion of tumor-associated macrophages as well as myeloid-derived suppressive cells consequently restoring T cell immune-surveillance. These results demonstrate the possible value of TI in the management of ovarian cancer and other intra-peritoneal tumors.

Novel approach for the detection of intraperitoneal micrometastasis using an ovarian cancer mouse model

Patients with epithelial ovarian cancer have the best overall survival when maximal surgical effort is accomplished. However, despite numerous technological advances, surgery still relies primarily on white-light reflectance and the surgeon’s vision. As such, micrometastases are usually missed and most patients clinically classified as a complete responder eventually recur and succumb to the disease. Our objective is to develop optical enhancers which can aid in the visualization of ovarian cancer micrometastasis. To this end we developed a nanoparticle (NP) platform, which is specifically targeted to the tumor microenvironment. Targeting is achieved by coating FDA-approved PLGA-PEG NP with the peptide sequence RGD, which binds with high affinity to αVβ3 integrins present in both the tumor-associated neovasculature and on the surface of ovarian cancer cells. Administration of the NP platform carrying fluorescent dyes to mice bearing intraperitoneal ovarian cancer allowed visualization of tumor-associated vasculature and its contrast against normal blood vessels. More importantly, we demonstrate the visualization of intraperitoneal ovarian cancer micrometastasis as small as 100 μm with optimal resolution. Finally, we demonstrate that the fluorescent dye cargo was able to penetrate intra-tumorally. Such modality could be used to allow microscopic surgical debulking to assure maximal surgical effort.

Results of second-look laparotomy in advanced ovarian cancer: one single center experience

Objective. The goal of the study was to analyse the results of 85 cases of second-look laparotomy (SLL) and explore the influence of this procedure on survival. Patients and Methods. We reviewed retrospectively 85 cases of SLL collected and treated in our institute between 1994 and 2003. Results. Complete pathologic response (CPR) was 25.8%, microscopic disease (Rmicro) was 38.8%, and macroscopic disease (Rmacro) was 35.4%. In patients with negative SLL results, disease recurrence was diagnosed in 41%. The 3- and 5-year overall survival rates for the entire population were 91% and 87%, respectively. The 3- and 5-year disease-free survivals were, respectively, 76.3% and 58.5% in negative SLL versus 55.7% and 16% in positive SLL. The difference between the group of patients with complete response (76%) and the patients with residual microscopic disease (72%) was not significant. The tumoral residuum after initial surgery was the only prognostic factor influencing significantly the disease-free survival. On Cox regression model analysis, only initial tumoral residuum (P = 0.04) and tumoral residuum after SLL (P = 0.02) were independent prognostic factors for survival. Conclusions. The most important advantage of SLL is the early detection of recurrence and thus the early administration of consolidation treatment resulting in a better prognosis.

[Follow-up of 70 patients with advanced ovarian cancer after negative second-look laparotomy]

OBJECTIVES

To analyze the results of treatment of 70 patients with stage III and IV ovarian cancer after second look laparotomy with negative findings and to identify causes of failure and prognostic factors.

MATERIALS AND METHODS

Between 1985 and 1998, seventy patients with ovarian cancer stage III and IV were treated with surgery and at least six courses of chemotherapy with cisplatin doxarubicin and cyclophosphamide. Then a second look laparotomy was performed.

RESULTS

The actuarial survival rate without evidence of disease was 50% at 5 years. Locoregional failure was observed in 31 patients (88%) and distant metastases in 9, but they were the sole reason for unsuccessful treatment in only 4 (12%). Adverse prognostic factors were: grade 3 differentiation, primary stage IIIC and IV, and residual infiltration exceeding 2 cm after first laparotomy.

CONCLUSION

Our results are comparable with reports in the literature. The actuarial survival rate without evidence of disease at 5 years in patients with advanced ovarian cancer after second look negative laparotomy is 50%.

Positron emission tomography application for gynecologic tumors

Positron emission tomography (PET) using fluorine-18-fluoro-2-deoxy-d-glucose (FDG), which originated as a research tool to evaluate glucose metabolism in cancer tissues, has now become an essential imaging modality for determining the appropriate therapeutic management of various cancer patients. The clinical role of FDG-PET for gynecologic tumors has not been established yet, but FDG-PET has come to be considered one of the important imaging modalities for evaluating patients with gynecological cancers. The objective was to review the literature regarding the utility of FDG-PET in the clinical setting of gynecological malignancies. Many articles reported that FDG-PET could be used for staging and restaging in patients with uterine cervical cancer. Although there is limited data about the feasibility of FDG-PET for endometrial cancer, preliminary results for detecting recurrence were promising. Furthermore, FDG-PET has been reported as a useful imaging modality, especially for restaging, in ovarian cancer, although the prognostic value needs to be fully investigated. Currently, a combined PET/computed tomography scanner is available, and its clinical application has begun. It is expected that this modality will contribute to the management of gynecological cancers, as has been reported recently for other malignancies.

Intérêt de la tomographie par émission de positons au [18F]-fluorodésoxyglucose dans le diagnostic, le bilan d'extension et la recherche de récidive des cancers gynécologiques et mammaires

Positron emission tomography (PET) using fluorodeoxyglucose (FDG) is a new metabolic imaging modality that is becoming accessible in France. Many centers have been or will be equipped soon. The indications of PET-FDG have been established in various settings in some oncology pathologies such as lymphoma or lung cancer, but not in gynaecological and breast cancers. Therefore, we aimed to precise the interest of PET-FDG to detect, stage and restage the cancers of breast, ovary, cervix and uterus by reviewing the recent publications.

Secondary cytoreductive surgery for recurrent epithelial ovarian carcinoma: proposal for patients selection

The value of secondary cytoreductive surgery (SCS) for recurrent ovarian cancer is still controversial. The aim of this study was to clarify candidates for SCS. Between January 1987 and September 2000, we performed SCS in 44 patients with recurrent ovarian cancer, according to our selection criteria, disease-free interval (DFI) >6 months, performance status <3, no apparent multiple diseases, age <75years and no progressive disease during preoperative chemotherapy, if undertaken. The variables were investigated by univariate and multivariate analyses. Of 44 patients, 26 (59.1%) achieved complete removal of all visible tumours at SCS. Secondary cytoreductive surgery outcome, complete or incomplete resection, was significantly related to overall survival (P=0.0019). As for variables determined before SCS, DFI >12 months, no liver metastasis, solitary tumour and tumour size <6 cm were independently associated with favourable overall survival after recurrence in the multivariate analysis. Patients with three or all four variables (n=31) had significantly better survival compared with the other patients (n=13) (47 vs 20 months in median survival, P<0.0001). In these patients, fairly good median survival (40 months) was obtained even in patients with incomplete resection. Secondary cytoreductive surgery had a large impact on survival of patients with recurrent ovarian cancer when they had three or all of the above-mentioned four factors at recurrence. These patients should be considered as ideal candidates for SCS.

Use of cisplatin, 5-fluorouracil, and second-look laparotomy for the management of gastrointestinal adenocarcinoma in three dogs

Three dogs with advanced-stage adenocarcinoma of the gastrointestinal tract were treated by use of resection, adjuvant chemotherapy with cisplatin and 5-fluorouracil, and second-look laparotomy (SLL). In combination with histologic examination of biopsy specimens obtained during the procedure, SLL is the most accurate diagnostic procedure for identification of residual or recurrent microscopic or macroscopic abdominal neoplasia; however, to the authors' knowledge, there are no reports of its clinical use in the field of veterinary oncology. This lack of clinical use in animals is likely because of factors such as cost, procedure-associated risks perceived by the owners and veterinarians, lack of data to define proper clinical application, and, perhaps to some degree, an entrenched belief that treatment of advanced stage cancer in animals is inappropriate. Nevertheless, the use of SLL should be considered for evaluation of abdominal tumors or intra-abdominal metastases in dogs that appear to be in complete clinical remission near or at the anticipated completion of chemotherapy (especially if effective second-line chemotherapy protocols are available) or when secondary cytoreduction might be beneficial.

Integrated FDG PET/CT in Patients with Persistent Ovarian Cancer: Correlation with Histologic Findings

PURPOSE

To prospectively evaluate the accuracy of integrated positron emission tomography (PET) and computed tomography (CT) for depiction of persistent ovarian carcinoma after first-line treatment, with use of histologic findings as the reference standard.

MATERIALS AND METHODS

Thirty-one women (mean age, 55.9 years) with ovarian carcinoma treated with primary cytoreductive surgery and followed up with platinum regimen chemotherapy were included. All 31 patients were scheduled for surgical second-look. Before surgical second-look, all patients underwent fluorodeoxyglucose (FDG) PET/CT. At PET/CT, three main categories of persistent disease were considered for data analysis: lymph nodal lesion, peritoneal lesion, and pelvic lesion. In all patients, imaging findings were compared with results of histologic examination after surgical second-look to determine the diagnostic accuracy of PET/CT in the evaluation of disease status. The kappa statistic (Cohen kappa) was used for statistical analysis.

RESULTS

Seventeen (55%) of 31 patients had persistent tumor at histologic analysis after surgical second-look, and fourteen (45%) had no histologically proved tumor. The total number of lesions that was positive for tumor cells at histologic analysis was 41 (lymph nodes, n = 16; peritoneal lesions, n = 21; pelvic lesions, n = 4); maximum diameter of these lesions was 0.3-3.2 cm (mean, 1.7 cm). A correlation was found between PET/CT and histologic analysis (kappa = 0.48). The overall lesion-based sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of PET/CT were 78%, 75%, 77%, 89% and 57%, respectively. In the detection of a tumor, a size threshold could be set at 0.5 cm, as this was the largest diameter of a lesion missed at PET/CT.

CONCLUSION

Integrated PET/CT depicts persistent ovarian carcinoma with a high positive predictive value.

[18F]FDG PET as a substitute for second-look laparotomy in patients with advanced ovarian carcinoma

The aim of this study was to compare the prognostic value of fluorine-18 fluorodeoxyglucose positron emission tomography (FDG PET) with that of second-look laparotomy (SLL) in patients with advanced ovarian carcinoma following primary chemotherapy. Fifty-five patients who had undergone cytoreductive surgery and adjuvant chemotherapy for advanced ovarian carcinoma were enrolled in the study. Thirty patients underwent SLL after primary treatment (SLL group), while 25 underwent FDG PET after primary treatment without SLL (PET group) We retrospectively reviewed the medical records of the 55 patients for comparison of progression-free interval and disease-free interval between the two groups. Ovarian carcinomas recurred in 37 of the 55 patients. When the progression-free interval and the disease-free interval in patients in the PET group were compared with those in the SLL group, no significant differences were observed. The progression-free interval in the PET and SLL groups were 28.8 +/- 12.7 months and 30.6 +/- 13.7 months, respectively (P = 0.29). The disease-free interval in the negative PET group was 40.5 +/- 11.6 months, and that in the negative SLL group was 48.6 +/- 12.1 months (P = 0.12). In conclusion, FDG PET has a similar prognostic value to SLL, and can substitute for SLL in the follow-up of patients who have had ovarian carcinoma, especially when there is a high risk for recurrence.

[The evaluation of the second-look operation of patients with ovarian carcinoma and tubal carcinoma by means of a retrospective comparison study]

INTRODUCTION

This investigation is a retrospective analysis to evaluate the influence of second-look surgery on the relapse-free and overall survival of patients with ovarian and tubal carcinomas.

METHOD

For 208 patients with and without second-look operation out of 469 of the total collective, a matched analysis and a Cox regression model were established in the framework of a multivariate analysis.

RESULTS

Second-look surgery in patients with ovarian cancer had no significant influence on the relapse-free and overall survival. The 10-year survival was equal in both groups:

CONCLUSION

Second-look surgery cannot be justified on the basis of clinically noninvasive methods such as radiological findings with additional use of tumor markers. It should only be done in control clinical trials to evaluate new means of treatment.

Positron emission tomography scanning in gynecologic and breast cancers

PURPOSE OF REVIEW

Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose represents a noninvasive functional imaging modality that is based on metabolic characteristics of malignant tumors. The recent findings of this technique in breast cancer, cervical cancer, ovarian cancer, and other gynecologic malignancies are discussed.

RECENT FINDINGS

In breast cancer, positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose is more accurate than conventional methods for the staging of distant metastases, enables early assessment of treatment response in patients undergoing primary chemotherapy. The diagnostic accuracy for axillary lymph node staging depends on the tumor load of the lymph nodes. The sensitivity of this technique in detecting primary breast cancer is limited in small breast lesions and invasive lobular cancer. In cervical cancer it is the most accurate noninvasive method for lymph node staging and it can accurately depict recurrent ovarian cancer in patients with elevated CA125 levels. False negative findings in well differentiated adenocarcinoma and borderline lesions as well as false positive findings in benign conditions limit the role of positron emission tomography scanning for the differential diagnosis of adnex tumors.

SUMMARY

Positron emission tomography with 2-[fluorine-18]-fluoro-2-deoxy-D-glucose reveals unique information about tumor metabolism in gynecologic malignancies and breast cancer. This technique is complementary to morphological imaging for primary diagnosis, staging and re-staging. It may become the method of choice for the early assessment of treatment response in breast cancer and the detection of recurrent disease in ovarian cancer. This method, however, cannot replace invasive procedures if microscopic disease is of clinical relevance.

2-[Fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography in the diagnosis of recurrent ovarian cancer

OBJECTIVE

The aim of the study was to investigate the role of 2-[fluorine-18]-fluoro-2-deoxy-d-glucose positron emission tomography (FDG PET) in the diagnosis of recurrent ovarian cancer.

METHODS

One hundred six FDG PET scans performed in 54 patients in the follow-up after cytoreductive surgery and chemotherapy of ovarian cancer were reevaluated. Fifty-eight scans were performed in patients with suspected recurrence and 48 scans in patients who were clinically disease free. Thirty-seven PET scans were validated by histology and 66 studies by a median follow-up of 22 months in disease-free patients or 12 months in patients with recurrent disease. Three scans were validated by concordant positive findings of tumor marker CA125, computed tomography, and FDG PET.

RESULTS

FDG PET correctly identified recurrent disease in 73/88 cases. PET ruled out recurrent disease in 15/18 cases. The sensitivity and specificity for PET were 83 and 83%, respectively. In patients with suspected disease, sensitivity was 94% compared to 65% in patients judged clinically disease free. The sensitivity of PET was 96% if suspicion of recurrence was based on a rise of CA125 alone. PET preceded the conventional diagnosis by a median of 6 months in patients judged clinically free of disease. The median relapse-free interval after a negative PET scan was 20 months.

CONCLUSION

FDG PET provides the chance to detect recurrent ovarian cancer at an earlier stage during follow-up. Patients with a negative PET scan have a longer relapse-free interval than patients with a positive PET scan.