Primary treatment of epithelial ovarian malignancies

Combined TRAIL and Bax gene therapy prolonged survival in mice with ovarian cancer xenograft

We evaluated the antitumor activity of the Bax gene and green fluorescent protein/tumor necrosis factor-related apoptosis-inducing ligand (GFP/TRAIL) fusion gene driven by the human telomerase reverse transcriptase promoter both separately and combined in the human ovarian cancer lines SKOV3ip and DOV13 and human lung cancer line H1299. In vitro study showed that both TRAIL- and Bax-expressing vectors elicited significant cell killing in H1299 and SKOV3ip cells, but only the GFP/TRAIL gene elicited significant cell killing in DOV13 cells. Combined TRAIL and Bax therapy also produced more profound cell killing in SKOV3ip and H1299 cells, but not DOV13 cells without escalation of the vector doses. To further evaluate the combined effects of Bax and TRAIL, abdominally spread tumors were established in nude mice via intraperitoneal inoculation of SKOV3ip cells followed by that of adenoviral vectors. Tumor growth, ascites formation, survival duration and toxicity were evaluated after treatment. We found that treatment using the Bax- or TRAIL-expressing vector alone significantly suppressed tumor growth and ascites formation, and prolonged animal survival when compared with that of using PBS or a control vector. Combined TRAIL and Bax therapy further prolonged survival significantly when compared with therapy using the TRAIL or Bax gene alone. Transgene expression and apoptosis induction were not detected in normal human ovarian epithelial cells in vitro or normal mouse tissues in vivo after intraperitoneal vector administration. Also, liver toxicity was not detected after either treatment. Thus, combined TRAIL and Bax gene therapy may be useful for treatment of abdominally spread tumors.

Preoperative serum concentration of hCGbeta as a prognostic factor in ovarian cancer

In spite of a gradual improvement, survival in epithelial ovarian cancer is disappointingly low. New therapeutic regimens are emerging, and it would be important to be able to predict the prognosis and to stratify patients for clinical trials before therapy. We have evaluated the prognostic value of the pretreatment serum concentrations of 3 tumor markers. The free beta subunit of human chorionic gonadotropin (hCGbeta), CA125 and tumor-associated trypsin inhibitor (TATI) were measured in pretreatment serum samples from 146 patients treated for ovarian cancer between 1990-1995. The patients were followed up until 1998. Elevated concentrations of hCGbeta, CA125 and TATI were observed in 29%, 79% and 33%, respectively. When tested as single variables in Cox's proportional hazards model, stage, grade, size of residual tumor and hCGbeta (all p < 0.001) and CA125 (p = 0.004) correlated with prognosis. However, when fitted as multiple variables together with stage, grade and age in the same model, hCGbeta (RR = 3.42) stage (RR = 2.77) and grade (RR = 3.80) were the only significant variables. When serum hCGbeta was normal, 5-year survival was 80%, but it was only 22% when hCGbeta was elevated. In patients with stage III or IV and minimal residual disease, 5-year survival was 75% if hCGbeta was normal compared with 0% if hCGbeta was elevated. hCGbeta in serum is a strong independent prognostic factor in epithelial ovarian cancer, and its prognostic value is similar to that of grade and stage. The availability of this marker before surgery could facilitate selection of treatment modalities.

Weekly and monthly regimens of paclitaxel and carboplatin in the management of advanced ovarian cancer. A preliminary report on side effects

This preliminary study was carried out over 18 months to evaluate whether the side effects in patients with advanced ovarian cancer receiving chemotherapy using paclitaxel-carboplatin differed between weekly (98 cycles in 14 patients) and monthly (102 cycles in 15 patients) administrations. We used paclitaxel (60 mg/m2) and carboplatin (AUC of 2) in the weekly regimen and 175 mg/m2 of paclitaxel and carboplatin (AUC of 6) in the monthly regimen. All eligible patients received at least four cycles of treatment in both regimens. The results revealed significantly decreased hematological toxicity in weekly regimens relative to monthly ones, ie, 7.1% vs. 18.6% of anemia (> or = grade 2), 7.1% vs. 32.3% of grade 3/4 granulocytopenia, and 0% vs. 15.7% of >grade 2 thrombocytopenia. There was no significant difference in nonhematological toxicities between the two regimens. The incidence of unscheduled events was much less in the weekly regimen than in the monthly one; ie, delayed treatment (3 vs. 18 events), unanticipated hospitalizations (3 vs. 15 times), and supplemental support with G-CSF (7 vs. 33 times). Complete responses were observed in 6 of 14 patients in the weekly regimen and in five of 15 patients in the monthly regimen, while partial responses were seen in four and five patients in the weekly and monthly regimens, respectively. The present results demonstrate that the weekly regimen can achieve the benefits of tolerable toxicity with significantly reduced myelosuppression and improved cost-effectiveness in terms of unscheduled events.

[Results of a randomized prospective trial comparing postoperative abdominopelvic radiotherapy with postoperative chemotherapy in early ovarian cancer]

PURPOSE

In a prospective randomized trial, our aim was to evaluate and compare the tolerance and efficacy of postoperative radiotherapy and chemotherapy in the treatment of early ovarian cancer.

MATERIAL AND METHODS

Between 1990 and 1996, 150 patients with ovarian cancer stage IA, IB grades G2-3, and all patients classified IC and IIA, who did not have evidence of residual disease after surgery, were randomized to two treatment branches: radiotherapy or chemotherapy (CH). In the radiotherapy branch (76 patients), a whole abdomen irradiation of 30 Gy in 24 fractions over 5 weeks, with a pelvic boost to 50 Gy, was delivered. In the chemotherapy branch (74 patients), there were six series of polychemotherapy separated with 3-weeks interval. In each series patients received association of cisplatin (50 mg/m2, d1), adriamycin (50 mg/m2, d1) and cyclophosphamide (500 mg/m2, d1).

RESULTS

The tolerance of the treatment was good and comparable in both groups. In the radiotherapy branch, three late grade G3 intestinal complications were observed (three bowel obstructions, which required surgery in two cases). The actuarial survival rate without evidence of disease was 81% at 5 years for both groups. In our series we found that histological grade had the strongest influence on survival prognosis; it was the only significant factor in a multivariate analysis. Patients with grade G3 tumors had the worst survival.

CONCLUSION

These data suggest that efficacy of postoperative radiotherapy and chemotherapy administered to our patients with early ovarian cancer gave approximately identical results.

Chemotherapy for ovarian cancer: current concepts

Ovarian cancer is the most common gynecologic cancer and has the highest case-fatality rate of all gynecologic malignancies: over one-half of all women diagnosed with ovarian cancer die of their disease. Chemotherapy for epithelial ovarian carcinoma has evolved rapidly during the last 15 years. Demonstrations that combination chemotherapy was superior to single-agent therapy began to improve outcome among women with this disease. By 1990, the advent of the platinum compounds had improved response rate, and the new standard of care combined platinum with alkylating agents. Recently, more significant progress has been made with utilization of the taxanes, which demonstrate not only improved response rates, but significantly prolonged survival as well. The most current clinical trials have established that taxane/platinum combination chemotherapy should be the standard of care for epithelial ovarian cancer. Recent and ongoing studies also address such issues as relative efficacy of different doses of taxanes and platinum, length of infusion for the taxanes, and interchangeability of the platinum compounds. This broad overview of the development of current standards of treatment also will address unresolved issues in this field, including intraperitoneal administration of chemotherapy and dose intensification.

Classification of 1H MR spectra of biopsies from untreated and recurrent ovarian cancer using linear discriminant analysis

Proton (1H) magnetic resonance (MR) spectra of ex vivo biopsy samples of ovarian cancers provided biochemical information that was used to discriminate cancer from normal ovarian tissue. Possible differences present in intrinsically resistant tumors or changes in biochemistry after the induction of resistance were identified. Using multivariate techniques, in particular linear discriminant analysis (LDA), ovarian cancer was distinguished from normal ovarian tissue with a sensitivity of 100%, a specificity of 95% and an accuracy of 98%. Moreover, LDA was able to distinguish untreated ovarian cancer from recurrent ovarian cancer with a sensitivity of 92%, a specificity of 100%, and an accuracy of 97%; removal of the single "fuzzy" specimen increased the accuracy to 100%. Applications of this knowledge to in vivo measurements could lead to noninvasive diagnosis of ovarian cancer.

Ovarian cancer. Current outlook on this deadly disease

The lifetime risk of ovarian cancer in the US population is about 1.4%. The risk is increased in women who have a strong family history of the disease. Unfortunately, no accurate screening tests are available. Transvaginal sonography and CA-125 determinations can be valuable in selected patients. Attempts at prevention with oral contraceptive use and indicated or prophylactic oophorectomy should be seriously considered. Conservative treatment is appropriate in selected patients with early-stage ovarian cancer. However, because the majority of patients present with advanced disease, maximum cytoreductive surgery followed by chemotherapy is usually required. Such an approach results in a high incidence of initial clinical remission and can prolong survival to 2 or 3 years. Eventually, however, relapse and death often occur in spite of additional therapy. Another operation may be needed for secondary cytoreduction or palliation. Bowel obstruction, recurrent ascites, and pleural effusion are often terminal events.

A phase I trial of intraperitoneal carboplatin and etoposide with granulocyte macrophage colony stimulating factor support in patients with intraabdominal malignancies

BACKGROUND

Although somewhat controversial, there are data to suggest that patients with ovarian cancer may experience a survival advantage if the dose intensity of platinum-containing regimens can be maximized. Administration of chemotherapeutic agents via the intraperitoneal route offers the opportunity to increase dose intensity of several chemotherapeutic agents.

METHODS

The authors conducted a Phase I trial of intraperitoneal carboplatin and etoposide in combination with granulocyte macrophage colony stimulating factor (GM-CSF) in an attempt to determine the maximum tolerated dose of carboplatin. The starting dose for carboplatin was 300 mg/m2 and for etoposide 400 mg/m2. The dose of carboplatin was escalated while the etoposide was maintained at the initial dose. The total dose of each agent was calculated and given daily over 3 days in amounts equal to one-third of the total dose. On day 1 of therapy, one-third of the dose was mixed in 2 liters of dextrose (D5W) and administered intraperitoneally (IP) as rapidly as possible. On Days 2 and 3, one-third of the dose was mixed in 1 liter of D5W and administered similarly. GM-CSF was begun on Day 4 as a subcutaneous injection at a dose of 500 micrograms/m2/d.

RESULTS

Unacceptable hematologic toxicity was encountered at a carboplatin dose of 800 mg/m2; therefore, a carboplatin dose of 600 mg/m2 is recommended for Phase II studies. An overall response rate of 54% with a complete response rate of 17% was observed in patients with ovarian cancer. The overall response rate for all patients was 45%.

CONCLUSION

Because of the significant toxicity encountered in this study, it is recommended that this regimen be used only in the context of a clinical study. The recommended Phase II study dose for this combination is carboplatin 600 mg/M2 and a total dose of etoposide 400 mg/M2 total dose given as three equal parts IP over 3 days. GM-CSF should begin on Day 4 at a dose of 500 micrograms/m2/day subcutaneously and should continue until the absolute neutrophil count is greater than 1000 granulocytes on 3 successive days.

A randomised study of cisplatin versus thiotepa as induction chemotherapy in advanced ovarian carcinoma

Between 1980 and 1984, a total of 171 patients with advanced epithelial ovarian carcinoma and residual tumour after surgery were randomly assigned to treatment groups receiving either cisplatin or thiotepa. The objective of the study was to evaluate the regimes with regard to response and survival. The two groups were well balanced with respect to age, FIGO stage, histology, grade and residual tumour after surgery. In the cisplatin group, 66% responsed to treatment compared to 38% in the thiotepa group (P < 0.00005). The median progression-free survival was 10.5 months and 6.3 months, respectively. The corrected survival was somewhat, but non-significantly, higher in the cisplatin group than in the thiotepa group, with an 8-year corrected survival of 10.6 and 7.4%, respectively. In a multivariate analysis, based on progression-free survival with FIGO stage, residual tumour after surgery, histological type and grade as covariables, treatment with thiotepa had a relative risk of 1.64 compared to cisplatin (95% confidence interval 1.17-2.30, P = 0.004).