The role of neoadjuvant chemotherapy in treating advanced epithelial ovarian cancer

The Effects of Negative Elements in Environment and Cancer on Female Reproductive System

With the development of human society, factors that contribute to the impairment of female fertility is accumulating. Lifestyle-related risk factors, occupational risk factors, and iatrogenic factors, including cancer and anti-cancer treatments, have been recognized with their negative effects on the function of female reproductive system. However, the exact influences and their possible mechanism have not been elucidated yet. It is impossible to accurately estimate the indexes of female fertility, but many researchers have put forward that the general fertility has inclined through the past decades. Thus the demand for fertility preservation has increased more and more dramatically. Here we described some of the factors which may influence female reproductive system and methods for fertility preservation in response to female infertility.

Involvement of non-coding RNAs in chemotherapy resistance of ovarian cancer

Ovarian cancer (OC) is the most lethal gynecological malignancy, with a low 5-year survival rate. Most patients with ovarian cancer are diagnosed in late-stages. A rising number of non-coding RNAs (ncRNAs) have been found to act as key regulators of gene expression by applying novel high-thought methods, such as next generation sequencing (NGS). Non-coding RNAs not only play important roles in carcinogenesis, but also affect the clinical treatment strategies. One of the biggest challenge in OC treatment was chemoresistance, which causes poor prognosis and high recurrence rate after applying traditional remedies. Of note, it has been proved that ncRNAs were deeply correlated with chemoresistance in several cancers, which made ncRNAs considered to be potential therapeutic targets in ovarian cancer. Among of all ncRNAs, the studies of miRNAs and lncRNAs in ovarian cancer chemoresistance were much clearer. In this study, we reviewed the most relevant researches in this field, and described the relationships between ncRNAs and chemoresistance in ovarian cancer.

Stonin 2 Overexpression is Correlated with Unfavorable Prognosis and Tumor Invasion in Epithelial Ovarian Cancer

Stonin 2 (STON2), which functions in adjusting endocytotic complexes, is probably involved in the monitoring of the internalization of dopamine D2 receptors which have an inhibitory action of dopamine on tumor progression. However, its clinical significance in tumor progression and prognosis remains unclear. We explored the association between STON2 and the clinicopathological characteristics of epithelial ovarian cancer (EOC). The STON2 levels in ovarian cancer and normal cell lines and tissues were detected by real-time PCR and Western blot analyses. STON2 protein expression was also detected by an immunohistochemical analysis. The clinical significance of STON2 expression in ovarian cancer was statistically analyzed. STON2 significantly increased in the ovarian cancer cell lines and tissues compared to the normal ones. In the 89 EOC samples tested, STON2 expression was significantly correlated with intraperitoneal metastasis, intestinal metastasis, intraperitoneal recurrence, ascites containing tumor cells, and CA153 level. Moreover, patients with STON2 protein overexpression were more likely to exhibit platinum resistance and to have undergone neoadjuvant chemotherapy. Patients with high STON2 protein expression had a tendency to have a shorter overall survival and a poor prognosis. A multivariate analysis showed that STON2 was an independent prognostic predictor for EOC patients. In conclusion, STON2 plays an important role in the progression and prognosis of ovarian carcinoma, especially in platinum resistance, intraperitoneal metastasis, and recurrence. STON2 can be a novel antitumor drug target and biomarker which predicts an unfavorable prognosis for EOC patients.

Clinical validation of chemotherapy predictors developed on global microRNA expression in the NCI60 cell line panel tested in ovarian cancer

OBJECTIVE

Ovarian cancer is the leading cause of death among gynecologic malignancies. This is partly due to a non-durable response to chemotherapy. Prediction of resistance to chemotherapy could be a key role in more personalized treatment. In the current study we aimed to examine if microRNA based predictors could predict resistance to chemotherapy in ovarian cancer, and to investigate if the predictors could be prognostic factors for progression free and overall survival.

METHODS

Predictors of chemotherapy-resistance were developed based on correlation between miRNA expression and differences in measured growth inhibition in a variety of human cancer cell lines in the presence of Carboplatin, Paclitaxel and Docetaxel. These predictors were then, retrospectively, blindly validated in a cohort of 170 epithelial ovarian cancer patients treated with Carboplatin and Paclitaxel or Docetaxel as first line treatment.

RESULTS

In a multivariate cox proportional analysis the predictors of chemotherapy-resistance were not able to predict time to progression after end of chemotherapy (hazard ratio: 0.64, 95% CI: 0.36-1.12, P = 0.117). However, in a multivariate logistic analysis, where time to progression was considered as either more or less than 6 months, the predictors match clinical observed chemotherapy-resistance (odds ratio: 0.19, 95% CI: 0.05-0.73, P = 0.015). Neither univariate nor multivariate, time-dependent, cox analysis for progression free survival (PFS) or overall survival (OS) in all 170 patients showed to match predicted resistance to chemotherapy (PFS: hazard ratio: 0.69, 95% CI: 0.40-1.19, P = 0.183, OS: hazard ratio: 0.76, 95% CI: 0.42-1.40, P = 0.386).

CONCLUSION

In the current study, microRNA based predictors of chemotherapy-resistance did not demonstrate any convincing correlation to clinical observed chemotherapy-resistance, progression free survival, or overall survival, in patients with epithelial ovarian cancer. However the predictors did reflect relapse more or less than 6 months.

Insulin-Like Growth Factors and Their Binding Proteins in Tumors and Ascites of Ovarian Cancer Patients: Association With Response To Neoadjuvant Chemotherapy

Purpose: Tumor cell growth and sensitivity to chemotherapy depend on many factors, among which insulin-like growth factors (IGFs) may play important roles. The aim of the present study was to evaluate the levels of insulin-like growth factors (IGFs) and IGF binding proteins (IGFBPs) in primary tumors and ascites as predictors of response to neoadjuvant chemotherapy in ovarian cancer (OC) patients. Materials and Methods: Tumor tissue samples and ascitic fluid were obtained from 59 patients with advanced OC. The levels of IGF-I, IGF-II, IGFBP-3, IGFBP-4 and PAPP-A were determined using ELISA kits. Taking into account the data on expression of these IGF-related proteins and outcome, logistic regression was performed to identify predictors of response to neoajuvant chemotherapy. Results: Human ovarian tumors expressed IGFs, IGFBP-3, IGFBP-4 and PAPP-A and these proteins were also present in ascites fluid and associated with its volume. IGFs and IGFBPs in ascites and soluble PAPP-A might play a key role in ovarian cancer progression . However, levels of proteins of the IGF system in tumors were not significant predictors of objective clinical response (oCR). Univariate analysis showed that the level of IGF-I in ascites was the only independent predictor for oCR. Conclusion: The level of IGF-I in ascites was shown to be an independent predictor of objective clinical response to chemotherapy for OC patients treated with neoadjuvant chemotherapy and debulking surgery.

Differential role of microRNAs in prognosis, diagnosis, and therapy of ovarian cancer

Ovarian cancer (OC) is the most lethal of malignant gynecological cancers, and has a very poor prognosis, frequently, attributable to late diagnosis and responsiveness to chemotherapy. In spite of the technological and medical approaches over the past four decades, involving the progression of several biological markers (mRNA and proteins biomarkers), the mortality rate of OC remains a challenge due to its late diagnosis, which is expressly ascribed to low specificities and sensitivities. Consequently, there is a crucial need for novel diagnostic and prognostic markers that can advance and initiate more individualized treatment, finally increasing survival of the patients. MiRNAs are non-coding RNAs that control target genes post transcriptionally. They are included in tumorigenesis, apoptosis, proliferation, invasion, metastasis, and chemoresistance. Several studies have within the last decade demonstrated that miRNAs are dysregulated in OC and have possibilities as diagnostic and prognostic biomarkers for OC. Additionally; recent studies have also focused on miRNAs as predictors of chemotherapy sensitivities and their potential as therapeutic targets. In this review, we discuss the current data involving the accumulating evidence of the altered expression of miRNAs in OC, their role in diagnosis, prognosis, and forecast of response to therapy. Given the heterogeneity of this disease, it is likely that advances in long-term survival might be also attained by translating the recent insights of miRNAs participation in OC into new targeted therapies that will have a crucial effect on the management of ovarian cancer.

Current status on microRNAs as biomarkers for ovarian cancer

Ovarian cancer (OC) is the most lethal gynecological malignancy in the Western world, and has a very poor prognosis, often due to late diagnosis and emergence of chemotherapy resistance. Therefore, there is an essential need for new diagnostic and prognostic markers that can improve and initiate more personalized treatment, eventually improving survival of the patients. MicroRNAs are small, non-coding RNA molecules, that post-transcriptionally regulate gene expression. Several studies have within the last decade shown that microRNAs are deregulated in OC and have potential as diagnostic and prognostic biomarkers for OC. Recently studies have also focused on microRNAs as predictors of chemotherapy responses and their potential as therapeutic targets. However, many of the published studies are difficult to interpret as a whole due to various methods of analysis. Future focus should be aimed at developing a general standardized analytical method, which can limit differences between studies thus allowing easier comparison across them. In addition, validation of studies in independent series that ideally should be histotype-specific is essential to determine the clinical role of microRNAs in different types of OC. In this review we summarize the current knowledge of microRNAs as potential biomarkers for OC, with focus on their clinical relevance.

High response rates to neoadjuvant platinum-based therapy in ovarian cancer patients carrying germ-line BRCA mutation

Preoperative therapy provides an advantage for clinical drug assessment, as it involves yet untreated patients and facilitates access to the post-treatment biological material. Testing for Slavic founder BRCA mutations was performed for 225 ovarian cancer (OC) patients, who were treated by platinum-based neoadjuvant therapy. 34 BRCA1 and 1 BRCA2 mutation carriers were identified. Complete clinical response was documented in 12/35 (34%) mutation carriers and 8/190 (4%) non-carriers (P = 0.000002). Histopathologic response was observed in 16/35 (46%) women with the germ-line mutation versus 42/169 (25%) patients with the wild-type genotype (P = 0.02). Somatic loss of heterozygosity (LOH) for the remaining wild-type BRCA1 allele was detected only in 7/24 (29%) post-neoadjuvant therapy residual tumor tissues as compared to 9/11 (82%) BRCA1-associated OC, which were not exposed to systemic treatment before the surgery (P = 0.009). Furthermore, comparison of pre- and post-treatment tumor material obtained from the same patients revealed restoration of BRCA1 heterozygosity in 2 out of 3 sample pairs presenting with LOH at diagnosis. The obtained data confirm high sensitivity of BRCA-driven OC to platinating agents and provide evidence for a rapid selection of tumor cell clones without LOH during the course of therapy.

Positive peritoneal cytology at interval surgery is a poor prognostic factor in patients with stage T3c advanced ovarian carcinoma: A retrospective study

AIM

The purpose of our study is to investigate clinically significant prognostic factors at the time of interval surgery (IS), comprising interval look surgery and interval debulking surgery, for T3c (International Federation of Gynecology and Obstetrics stage IIIc to IV) advanced ovarian cancer (AOC) patients during primary treatment.

METHODS

We reviewed records of patients with T3c AOC who underwent IS following neoadjuvant chemotherapy or up-front primary debulking surgery with adjuvant chemotherapy at our institution between January 1996 and December 2010. For analysis of prognostic factors, cytology of peritoneal exfoliative cells at IS was added to clinicopathological variables.

RESULTS

A retrospective analysis was performed on 50 cases. The median age was 61.1 years (range, 38-78), with median follow-up of 45.9 months (range, 12-122). Macroscopic tumors were completely resected in 32 cases (64%) at IS. Univariate analyses of clinicopathological factors for IS identified preoperative serum cancer antigen-125 levels (≥20 IU/mL; P = 0.0539), number of residual lesions at IS (≥20; P = 0.0554), incomplete surgery at IS (P = 0.0171) and positive peritoneal cytology at IS (P = 0.0015) as significant factors for prognosis regarding progression-free survival (PFS). Multivariate analysis identified positive peritoneal cytology (P = 0.0303) as a unique independent predictor of poor prognosis in PFS.

CONCLUSION

Positive peritoneal cytology at IS appears to be a significant factor for poor prognosis in PFS, which may provide useful information for post-IS chemotherapy planning. IS in the treatment of AOC may be useful for not only complete resection, but also for identification of patients with poor prognosis.

Natural history of epithelial ovarian cancer and its relation to surgical and medical treatment

Epithelial ovarian cancer (EOC) represents approximately 90% of primary malignant ovarian tumors, the sixth most common cancer in women and the second most common gynecologic cancer. Approximately 80%-85% of all ovarian carcinomas in Western society are serous and up to 95% of patients are in advanced stages (FIGO stage III-IV) at diagnosis. Treatment of ovarian cancer is mainly based on three key approaches: surgical removal of neoplasia; chemotherapy to kill cancer cells; direct chemotherapy on peritoneal surfaces. The application of hyperthermic chemotherapy to the peritoneal cavity (HIPEC) after radical surgery may also be an attractive option. We analyzed the natural history of EOC in the literature and identified various time-points where sensitivity to chemotherapy, freedom from disease and overall survival are different. We propose eight time-points in EOC history with homogeneous oncological findings. The effectiveness of HIPEC in EOC treatment should be evaluated based on these eight time-points and we believe that retrospective and prospective studies of HIPEC should be evaluated according to these time-points.

microRNA-106a modulates cisplatin sensitivity by targeting PDCD4 in human ovarian cancer cells

microRNAs (miRNAs/miRs) are a cluster of short non-protein coding RNAs that negatively regulate gene expression, which is involved in fundamental cellular processes, including the response of tumor cells to chemotherapeutic agents. The present study investigated the role of miR-106a in the development of drug resistance in ovarian cancer cells. The expression of miR-106a in the ovarian cancer OVCAR3 cell line and the cisplatin (CDDP)-resistant ovarian cancer OVCAR3/CIS cell line was detected using stem-loop quantitative (q)PCR. The OVCAR3 and OVCAR3/CIS cells were transfected with mimics or inhibitors of miR-106a or with negative control (NC) RNA using lipofectamine 2000. Luciferase reporter assays were used to determine whether PDCD4 was a direct target of miR-106a in the OVCAR3 cells. The expression levels of the PDCD4 proteins were assessed using qRT-PCR and western blotting, respectively. Drug sensitivity was analyzed using a 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, while apoptosis was determined by fluorescence-activating cell sorting analysis. The expression levels of miR-106a were upregulated in the CDDP-resistant ovarian cancer OVCAR3/CIS cell line compared with the parental OVCAR3 cell line. However, the PDCD4 protein levels were decreased in the OVCAR3/CIS cells compared with the OVCAR3 cells. The luciferase reporter assays revealed that PDCD4 was a direct miR-106a target in the OVCAR3 cells. Transfection of the OVCAR3/CIS cells with inhibitors of miR-106a enhanced the sensitivity of the OVCAR3/CIS cells to CDDP and increased CDDP-induced apoptosis. The expression of the PDCD4 protein and the sensitivity to CDDP was decreased in the OVCAR3 cells that were transfected with the mimics of miR-106a. The knockdown of PDCD4 expression using PDCD4-specific siRNAs in the OVCAR3 cells demonstrated that PDCD4 is a key signaling molecule in OVCAR3 cell CDDP-induced resistance. miR-106a may be involved in the development of drug resistance and the regulation of PDCD4 expression, at least in part, by modulating CDDP-induced apoptosis in ovarian cancer cells.

Neoadjuvant chemotherapy in ovarian, primary peritoneal and tubal carcinoma: can imaging results prior to interval debulking predict survival?

Objective

To assess whether there is an association between improvement of computed tomography imaging results prior to interval debulking with survival in patients treated by neoadjuvant chemotherapy.

Methods

The clinical and outcome data of all advanced ovarian, primary peritoneal and tubal carcinoma patients who after diagnosis had neoadjuvant chemotherapy and underwent interval debulking during the period 2000-2010, were abstracted. Results of computed tomography imaging at diagnosis and prior to interval debulking were compared. Two parameters were assessed: the change of the size and number of abnormal findings and the change in the amount of ascites. CA-125 level response was also calculated. An assessment of progression free survival and of survival by the Kaplan-Meier method was made according to the change in computed tomography imaging results and according to response of CA-125 levels.

Results

The median progression free survival and the median survival of the 37 study group patients were 7.9 and 49.2 months respectively. No significant difference in progression free survival and survival was observed between patients with marked improvement in the computed tomography results and those with less desirable results (7.93 vs. 7.23 months respectively, p=0.89; 45.8% vs. 52.5% months respectively, p=0.95). There were also no statistically significant difference according to CA-125 level response.

Conclusion

It seems that neither improvement in imaging results nor CA-125 level response can predict the survival of ovarian carcinoma patients prior to interval debulking after neoadjuvant chemotherapy.

Neoadjuvant chemotherapy in the Medicare cohort with advanced ovarian cancer

OBJECTIVE

The value of neoadjuvant chemotherapy (NAC) for the treatment of advanced ovarian cancer has yet to be determined. While NAC may facilitate and simplify complete cytoreduction and reduce the risk of surgery, the delay of surgery related to NAC needs to be balanced against any potential benefit.

METHODS

Surveillance, Epidemiology and End-Results (SEER) data linked to Medicare claims were used to identify 6844 women with treated stage III/IV epithelial ovarian cancer (1995-2005). Patients were classified by primary treatment (surgery (PDS) or chemotherapy), and the primary chemotherapy group was characterized as having NAC or palliative chemotherapy (PC) based on whether there was documentation that surgery was recommended. We compared surgical complications and survival between the groups.

RESULTS

4827 (71%) of women were treated with PDS, 958 received NAC (14%) and 1059 (15%) had PC. Only 577 (60%) of women with NAC underwent surgery and they had fewer ostomies (8.5% vs. 19.2%, p<0.001) and fewer infections, gastrointestinal and pulmonary complications than PDS (all p<0.01). Comparing NAC to PDS there was a 16% increase in the risk of death at 2years (RR 1.16, 95%CI 1.01-1.34) for women with stage III disease and a 15% reduction in the risk for women with stage IV disease (RR 0.85, 95%CI 0.73-0.99).

CONCLUSIONS

NAC followed by surgery was associated with fewer surgical complications than PDS. The direction and magnitude of the difference in survival between women receiving NAC and those receiving PDS differed according to the stage of disease and follow up time.

Bim protein degradation contributes to cisplatin resistance

Cisplatin is the first-line chemotherapy for the treatment of several cancers. However, the development of cisplatin resistance represents a major clinical problem, and the mechanisms of acquired resistance are not fully understood. Here we show that degradation of the Bcl-2 homology 3-only proapoptotic protein Bim plays an important role in cisplatin resistance in ovarian cancer. Specifically, we show that treatment of ovarian cancer cells with cisplatin caused Bim phosphorylation and subsequent degradation and that its degradation is associated with cisplatin resistance. We also show that cisplatin treatment caused the activation of ERK, which correlated with Bim phosphorylation and degradation. By inhibiting ERK phosphorylation with the MEK inhibitor and knocking down ERK expression with siRNA, we show that Bim phosphorylation and degradation were blocked, which suggests that Bim is phosphorylated by ERK and that such phosphorylation is responsible for cisplatin-induced Bim degradation. We show that ERK was activated in cisplatin-resistant OV433 cells as compared with their counterpart parental OV433 cells. We also show that Bim was phosphorylated and degraded in cisplatin-resistant OV433 cells but not in the parental OV433 cells. Importantly, we show that inhibition of Bim degradation by the proteasome inhibitor MG132 sensitized resistant OV433 cells to cisplatin-induced death. Taken together, our data indicate that degradation of Bim via ERK-mediated phosphorylation can lead to cisplatin resistance. Therefore, these findings suggest that cisplatin resistance can be overcome by the combination of cisplatin and the proteasome inhibitors in ovarian cancer cells.

Neoadjuvant intraperitoneal chemotherapy with paclitaxel for the radical surgical treatment of peritoneal carcinomatosis in ovarian cancer: a prospective pilot study

PURPOSE

The admitted benefits of intraperitoneal chemotherapy during postoperative administration for the treatment of peritoneal carcinomatosis from ovarian origin are limited by their associated morbidity and restricted diffusion by the presence of multiple intra-abdominal adherences. The purpose of the study was to evaluate the security, effectiveness, and cytoreduction optimization of intraperitoneal paclitaxel administration previously to radical surgery/peritonectomy/HIPEC (hyperthermic intraoperative intraperitoneal chemotherapy) either in monotherapy or combined with intravenous carboplatin.

METHODS

Prospective pilot study of 10 patients with ovarian peritoneal carcinomatosis in stage IIIc-FIGO without previous treatment. After staging of the diseases by laparoscopy, five patients received paclitaxel by weekly intraperitoneal administration (60 mg/m(2), 10 cycles), and other five patients additionally received intravenous carboplatin every 21 days (AUC 6, 4 cycles). Subsequently radical surgery/peritonectomy with HIPEC was performed.

RESULTS

The presence of moderate abdominal pain was the most common (70%) side effect associated with neoadjuvant paclitaxel intraperitoneal administration. The intravenous carboplatin administration was not associated with significant increase in adverse effects. It boosted intraperitoneal paclitaxel-associated antitumoral activity with a high average decrease in Index Cancer Peritoneal (21.2 vs. 14.4, P = 0.066) and CA 125(1,053 vs. 346, P = 0.043). All the patients who received combined neoadjuvant chemotherapy obtained R0 cytoreduction. Five-year overall survival was 62%.

CONCLUSIONS

The intraperitoneal paclitaxel weekly administration combined with intravenous carboplatin administration prior to radical surgery/peritonectomy with HIPEC is a safe and effective option in the treatment of ovarian peritoneal carcinomatosis. This study shows the possibility to investigate other forms of intraperitoneal chemotherapy and their combinations thoroughly.

Trends in treatment of advanced epithelial ovarian cancer in the Medicare population

OBJECTIVE

Optimal care for most patients with advanced ovarian cancer generally includes both surgery and chemotherapy. Little is known about the proportion of women in the US who receive combination care or the sequence in which this care is delivered. This study evaluated patterns of care, frequency of completion of recommended therapy and factors associated with sequencing of therapy.

METHODS

Using the Surveillance, Epidemiology and End-Results data we identified a cohort of 8211 women aged 65 and above with stage III/IV epithelial ovarian cancer diagnosed between 1995 and 2005. Receipt of chemotherapy or surgery was identified using Medicare claims. Logistic regression was used to evaluate factors associated with sequencing of treatment and the receipt of surgery.

RESULTS

3241 (39.1%) had surgery and at least 6 cycles of chemotherapy in either order. Surgery was performed initially in 4827 (58.8%) women and 3658/4827 (75.8%) had subsequent chemotherapy. 2017 (24.6%) had primary chemotherapy and 649/2017 (32.2%) of these women had subsequent surgery. Advanced age, African American race, stage IV disease, non-married status and increasing medical comorbidity were all associated with the failure to receive both surgery and at least 6 cycles of chemotherapy (all p<0.01).

CONCLUSIONS

The majority of women with advanced ovarian cancer in the Medicare population do not receive both combination therapy with surgery and at least 6 cycles of chemotherapy. A large proportion of women are receiving chemotherapy as primary treatment for advanced ovarian cancer, and the majority of these patients do not have cancer-directed surgery.

The Role of Surgery in the Management of Epithelial Ovarian Cancer

Background

Epithelial ovarian cancer is the most deadly gynecologic cancer in the United States. Multiple modalities of therapy are utilized in the management of the disease. The role of surgery remains important in the treatment of this disease and is described herein.

Methods

Medline and PubMed were utilized to search the English language medical literature up to March 2010. A broad range of studies and quality of data were analyzed, including prospective studies, case control analyses, and meta-analyses. When possible, the highest level of evidence was reviewed and presented.

Results

For the medically fit patient, optimal cytoreductive surgery positively impacts survival. For some highly selected patients, there is a role for a minimally invasive approach. In the recurrent setting, factors such as interval to recurrence and the distribution of disease will determine the utility of secondary cytoreductive surgery. A subgroup of patients may benefit from palliative surgical procedures in the recurrent setting.

Conclusions

Despite advances in the use of chemotherapy and biologic agents, surgery remains an important modality in the diagnosis and treatment of ovarian cancer.

Centralized treatment of advanced stages of ovarian cancer improves survival: a nationwide Danish survey

OBJECTIVE

This retrospective, nationwide, observational study was designed to compare treatment in tertiary referral centers vs. regional hospitals on overall survival for patients with stage IIIC and IV ovarian cancer.

MATERIAL AND METHODS

The study took place in all gynecological departments in Denmark, involving a total of 1,160 patients with stage IIIC or IV ovarian cancer. Data were extracted for 2,024 patients with all stages of ovarian cancer recorded in the Danish Gynecological Cancer Database between 1 January 2005 and 31 December 2008. The main outcome measure was overall survival.

RESULTS

No difference was found between tertiary centers and regional hospitals with regard to age, body mass index, American Society of Anesthesiologists score or comorbidity. Patients in regional hospitals had poorer Eastern Cooperative Oncology Group performance status, i.e.1.0 vs. 2.0 (p= 0.005). Patients in referral centers presented more often with stage IIIC and IV disease, i.e. 59.7 vs. 51.7% (p < 0.001). Patients with stage IIIC and IV disease in regional vs. tertiary hospitals had a higher rate of primary cytoreductive surgery, i.e. 89.5 vs. 82.5% (p= 0.004), a poorer rate of complete cytoreductive surgery following primary cytoreductive surgery, i.e. 13.9 vs. 25.2% (p < 0.001), a lower rate of neoadjuvant chemotherapy, i.e. 5.5 vs. 13.4% (p < 0.001), and more often underwent acute surgery, i.e. 17.0 vs. 9.2% (p < 0.001). Patients treated in referral centers had better overall survival (p= 0.021). Treatment in a referral center was an independent prognostic factor for overall survival hazard ratio, 0.83 (confidence interval 0.70-0.98).

CONCLUSION

Patients with stage IIIC and IV ovarian cancer benefit from treatment in a tertiary referral center.

Safety and potential benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) in peritoneal carcinomatosis from primary or recurrent ovarian cancer

OBJECTIVES

To analyze the outcomes of cytoreductive surgery and HIPEC in patients with peritoneal carcinomatosis from ovarian cancer.

METHODS

Fifty-three patients with peritoneal carcinomatosis from primary (45 cases) and recurrent (8 cases) ovarian cancer were previously treated by systemic chemotherapy with platinum and taxanes and then submitted to surgical cytoreduction and HIPEC (cisplatin and mitomycin-C) with a closed abdomen technique. The median follow-up period was 27 months (range: 3-107).

RESULTS

At the end of operation a complete cytoreduction (CCR-0) was obtained in 37 patients (70%). Major morbidity occurred in 12 patients (23%); reoperation was necessary in 2 patients (4%), and no postoperative mortality was observed. Overall 5-year survival probability was 55%; it was 71% in CCR-0, 44% in CCR-1, and none in patients with CCR-2 or CCR-3 residual tumor (log-rank test: P = 0.017). The cumulative risk of recurrence in 37 CCR-0 cases was 54% at 5 years from operation.

CONCLUSIONS

The results of our study indicate the feasibility and the potential benefit of a protocol including systemic chemotherapy, surgical cytoreduction and HIPEC in patients with peritoneal carcinomatosis from ovarian cancer. A phase III trial to compare this approach with conventional treatment is needed.