Pilot evaluation of high-dose carboplatin and paclitaxel followed by high-dose melphalan supported by peripheral blood stem cells in previously untreated advanced ovarian cancer: a gynecologic oncology group study

Abagovomab as maintenance therapy in patients with epithelial ovarian cancer: a phase III trial of the AGO OVAR, COGI, GINECO, and GEICO--the MIMOSA study

PURPOSE

To determine whether abagovomab maintenance therapy prolongs recurrence-free (RFS) and overall survival (OS) in patients with ovarian cancer in first clinical remission.

PATIENTS AND METHODS

Patients with International Federation of Gynecology and Obstetrics stage III to IV ovarian cancer in complete clinical remission after primary surgery and platinum- and taxane-based chemotherapy were randomly assigned at a ratio of 2:1 in a phase III, double-blind, placebo-controlled, multicenter study. Abagovomab 2 mg or placebo was administered as 1-mL suspension once every 2 weeks for 6 weeks (induction phase) and then once every 4 weeks (maintenance phase) until recurrence or up to 21 months after random assignment of the last patient. The primary end point was RFS; secondary end points were OS and immunologic response.

RESULTS

Characteristics of the 888 patients included: mean age, 56.3 years; Eastern Cooperative Oncology Group performance status, ≤ 1 in > 99% of patients; serous papillary subtype, 81.5%; stage III, 85.9%; and cancer antigen 125 ≤ 35 U/mL after third cycle, 80.9%. Mean exposure to study treatment (± standard deviation) was 449.7 ± 333.08 days. Hazard ratio (HR) of RFS for the treatment group using tumor size categorization (≤ 1 cm, > 1 cm) was 1.099 (95% CI, 0.919 to 1.315; P = .301). HR of OS using tumor size categorization (≤ 1 cm, > 1 cm) was 1.150 (95% CI, 0.872 to 1.518; P = .322). The most frequently reported type of adverse event was an injection site reaction in 445 patients (50.2%), followed by injection site erythema and fatigue in 227 (25.6%) and 212 patients (23.9%), respectively. By the final visit, median anti-anti-idiotypic antibody level was 493,000.0 ng/mL, indicating a robust response.

CONCLUSION

Abagovomab administered as repeated monthly injections is safe and induces a measurable immune response. Administration as maintenance therapy for patients with ovarian cancer in first remission does not prolong RFS or OS.

Abagovomab: an anti-idiotypic CA-125 targeted immunotherapeutic agent for ovarian cancer

Ovarian cancer remains the leading cause of death due to gynecologic malignancies. Most patients present with advanced disease at the time of diagnosis. Although many have a good initial response to surgical debulking and platinum-based chemotherapy, relapse is common, with the eventual development of chemotherapy resistance. Innovative treatments are needed in the remission setting to prolong the disease-free interval or prevent recurrence. Abagovomab is a murine monoclonal anti-idiotypic antibody (molecular weight: 165-175 kDa) that functionally imitates the tumor-associated antigen, CA-125. It has been shown to be well tolerated and to induce a sustained immune response in initial Phase I and II clinical trials. An ongoing, double-blind, placebo-controlled, multicenter, Phase III trial (MIMOSA) completed its double-blind period in December 2010 and will compare abagovomab maintenance therapy to placebo, which will definitively determine the efficacy of this immunotherapeutic approach in patients with ovarian cancer.

Consolidation strategies in ovarian cancer: observations for future clinical trials

PURPOSE.: To describe the characteristics of a series of study populations of ovarian cancer patients with identical eligibility criteria in second or subsequent clinical remission (cCR) and to propose endpoint benchmarks for future consolidation studies. PATIENTS AND METHODS.: The patient populations consisted of those (1) untreated (U; observed until progression; n=35, (2) receiving imatinib (G; n=32), (3) receiving goserelin and bicalutamide (A; n=32), and (4) receiving vaccine (V; n=68; total=167). The endpoint of the combined analysis was progression-free survival in second remission (PFS 2). Patient characteristics were compared by chi-square test, and factors predicting PFS 2 evaluated in multivariate Cox model. RESULTS.: Groups were comparable for age, stage, grade, and debulking. Multivariate model to predict PFS 2 duration included histology, stage, optimal debulking, PFS 1 duration, and the type of intervention. As a benchmark for future studies, the median PFS 2 of the combined population of G, A, and U (removing V which had the most impact in prolonging PFS 2, n=68) was 11.3 months (95% CI: 10.4-12.5 months). The percent of patients with PFS 2>PFS 1 was 14/90 (16%). At 12 months, 43% remain progression-free. CONCLUSION.: Preliminary benchmarks for efficacy endpoints are suggested for future consolidation trials of patients in cCR. However, the suggested strategies will require validation in randomized trials and larger data sets.

Consolidation Therapy in Ovarian Cancer: A Clinical Update

Objectives:

To evaluate current strategies under investigation for use as consolidation or maintenance treatment in patients with ovarian cancer.

Patients with epithelial ovarian cancer often enter a complete remission after primary treatment. Many relapse, unfortunately, but some can return to remission after additional treatment. Outcomes can be improved by applying effective consolidation or maintenance approaches to patients in a complete primary or subsequent remission.

Methods:

A selective review of the literature is undertaken to consider strategies that are being or will likely be evaluated in randomized trials while we assess whether consolidation or maintenance will have a place in the treatment of patients with ovarian cancer.

Results:

The application of extended standard cytotoxic agents has been generally disappointing, and no strategy applied in the first remission setting has prolonged overall survival.

Conclusions:

As treatment options move beyond classic chemotherapy to novel hormones, immune interventions, and biologic agents, the consolidation strategy is regaining interest. This is particularly attractive in that many of these agents have stable disease as best outcome, and this is most appropriate to evaluate in patients with minimal volume disease. A consideration of toxicity is paramount, and any strategy to be considered in an otherwise asymptomatic patient in remission must be well tolerated. In addition, patients in second or third complete remission are also being considered as an appropriate group in which to evaluate new agents. Numerous other phase 2 trials with novel agents not considered here are underway, and it is to be hoped that some will emerge as contenders for randomized trials. Participation in these trials remains a priority for patients who otherwise must pursue a difficult watch-and-wait strategy.

Phase I trial of autologous hematopoietic SCT with escalating doses of topotecan combined with CY and carboplatin in patients with relapsed or persistent ovarian or primary peritoneal carcinoma

We designed a phase I clinical trial of escalating doses of topotecan with CY and carboplatin in combination with autologous hematopoietic SCT (AHSCT) for the treatment of relapsed or persistent platinum sensitive ovarian or primary peritoneal carcinoma. After stem cell collection, 16 patients received topotecan at 1.5, 2.5, 3.5, 4.5 or 6.0 mg/m(2)/d combined with CY 1.5 g/m(2)/d and carboplatin 200 mg/m(2)/d, all by 4-day continuous infusion. Steady state pharmacokinetics of topotecan and carboplatin were examined. Pre-treatment biopsies were examined for the expression of topoisomerase (topo) I, Ki67 and Bcl-2 family members by immunohistochemistry. One of six patients at a topotecan dose of 4.5 mg/m(2)/d and two of three patients at 6.0 mg/m(2)/d had dose-limiting toxicity of grade 3 stomatitis lasting >2 weeks. There was no treatment-related mortality. As topotecan clearance was constant over the dose range examined, topotecan steady state plasma concentrations increased with dose. Median progression-free survival and overall survival were 6.5 months and 2.7 years, respectively. Shorter progression-free survival was observed in tumors with low topo expression (P=0.04). Topotecan can safely be dose escalated to 4.5 mg/m(2)/d in combination with CY, carboplatin and AHSCT. This trial is registered at ClinicalTrials.gov as NCT00652691.

Whole abdomen irradiation in epithelial ovarian cancer: A single institution study

Background: The examination of the use of whole abdomen irradiation open field technique in optimally debulked patients with no residual disease with epithelial ovarian cancer (OC). Methods: Between 1993 and 2007, 20 patients with optimally cytoreduced epithelial OC were treated with WAI. The stage distribution was stage I in 15 patients, stage II in 1, and stage III in 4. The grade distribution was grade 1 in 10 patients, grade 2 in 4, and grade 3 in 6. WAI consisted of 30 Gy, delivered in daily fractions, mainly of 1.5 Gy (95%), 5 days/weekly, in 14 patients. After abdominal irradiation, in 75% of the patients a pelvic boost, and in 7 a boost to other risk sites was given to reach 45 - 50 Gy. Nine patients received platinum based chemotherapy (CT). Median follow-up was 7.96 years. Results: The overall survival (OS) rate was 82% and 70% at 5 and 10 years. A tendency to better survival was found in patients with age ? 40 than in those with > 40 years (100%:100% vs. 68%:51%; p=0.03). Patients with grade 1-2 tumors had significantly better 5- and 10-year survival rate than those with grade 3 tumors (100%:100% vs. 40%:20%; p<0.00). The 5- and 10-year OS for the patients 'with' and 'without' a pelvic boost turned to be in favor of the patients 'with' the boost (91%:91% vs. 60%:40%; p=0.02). In 15 patients (75%) RT was transiently interrupted because of acute gastrointestinal and hematological toxicity. Neither grade 4 acute complications nor was mortality observed. Late gastrointestinal effect developed in 1 patient, presented with grade 4 complications. The development of second primary malignancy was not observed during the follow-up period. Conclusion: WAI achieves a quite favorable 5- and 10-year survival rate with an acceptable risk of acute and late side effects in properly selected patients with epithelial OC.

Pharmaceutical management of ovarian cancer : current status

Over recent decades, truly impressive progress has been made in the outcome associated with the pharmacological antineoplastic management of women with advanced ovarian cancer. Following initial surgery, the large majority of patients with this malignancy will receive a chemotherapy regimen that includes a platinum drug (carboplatin or cisplatin) and a taxane (paclitaxel or docetaxel). Currently, objective responses are observed in approximately 60-80% of patients treated in the front-line setting, with documented improvements in overall survival compared with prior non-platinum and taxane programmes. Unfortunately, despite the high response rate to initial chemotherapy, the majority of women with advanced disease will experience recurrence of the malignant process and be candidates for a variety of possible second-line therapeutic options. It is well recognized that ovarian cancer patients who are documented to experience an initial response to platinum-based chemotherapy but where the disease recurs approximately 6 or more months following the completion of primary therapy, may have another clinically meaningful response (both objective and subjective) to a second platinum-based strategy. However, an optimal management approach in this setting remains to be defined. Furthermore, the malignant cell populations in all ovarian cancer patients who experience an initial relapse of the disease process will eventually be resistant to the platinum agents. In this setting, multiple drugs have been shown to be biologically active. Again, an optimal strategy to be employed in the platinum-resistant setting has yet to be demonstrated through the conduct of evidence-based trials. Reasonable goals of therapy in women with recurrent or resistant ovarian cancer are to improve overall survival, reduce the severity (and delay the occurrence) of symptoms and optimize overall quality of life.

High-dose melphalan and autologous stem cell transplantation as consolidation treatment in patients with chemosensitive ovarian cancer: results of a single-institution randomized trial

The role of high-dose chemotherapy (HDCT) in epithelial ovarian cancer (EOC) remains controversial. This study was initiated to compare the efficacy and tolerability of HDCT as a consolidation approach in women with chemosensitive advanced EOC (FIGO stages IIC-IV). Patients who had achieved their first clinical complete remission after six cycles of conventional paclitaxel and carboplatin combination chemotherapy were randomly assigned to receive or not high-dose melphalan. The primary objective was to compare time to disease progression (TTP). A total of 80 patients were enrolled onto the trial. Patients who were randomized to receive HDCT were initially treated with cyclophosphamide 4 g/m(2) for PBPC mobilization. HDCT consisted of melphalan 200 mg/m(2). Of the 37 patients who were allocated to HDCT, 11 (29.7%) did not receive melphalan either due to patient refusal (n=5) or due to failure of PBPC mobilization (n=6). In an intent-to-treat analysis, there were no significant differences between the two arms in TTP (P=0.059) as well as in overall survival (OS) (P=0.38).

Phase III Trial of High-Dose Sequential Chemotherapy With Peripheral Blood Stem Cell Support Compared With Standard Dose Chemotherapy for First-Line Treatment of Advanced Ovarian Cancer: Intergroup Trial of the AGO-Ovar/AIO and EBMT

Purpose

Although ovarian cancer is one of the most chemotherapy-sensitive solid tumors, cure after radical surgery and chemotherapy is uncommon. A randomized trial comparing high-dose sequential chemotherapy with peripheral blood stem cell (PBSC) support with platinum-based combination chemotherapy was conducted to investigate whether dose-intensification improves outcome.

Patients and Methods

One hundred forty-nine patients with untreated ovarian cancer were randomly assigned after debulking surgery to receive standard combination chemotherapy or sequential high-dose (HD) treatment with two cycles of cyclophosphamide and paclitaxel followed by three cycles of HD carboplatin and paclitaxel with PBSC support. HD melphalan was added to the final cycle. The median age was 50 years (range, 20 to 65 years) and International Federation of Gynecology and Obstetrics stage was IIb/IIc in 4%, III in 78%, and IV in 17%.

Results

Seventy-six percent of patients received all five cycles in the HD arm and the main toxicities were neuro-/ototoxicity, gastrointestinal toxicity, and infection and one death from hemorrhagic shock. After a median follow-up of 38 months, the progression-free survival was 20.5 months in the standard arm and 29.6 months in the HD arm (hazard ratio [HR], 0.84; 95% CI, 0.56 to 1.26; P, .40). Median overall survival (OS) was 62.8 months in the standard arm and 54.4 months in the HD arm (HR, 1.17; 95% CI, 0.71 to 1.94; P, .54).

Conclusion

This is the first randomized trial comparing sequential HD versus standard dose chemotherapy in first-line treatment of patients with advanced ovarian cancer. We observed no statistically significant difference in progression-free survival or OS and conclude that HD chemotherapy does not appear to be superior to conventional dose chemotherapy.

Current management strategies for ovarian cancer

Epithelial ovarian cancer originates in the layer of cells that covers the surface of the ovaries. The disease spreads readily throughout the peritoneal cavity and to the lymphatics, often before causing symptoms. Of the cancers unique to women, ovarian cancer has the highest mortality rate. Most women are diagnosed as having advanced stage disease, and efforts to develop new screening approaches for ovarian cancer are a high priority. Optimal treatment of ovarian cancer begins with optimal cytoreductive surgery followed by combination chemotherapy. Ovarian cancer, even in advanced stages, is sensitive to a variety of chemotherapeutics. Although improved chemotherapy has increased 5-year survival rates, overall survival gains have been limited because of our inability to eradicate all disease. Technologic advances that allow us to examine the molecular machinery that drives ovarian cancer cells have helped to identify numerous therapeutic targets within these cells. In this review, we provide an overview of ovarian cancer with particular emphasis on recent advances in operative management and systemic therapies.

Maintenance or consolidation therapy in advanced ovarian cancer

Most patients with advanced epithelial ovarian cancer (EOC) achieve a clinical complete response (CR) or have no clinical evidence of disease after aggressive cytoreductive surgery and 6 cycles of platinum-/taxane-based chemotherapy. From the reported randomized trials using different durations or different cycles of chemotherapy, none of these showed improvement in survival beyond 6 cycles. Data from the literature do not support a relationship between the number of cycles and response or between the cumulative dose and response. In addition, no benefit in survival was detected with high-dose and intensity chemotherapy administered for a short time compared with standard-dose chemotherapy given for a longer time. However, statistically significant differences in progression-free survival were found in patients who achieved a clinically defined CR to a platinum (CDDP)-/paclitaxel-based chemotherapy and who continued single-agent paclitaxel for an extended time period. Notably, this randomized trial most likely did not offer any survival advantage, as it was closed prematurely by the Data Safety Monitoring Committee in accordance with the guidelines planned for interim analysis of primary end-points.

A randomised phase III study comparing high-dose chemotherapy to conventionally dosed chemotherapy for stage III ovarian cancer: the Finnish Ovarian Cancer (FINOVA) study

Women with stage III ovarian cancer and with < or = 2 cm residual tumour were randomly assigned to receive either conventionally dosed chemotherapy (group A) or HDCT (group B). Patients allocated to group A received 6 cycles of paclitaxel (T) 135 mg/m2 and cisplatin (P) 75 mg/m2 every 3 weeks, and those allocated to HDCT received 3 TP cycles followed by peripheral blood stem cell mobilisation with cyclophosphamide (C) 3000 mg/m2 and T 175 mg/m2, and subsequently HDCT with carboplatin 1500 mg/m2, C 120 mg/kg, and mitoxantrone 75 mg/m2. The trial was closed early after 42 patients were entered due to slow accrual. The median follow-up time of patients who were alive was 81 months. The median progression-free survival time was 15.9 and 16.6 months (hazard ratio, HR 0.83; 95% CI 0.41-1.69, P = 0.61) and the median overall survival time was 43.7 and 64.3 months (HR, 0.74; 95% CI 0.34-1.61, P = 0.44) in groups A and B, respectively. Although one patient died of HDCT-related toxicity, the regimen was otherwise relatively well tolerated. We conclude that the HDCT regimen used was feasible, but did not result in significantly improved survival in this prematurely closed trial. A clinically important survival benefit cannot be excluded due to the small sample size.

Standard treatment in advanced ovarian cancer in 2005: the state of the art

What are standards? The oncology community expends considerable effort to review the results from definitive treatment studies and define recommendations for future studies, as well as standards of care for the community and patients who are not participating in clinical trials. This is a thoughtful and well-intentioned process but subject to considerable bias due to limitations in the data and/or their interpretation. While ovarian cancer is highly responsive to platinum-based therapy after initial cytoreductive surgery, there is a substantial risk of recurrence, which is accompanied by the emergence of drug-resistant disease. Better treatments with improved long-term outcomes are needed. From this perspective, standards can help to provide a baseline for assessing gaps in our current knowledge and defining priorities for future clinical trials. While not an exhaustive review, this study will focus on key clinical concepts that are guiding ovarian cancer research and treatment.

High-dose chemotherapy with autologous haemopoietic support for advanced ovarian cancer in first complete remission: retrospective analysis from the Solid Tumour Registry of the European Group for Blood and Marrow Transplantation (EBMT)

The majority of advanced ovarian cancer patients achieve an objective response following chemotherapy; however, only 20-30% are in remission after 5 years. Intraperitoneal or high-dose chemotherapy (HDC) may prolong disease-free and overall survival (OS) in patients with platinum-sensitive, small volume disease. To better define the subsets of patients who might benefit from HDC, we performed a retrospective analysis on 91 patients in 1st complete remission (CR) treated from 21 centres of the EBMT group. At a median follow-up of 48 months, median time-to-progression (TTP) and OS were 21.2 and 44.4 months, respectively. Tumour grade, stage, residual disease, disease status before HDC, type and year of transplant, source of haemopoietic progenitors and use of haemopoietic growth factors (HGF) after transplant were analysed for TTP and OS. The only significant parameter was the use of HGF: median OS for patients receiving or not receiving HGF was 46.2 vs 17.8 months, respectively (P: 0.035); this difference was maintained after multivariate analysis (P: 0.02). Our analysis does not identify any subgroup of patients in 1st CR who can benefit from HDC; however, median survival of patient with no residual disease has not been reached. The role of HGF after HDC deserves further investigation.

Randomized Phase II trial of two high-dose chemotherapy regimens with stem cell transplantation for the treatment of advanced ovarian cancer in first remission or chemosensitive relapse: a Southwest Oncology Group study

OBJECTIVES

To evaluate response rates, progression-free survival (PFS), overall survival (OS), and toxicity of two high-dose chemotherapy regimens with stem cell rescue used to treat patients with recurrent or persistent stage III/IV ovarian cancer, with the goal of taking one forward into a Phase III comparison with conventional therapy.

METHODS

Patients under 65 with clinically or pathologically persistent disease after initial chemotherapy or those relapsing >6 months after a complete remission (CR) were randomized to CMC carboplatin (1500 mg/m(2)), mitoxantrone (75 mg/m(2)), and cyclophosphamide (120 mg/kg)], or CTC: [cisplatin (165 mg/m(2)), thiotepa (600 mg/m(2)), and cyclophosphamide (5625 mg/m(2))] with stem cell rescue.

RESULTS

Of 67 randomized, the 32 and 26 eligible in the CMC and CTC arms were matched including age (median 49), maximum tumor diameter, and disease status at transplant. Low-risk disease (maximum diameter disease <or= 0.5 cm and platinum sensitivity) was demonstrated in only approximately one-half of the patients. There were two treatment-related deaths in each arm. The median PFS was 13 and 8 months, respectively, for the CMC and CTC arms. The median OS was 29 and 22 months for the CMC and CTC arms. In a multivariate analysis of PFS, normal CA125 at transplant and CR to primary therapy were significant; for OS, normal CA125 and platinum sensitivity were significant.

CONCLUSIONS

The CMC regimen was the superior regimen. However, few patients were long-term progression-free survivors. A clinical CR to primary therapy and a normal CA125, seen in a minority of patients, were requirements for a favorable outcome.