Cisplatin regimens and improved prognosis of patients with poorly differentiated ovarian cancer

Neoadjuvant chemotherapy for the management of ovarian cancer

Neoadjuvant chemotherapy refers to the administration of chemotherapy before definitive surgery is performed; this approach was introduced into the management of ovarian cancer approximately one decade ago, initially for use in women who were medically unable to tolerate aggressive cytoreductive surgery. Subsequently, neoadjuvant chemotherapy was employed in women who, by diagnostic imaging analysis, were unlikely to undergo successful optimal cytoreductive surgery. Only very limited data are available on the use of neoadjuvant chemotherapy in the management of women with apparent advanced ovarian cancer; these data are derived mainly from single institution experiences and suggest that this approach may increase disease-free survival but does not improve overall survival for the patient. However, it has consistently enhanced the feasibility of optimum surgical cytoreduction once neoadjuvant chemotherapy has been administered. Reduced blood loss, and shorter operations, intensive care unit stays and overall hospitalizations have been well documented. The methods for selecting candidates for neoadjuvant chemotherapy vary among institutions. Non-optimal surgical cytoreducibility has been assessed on the basis of diagnostic imaging studies, laparoscopic assessment and/or laparotomies. Currently, neoadjuvant chemotherapy is most beneficial for women who are medically impaired and unable to tolerate aggressive cytoreductive surgery and for women who are found to have such aggressive cancers that optimal cytoreductive surgery does not appear by diagnostic imaging or direct visualization to be possible.

Current treatment for ovarian cancer

Ovarian cancer is the most lethal gynaecologic malignancy. Epithelial ovarian cancer (EOC) constitutes approximately 90% of cases of ovarian cancer and 70% of the patients with EOC present in advanced stage. Treatment of EOC usually consists of cytoreductive surgery which includes total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), omentectomy and lymphadenectomy followed by adjuvant chemotherapy. Current adjuvant chemotherapy includes paclitaxel and either cisplatin or carboplatin given every 3 weeks for six cycles. The combination paclitaxel and platinum chemotherapy achieves clinical response in approximately 80% of patients. However, most patients will have tumour recurrence within 3 years following treatment. Patients with platinum-sensitive tumours can be re-treated with platinum and/or paclitaxel. Those with platinum-resistant tumours have poor prognosis and treatment is palliative. Options of treatment in these patients include topotecan, doxil, gemcitabine, etoposide, or enrolment in clinical trials. Future research needs to focus on the role of cytoreductive surgery, second-look surgery, consolidation chemotherapy, development of new chemotherapeutic agents, chemoresistance modulators, as well as new approaches to the treatment of women with ovarian cancer.

Altretamine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in cancer chemotherapy

Altretamine (hexamethylmelamine) is a cytotoxic antineoplastic agent which appears to require metabolic activation. Metabolic intermediates may act as alkylating agents; however, altretamine is not directly cross-resistant with classical alkylating agents. Objective response rates to orally administered altretamine as salvage therapy in patients with advanced ovarian cancer were 0 to 33%, with disease stabilisation in a further 8 to 78% of patients. Response rates appear to be higher in patients who have responded to previous alkylating agent or cisplatin-based therapy. There is some evidence that addition of altretamine to platinum-based combination regimens used for induction therapy of advanced ovarian cancer may improve long term survival, particularly in patients with limited residual disease. Although altretamine displays some activity in small cell lung cancer, it is unlikely to have any clinical role in the management of non-ovarian cancer. Altretamine appears to be relatively well tolerated, with gastrointestinal, neurological and haematological toxicities being the main dose-limiting adverse effects. However, assessment of accurate incidence rates for these effects is complicated by the use of altretamine with cisplatin. On the basis of the emerging body of clinical evidence, altretamine appears to have a limited role in the treatment of persistent or recurrent advanced ovarian cancer, primarily in patients who are potentially platinum sensitive yet intolerant of platinum analogues. Additionally, altretamine may be added to platinum-based regimens for induction therapy of advanced ovarian cancer. At the doses currently recommended, altretamine offers a reasonably well tolerated regimen that can be administered orally and is suitable for use on an outpatient basis.

Meta-analysis of surgery in advanced ovarian carcinoma: is maximum cytoreductive surgery an independent determinant of prognosis?

OBJECTIVE

If maximum cytoreductive surgery benefits the survival of women with advanced ovarian cancer, the median survival time of groups of such women will improve as the proportion of women undergoing maximum cytoreductive surgery is increased.

STUDY DESIGN

Fifty-eight suitable studies that encompass 6962 patients with advanced ovarian cancer were identified. Multiple linear regression was used to analyze the effects on median survival time of the following variables: the proportion of each cohort undergoing maximum cytoreductive surgery, the use of platinum-containing chemotherapy, the dose intensity of chemotherapy, the proportion of each cohort with stage IV disease, and the year of publication of the study.

RESULTS

Maximum cytoreductive surgery was associated with only a small improvement in median survival time, but platinum-containing chemotherapy improved median survival time substantially. Increased dose intensity also conferred a useful survival benefit.

CONCLUSION

Cytoreductive surgery probably has only a small effect on the survival of women with advanced ovarian cancer. The type of chemotherapy used is more important.

Hexamethylmelamine for the treatment of ovarian cancer--the Mount Sinai experience

Two regimens were tested, CHAP I and CHAP II, the latter, a hexamethylmelamine dosage-intensive regimen, first as second line (salvage) therapy and then as primary therapy. Both produced the most successful results achieved in the Mount Sinai series up to the time of their introduction, when compared to their predecessor regimens: CAP, AP and P. In an overall interim comparison, CHAP II was significantly superior to historical AP and CAP as primary therapy, as was CHAP I vs. AP in several important subgroups compared as part of a randomized trial. CHAP II overall progression-free survival was improved in spite of added new sensitive test methods. Salvage therapy also improved markedly with the addition of intensive hexamethylmelamine. Several biological and treatment characteristics strongly influenced outcome, especially young age and adding hexamethylmelamine. Other possible factors included: poor tumor grade, poor performance status, and extent of surgical debulking, even to intermediate residual, 2-6 cm size [CHAP II only]; extensive (optimum) surgery [CHAP I only]. The hexamethylmelamine-containing regimens interact favorably with some of these factors, better than did the preceding regimens. Five-year follow-up analyses weakened slightly for extensive surgery, intermediate size and poorly differentiated tumors. It confirmed and strengthened several findings favoring CHAP I & II, the hexamethylmelamine-containing regimens.

A meta-analysis of prognostic factors in advanced ovarian cancer with median survival and overall survival (measured with the log (relative risk)) as main objectives

We performed a meta-analysis of 38 articles containing 66 treatment groups and 3443 patients in order to evaluate prognostic factors in advanced epithelial ovarian cancer. To evaluate overall survival we designed a method to summarize the overall survival curve into one single figure: the log (relative risk) (LRR). This is the first meta-analysis using overall survival (measured with the LRR) as an objective. We found that the main prognostic factors predicting an improved survival (measured with the LRR) are: chemotherapy including cisplatin as initial treatment, a residual tumour mass of less than 2 cm prior to therapy, FIGO stage II/III and a good performance status. In a multivariate model, the use of cisplatin and the residual tumour were found to be the only factors of prognostic relevance. No relation between median survival and the overall clinical response rate of all patients entered in the denominator, could be demonstrated. Undifferentiated tumours and patients treated with cisplatin regimens had higher response rates to treatment but younger patients and those with endometrioid histology were less likely to respond. A surgical complete remission was encountered more frequently among studies that included a high number of patients with small tumour masses prior to treatment. Trials using cisplatin included more patients with small tumour nodules in their patient material compared to studies not using this drug. The data illustrate the danger of comparing studies with each other. In the trials with a high percentage of patients with small tumour residuals in the study population more toxic deaths were seen. This probably reflects the fact that they had received more intensive treatment. The LRR correlated strongly with the median survival, response and the percentage of surgical complete remissions. We concluded that the introduction of the LRR can be a meaningful addition to the evaluation of the influence of prognostic factors on overall survival.

In vitro evaluation of cisplatin interaction with doxorubicin or 4-hydroperoxycyclophosphamide against human gynecologic cancer cell lines

Doxorubicin, cisplatin, and cyclophosphamide are the three drugs most commonly used in the treatment of ovarian cancer, but no effect greater than additivity was observed for any combination of these drugs in the present study. Only a few studies have been reported concerning the degree of their additivity or their best order of sequencing. In our in vitro studies, cisplatin in combination with doxorubicin or 4-hydroperoxycyclophosphamide (4HC) was tested against seven human gynecologic tumor-cell lines in different sequences, using a double-agar layer tissue-culture system. Drug interactions with respect to inhibition of tumor clonogenicity were evaluated by isobologram and fractional survival methods. Doxorubicin and 4HC were sequenced simultaneously and at 1, 6 and 24 h after cisplatin, and cisplatin was sequenced at 1, 6 and 24 h after 4HC. The isobolograms constructed for doxorubicin or 4HC plus cisplatin revealed strict additivity between these agents against ovarian cancer clonogenicity. Both doxorubicin and 4HC showed the greatest additivity when used simultaneously and at 1 h vs 6 or 24 h after cisplatin. Although the mechanisms by which these sequencing effects occur are unknown, these studies provide new leads for the design of clinical trials with combinations of these three agents.

The treatment of advanced ovarian carcinoma (I): clinical variables associated with prognosis

New therapy regimens including cytoreductive surgery and cisplatin-based combination chemotherapy have improved survival for a small group of patients with advanced ovarian carcinoma. However, for the entire group survival remains poor. In this analysis of 65 patients treated at Leiden University Medical Center, the patient group that benefited the most from this approach was characterized by a younger age, good performance status, less extensive disease, low histologic grade and the absence of peritoneal carcinomatosis and ascites, and residual disease less than or equal to 15 mm (successful cytoreduction) after the first operation. Patients who did not have these favorable characteristics but in whom the first operation resulted in residual disease less than or equal to 15 mm, did survive worse than the other patients with individual tumor nodules less than or equal to 15 mm, but still better than those in whom a successful cytoreduction at the first operation could not be achieved. The diameter of the largest residual disease, the diameter of the largest metastasis before cytoreduction, and the presence of ascites and peritoneal carcinomatosis influenced prognosis. Thus the initial tumor burden as well as the burdened tumor volume left behind are of significance with respect to prognosis. However, in the Cox regression analysis the performance status and ascites proved to be the only independent factors influencing survival. A prospective study is needed to establish the proper value of cytoreductive surgery in advanced ovarian carcinoma.

Prognostic factors in borderline and invasive ovarian tumors of the common epithelial type

Present reports show that surgical factors, response to therapy and histological criteria are important for predicting the prognosis of patients with common epithelial types of ovarian tumors. Newer techniques such as morphometry, DNA cytometry, immunological and immunopathological techniques may help to define prognostic factors even more accurately. As a result, these recently developed methods may enhance the value of well-established classical predictors of the outcome in case of borderline or invasive ovarian tumour.

A randomized study of cyclophosphamide and cis-platinum with or without doxorubicin in advanced ovarian carcinoma

Two hundred sixty-seven patients with advanced epithelial ovarian carcinoma were randomized to cis-platinum and cyclophosphamide versus cis-platinum, cyclophosphamide, and doxorubicin. Complete pathological response, evaluated at second-look laparotomy and survival, showed no differences between the two treatment groups. Recurrence-free survival after negative second look was 61% at 24 months.

Advanced ovarian cancer: three-year results of a 6-8 month, 2-drug cisplatin-containing regimen

Fifty-two patients with advanced (stage III and IV) ovarian cancer were treated with a regimen of cisplatin (100 mg/m2 over 5 days) and cyclophosphamide (600 mg/m2/day 4). Treatment was repeated every 3-4 weeks for 6-8 months and followed by second look surgery. The median follow up for this single institution study (1980-1984) is 36 months. The median progression-free survival (projected) is 24 months and the median overall survival (projected) is 37 months in this group of patients with unfavorable pretreatment characteristics: median age: 61, median performance status (ECOG) 2, poorly-differentiated tumors: 60%, extensive residual tumors (greater than 2 cm): 65%. Pretreatment performance status was the only independent predictor for prolonged survival. Pathologically documented complete responses were observed in 23% of all patients and 43% of the patients who underwent second-look surgery (28 patients). Neurotoxicity from this regimen was substantial: it occurred in 65% of cases, was severe in 17% and was often not entirely reversible. The results with this intensive 2-drug cisplatin-containing regimen compare favorably to other more complex regimens in the literature. It is possible that the 'dose intensity' of cis-platinum may be the most important element of current therapeutic regimens in ovarian cancer.

Epithelial ovarian cancer: do all metastases present similar chemosensitivity?

Three cases of advanced epithelial ovarian carcinoma Stage III-IV which could not be submitted to classical surgical and oncological treatment (BSO-TH) are presented. After a year of chemotherapy a complete remission was observed. Myometrial and myocervical micrometastases were found in a specimen from the hysterectomy, carried out during second-look, that was negative. These micrometastases, when they are present, apparently show a different chemosensitivity, as compared with other metastasis localization. The causes of this phenomenon are analyzed.

A randomized trial of cyclophosphamide and doxorubicin with or without cisplatin in advanced ovarian carcinoma. A Gynecologic Oncology Group Study

A randomized clinical trial was conducted in women with bulky (suboptimal) Stage III and Stage IV ovarian carcinoma, using doxorubicin (Adriamycin) and cyclophosphamide with or without cisplatin. There were 440 evaluable cases, of which 227 had measurable disease. One hundred twenty of these latter patients were treated with cyclophosphamide and doxorubicin (CA), while 107 received cyclophosphamide, doxorubicin and cisplatin (CAP). The clinical complete response (CR) rate for CA was 26% (31/120) compared with 51% (55/107) for CAP (P = less than 0.0001). Of 23 CRs receiving CA who had a second-look laparotomy, only four were negative; of 39 CRs receiving CAP and a second-look, 13 were negative (not statistically significant). The response duration for patients with measurable disease (median 14.6 versus 8.8 months), progression-free interval for all patients (13.1 versus 7.7 months), and survival for patients with measurable disease (19.7 versus 15.7 months) showed a statistically significant advantage for CAP; however, there was no difference in survival of patients with nonmeasurable disease. Toxicity was more severe with CAP but was tolerable. Thus, the addition of cisplatin improves the chemotherapy of advanced ovarian carcinoma.

Individual chemosensitivity of in vitro proliferating mammary and ovarian carcinoma cells in comparison to clinical results of chemotherapy

Cell lines established from advanced mammary and ovarian carcinomas were assayed for the inhibition of in vitro proliferation by various antineoplastic drugs. The assays were performed with multiple experimental cultures derived from stock cultures of the tumor cell lines in early passages of the cultivation. As determined by comparison of the 50% inhibition of in vitro growth, differential sensitivity of the individual cell lines was observed. Based on the 2-h plasma level of the drugs as discriminatory threshold between resistance and sensitivity, the in vitro effectiveness of each drug on the individual cell lines was compared with the clinical results of chemotherapy applied to the corresponding patients. In total, positive in vitro/in vivo correlations were observed in 39 of 42 cases. The 17 cell lines evaluated retrospectively were resistant to those drugs which had been tried unsuccessfully during chemotherapy. Among the 25 cases tried prospectively 11 cases showed sensitivity in vitro and in vivo, and furthermore 11 prospective cases were resistant in vitro and in vivo.

Treatment selection for cancer patients: application of statistical decision theory to the treatment of advanced ovarian cancer

Optimal treatment selection for patients with chronic disease, especially advanced cancer, requires careful consideration in weighing risks and benefits of each therapy. The application of statistical decision theory to such problems provides an explicit and systematic means of combining information on risks and benefits with individual patient preferences on quality-of-life issues. This paper evaluates the strengths and weaknesses of this methodology by using, as an example, treatment selection in advanced ovarian cancer. Possible treatment options and the major consequences of each are first outlined on a decision tree. The probability of various outcomes is estimated from the literature and methods for assessing the relative value or utility of each outcome are illustrated by interviews with 9 volunteers. Based on decision analysis, the recommended treatment for advanced ovarian cancer is found to be highly dependent on survival estimates but far less dependent on other probability estimates or the method of obtaining utilities. Individual preferences are also found to influence the treatment choice. The analysis illustrates that an important strength in using decision theory is its ability to identify key factors in the decision through sensitivity analysis. This may help both the physician selecting treatment and the investigator planning clinical trials which compare these therapies. In addition, this method can help in planning a trial's sample size by determining what survival difference between therapeutic strategies is worth detecting. Some problems identified with this methodology include the need for several simplifying assumptions and the difficulties in assessing individual preferences. On balance, we believe decision theory in this setting can play a useful role in complementing the physician's clinical judgement.

Treatment of advanced and recurrent ovarian carcinoma with cyclophosphamide, doxorubicin, and cisplatin

Forty-seven patients with primary advanced (N = 37) or recurrent ovarian carcinoma (N = 10) completed a 12-month course of CAP chemotherapy or developed progressive disease while on therapy and were evaluated. All patients were treated between August 1, 1977 and August 1, 1982. Cyclophosphamide 400 mg/m2, Adriamycin (doxorubicin) 40 mg/m2, and cisplatin 60 mg/m2, were administered every 4 weeks intravenously. After 8 courses the cisplatin was stopped. The patients then received 500 mg/m2 of cyclophosphamide and 50 mg/m2 of Adriamycin. At the cumulative dose of 450 mg/m2, the Adriamycin was stopped and cyclophosphamide was given at 1 g/m2 alone until the patient had received a total of 12-13 courses from the initiation of the chemotherapy protocol. The cardiac, renal, and hematopoetic toxicity of the regimen was mild to moderate. The median survival of the entire study population was 32 months. The median survival of the patients with primary disease was 36 months. The median survival of patients with recurrent disease was 20 months. There was a significant difference in median survival based on size of the largest lesion prior to initiation of chemotherapy. There was no difference in median survival based on tumor grade or comparing Stage III to Stage IV tumors. The most important aspects of the study appeared to be the length of the median survival of the patients, the fact that all patients who were complete responders and who were considered to have no evidence of disease, have been documented by second look, and the success of secondary treatment after second-look procedures revealed persistent tumor. The authors additionally report the use of weight change as an indicator of tumor response, and the importance of the pelvic examination complimented by fine-needle aspiration in following the course of these patients.