Whole-abdomen radiation therapy in ovarian carcinoma: its role as a salvage therapeutic modality

Selective irradiation for the treatment of recurrent ovarian carcinoma involving the vagina or rectum

OBJECTIVE

The aim of this study was to evaluate the role of selective irradiation in the management of recurrent or persistent ovarian carcinoma involving the vagina or rectum after initial surgery or surgery and chemotherapy.

METHODS

Twenty-eight patients with recurrent or persistent vaginal and/or perirectal disease from ovarian carcinoma received selective irradiation and were evaluated for local control, survival, and quality of life. Seventy-nine percent had previously received various combinations of chemotherapy after initial surgery. At recurrence, 68% of the 28 patients were treated with external beam irradiation only, 7% with brachytherapy only, and 18% with both external beam irradiation and brachytherapy. In addition, 50% of the patients received various combinations of chemotherapy before or after radiotherapy and 3 patients received additional surgery.

RESULTS

Vaginal bleeding was controlled in all patients and a complete symptomatic response was achieved in 79% of the symptomatic patients. Survival after recurrence at 2 years was 57% for patients who had no liver or extra-abdominal metastasis at the time of radiotherapy (21 patients) and 0% for patients who had liver or extra-abdominal metastases (7 patients). Median survival of 5 patients with abdominal and pelvic disease and 16 patients with no extrapelvic disease at the time of recurrence was 2.16 (0.16-10.67) and 2.08 (0.58-27) years, respectively, after recurrence. Fifty percent of the 16 patients without extrapelvic disease had a complete response to radiotherapy (CR group) and the remaining had a partial response or stable disease (non-CR group). The 1-year survival after salvage irradiation in this same group was 100% in the CR group and 37.5% in the non-CR group (P < 0.0001). There are 4 long-term survivors in the CR group who are still alive in excess of 5 years after salvage radiotherapy. Thirty-five percent (5/14) of the patients with pelvic disease only recurred in the unirradiated upper abdomen.

CONCLUSIONS

Radiation can be considered an effective treatment option for patients with vaginal and/or perirectal recurrences of ovarian carcinoma. It offers excellent palliation to patients with disseminated disease and may result in both local control and long-term survival in patients with nondisseminated disease. This location may represent a sanctuary site from chemotherapy. Pelvic irradiation alone may be effective salvage and the addition of brachytherapy may improve local control, particularly in patients with disease confined to the pelvis who undergo debulking or chemotherapy.

Is there place for radiotherapy in the treatment of advanced ovarian cancer?

BACKGROUND AND PURPOSE

Irradiation of advanced ovarian cancer has been performed during the years 1976-1984 with six-field technique. Results of this treatment in a long follow-up have never before been evaluated.

MATERIAL AND METHODS

Seventy-five patients with stage IIb-IV of invasive ovarian cancer have been treated with a combination of surgery, radiotherapy and chemotherapy. The results of the treatment were compared with 98 patients treated during the year 1991-1992 with surgery and chemotherapy only.

RESULTS

After controlling for the differences in background factors between the groups considered, there was still a significantly better survival rate for the patients treated with radiotherapy.

CONCLUSION

The results suggest that the role of radiotherapy in advanced ovarian cancer should be investigated in a prospective randomized trial.

Ovarian cancer

This synthesis of the literature on radiotherapy for cancer originating in the ovaries is based on 74 scientific articles, including 12 randomized studies, 18 prospective studies, and 36 retrospective studies. These studies involve 6,140 patients. Treatment for patients at early stages of ovarian cancer (stages I and II) is surgery. The value of adjuvant treatment, ie, chemotherapy or radiotherapy, is not demonstrated. Tumor volume is decisive to the success of radiotherapy. Microscopic or small macroscopic cancer residuals, remaining after surgery, may respond to radiotherapy, thereby promoting survival. The importance of radiotherapy for advanced ovarian cancer is controversial, and studies frequently show contradictory results. Two studies have shown the favorable role played by radiotherapy in consolidation treatment of patients if they become cancer-free at advanced stages. The role of radiotherapy in treating larger volumes of residual cancer has not been demonstrated, except for strictly palliative treatment.

Stage III ovarian carcinoma: an analysis of treatment results and complications following hyperfractionated abdominopelvic irradiation for salvage

PURPOSE

Patients with persistent disease found at laparotomy following platinum-based chemotherapy for Stage III ovarian carcinoma have a remote chance of cure with second-line chemotherapy or conventional radiotherapy. To decrease relapse rates and improve tolerance, we have used twice-daily radiotherapy in 28 such patients.

METHODS AND MATERIALS

Twenty-eight patients with Stage III epithelial ovarian carcinoma were treated with curative intent at the University of Florida with hyperfractionated, continuous-course radiotherapy for persistent disease at laparotomy after administration of platinum-based chemotherapy. All patients received .8 Gy per fraction, twice daily, to a mean total dose of 30.2 Gy to the whole abdomen and pelvis; 20 patients had additional radiotherapy to the pelvis (mean, 14.54 Gy). All patients had undergone two to four (mean, 2.6) laparotomies for ovarian carcinoma and had received 6-28 (mean, 12) cycles of chemotherapy before irradiation.

RESULTS

With a 2-year minimum follow-up, survival rates at 1, 2, and 5 years were as follows: absolute survival, 79%, 50%, 21%; relapse-free survival, 52%, 36%, 19%. For the 11 patients with no evidence of gross residual disease after the second-look laparotomy, the absolute survival rates were 100%, 73%, and 27%. This was superior to the rates of 65%, 34%, and 18% for the 17 patients who had gross residual disease. Only two patients required treatment breaks. Four patients required surgical intervention for small-bowel obstruction, which in two cases revealed recurrent disease. Two patients died of treatment-related complications. Twenty-two of 23 failures occurred in the abdomen and/or pelvis.

CONCLUSION

Although most patients eventually relapse, a small percentage have had a prolonged disease-free interval. Since treatment was relatively well tolerated, escalation of the dose of hyperfractionated abdominopelvic irradiation is being investigated.

Complications of whole abdominal and pelvic radiotherapy following chemotherapy for advanced ovarian cancer

We examined the records of 105 patients with advanced ovarian cancer who had been treated with cisplatin combination chemotherapy followed by abdominopelvic radiotherapy. The purpose was to define the morbidity of this approach, and identify those factors predictive of toxicity. Acute toxicity resulting in delay or failure to complete treatment was most commonly due to myelosuppression. Nine of 105 patients (8.6%) required surgery for bowel obstruction that was not due to recurrent disease, 3 had an episode of bowel obstruction that settled conservatively, and a further 5 underwent surgery for obstruction due to recurrent tumor. The presence of both a dose of abdominopelvic radiotherapy over 2250 cGy, as well as a second-look laparotomy prior to radiotherapy, was associated with an increased risk of serious bowel complications. The increased frequency of late bowel morbidity seen in the combined modality group is likely explained by the presence of these two factors, rather than the exposure to chemotherapeutic agents per se. These observations are supported by the published literature.

Twice-daily, split-course abdominopelvic radiation therapy after chemotherapy and positive second-look laparotomy for epithelial ovarian carcinoma

Between July 1983 and December 1988, 34 patients with ovarian carcinoma received whole abdominal irradiation in an attempt to eliminate residual disease following second-look laparotomy. Three additional patients who had initial complete responses to chemotherapy were treated for a recurrence of their disease. All patients had been treated with chemotherapy that included cisplatin and cyclophosphamide. Three patients had also received doxorubicin with some or all chemotherapy cycles. Thirty Gray of abdominopelvic radiation therapy (APRT) was delivered using a twice-daily, split-course schedule. Eleven patients also had a boost of 9-20 Gy to sites of residual disease. Treatment was well tolerated. Only one patient did not complete therapy and two patients had 1-week prolongations of treatment because of hematologic toxicity. Thirty-two percent of patients had grade 2 neoplasms and 61% had grade 3 disease. Three patients with grade 1 tumors continue to have no evidence of disease 20-50 months after irradiation. Patients with grade 2 and 3 neoplasms who had microscopic residual disease prior to APRT had relapse-free survival rates at 3-years of 10% and 14%, respectively. Twelve patients with gross residual disease had rapid recurrences (median time to relapse, 4.9 months) and all have died of their disease. Although 14 patients (38%) have experienced small bowel obstructions, all of these had known recurrent abdominal disease at the time. Twenty patients (54%) had undergone more than two abdominal surgeries prior to APRT, and several were noted to have extensive adhesions at second-look laparotomy. None of the five patients currently believed to be free of disease has experienced a small bowel obstruction. Radiation is only one of several factors that contributed to bowel obstructions. Although APRT may be able to eliminate residual disease in a small proportion of patients with microscopic residual disease after chemotherapy, the aggressive biology of tumors that respond incompletely to chemotherapy and the compromises in radiation dose and schedule that must be made in these heavily treated patients probably contribute to the disappointing results of this treatment.

The impact of whole-abdomen radiotherapy on survival in advanced ovarian cancer patients with minimal residual disease after chemotherapy

Between March 1982 and March 1987, 26 patients with minimal residual epithelial ovarian cancer after cisplatin-based chemotherapy were treated with whole-abdomen irradiation [moving-strip technique (MST)] with or without pelvic boost. Prior to radiation residual disease was macroscopic (less than or equal to 0.5 cm) in 8 cases and microscopic (positive random biopsies) in 18 cases (8 diffuse, 10 localized). Eighty percent of patients completed the planned therapy, 34% with interruptions secondary to hematologic or gastrointestinal toxicity. With a median follow-up time from completion of radiotherapy of 24 months, 34.6% of patients remain alive. The 3-year survival rates (from the second-look procedure) are 50% for the patients with microscopic tumor and 25% for those with macroscopic residual disease. Progression-free intervals are statistically different in the two groups: 16.9 months for microscopic residuals and 6.16 months for macroscopic tumors (P = 0.037). All but two of the recurrences were in the irradiated field (pelvis and/or abdomen); one was distant (pleural) and one only retroperitoneal. Small bowel injury was the most limiting complication: 3.8% was registered as fatal acute enteritis and 19% as late obstruction or malabsorption syndrome, necessitating surgical intervention in 10% of treated cases.