Cisplatin-based chemotherapy for stage II ovarian adenocarcinoma: a preliminary report

High-dose whole abdominal and pelvic irradiation for treatment of ovarian carcinoma: long-term toxicity and outcomes

PURPOSE

To evaluate the role of high-dose whole abdominal and pelvic irradiation (WART) in the treatment of epithelial ovarian carcinoma.

METHODS AND MATERIALS

A retrospective review was performed on 71 patients with Stage I-III ovarian carcinoma who were treated with WART using an open field technique after total abdominal hysterectomy and bilateral oophorectomy with or without omentectomy. Whole abdominal doses greater than typically recommended were used in a series of patients to enhance local control and to decrease abdominal recurrence. None of the patients had received chemotherapy before RT. Thirty-one patients received Alkeran or cyclophosphamide and two received cisplatin-based chemotherapy after WART. The median whole abdominal dose was 36 Gy (range 9-45.5), delivered in a median of 30 fractions (range 8-46). A pelvic boost was delivered using AP-PA fields during whole abdominal RT to a total midline pelvic dose of 200 cGy/d. The median pelvic dose was 51 Gy (range 16-59). The right lobe and a portion of the left lobe of the liver were shielded with custom blocks at a median dose of 25 Gy (range 9-41). The kidneys were shielded either AP-PA or PA from the first day of RT. The median dose to the kidneys was 19 Gy (range 4-30).

RESULTS

The 5-year overall survival rate was 93%, 48%, and 29% for Stage I, II, and III patients, respectively. On multivariate analysis, stage and the extent of residual disease were independent prognostic factors. The 5- and 10-year overall survival rate for the 46 patients in the intermediate-risk group was 61% and 54%, respectively. For this group, a total abdominal dose of > or /=36 Gy was associated with a longer overall survival independent of stage, grade, and the amount of residual disease. This was most likely due to a significant reduction in the incidence of abdominal recurrence in patients receiving >36 Gy to the whole abdomen (18% vs. 49%, p = 0.006). Multivariate analysis revealed that grade (p = 0.023) and abdominal dose (p = 0.018) were independent factors influencing the rate of abdominal recurrence. Pelvic recurrence was rare as a first site of failure (6%). Twenty-one percent (n = 15) of the patients developed Grade 3 or 4 (Radiation Therapy Oncology Group [RTOG] criteria) chronic small or large bowel toxicity. Eleven percent of all patients had a small bowel obstruction requiring surgery. A whole abdominal dose >30 Gy and a pelvic dose >50 Gy were associated with a significant increase in small bowel obstruction (p = 0.01) independent of other factors. Chronic Grade 3 or 4 (Common Toxicity Criteria) anemia, thrombocytopenia, and leukopenia were seen in 7%, 1%, and 4% of the patients, respectively. Transient liver enzyme elevation was common (62%). Two patients had Grade 3 (RTOG) hepatic toxicity. Grade 3 or 4 renal toxicity (RTOG) was observed in 4%, and 2 patients (3%) were diagnosed with pelvic insufficiency fractures that were managed conservatively.

CONCLUSION

Survival after RT for ovarian carcinoma rivals that achieved with systemic chemotherapy. The results of this study suggest a possible dose-control relationship between the whole abdominal dose and the risk of abdominal recurrence; however, a higher rate of small bowel obstruction was observed when greater abdominal doses and greater pelvic doses were combined. Careful attention to balancing toxicity and efficacy is imperative if RT is to have a future role in the treatment of this disease.

Adjuvant 32P in the treatment of ovarian carcinoma

The purpose of this study was to evaluate the efficacy of adjuvant 32P for patients with high-risk, early-stage ovarian carcinoma. Twenty-five patients underwent apparent complete resection followed by 32P (15 mCi) at the University of Florida between 1976 and 1993. Minimum and median follow-up times were 3 and 8 years, respectively. The rate of local control at 10 years was 83%. Four of the 5 patients who experienced recurrent disease had a component of intra-abdominal disease at the time of relapse. The absolute and cause-specific survival rates at 10 years were 68% and 82%, respectively. There were no severe acute complications. Five patients experienced significant late complications, including chronic abdominal cramping that was treated conservatively (3 patients) and small bowel obstruction necessitating surgical intervention (2 patients). Adjuvant 32P results in disease control and survival rates that are similar to those observed after adjuvant chemotherapy. However, the risk of late complications, particularly small bowel obstruction, is higher.

WART revisited: the treatment of epithelial ovarian cancer by whole abdominal radiotherapy

The present study investigated outcomes for 78 women with epithelial ovarian carcinoma treated by whole abdominal radiotherapy (WART) after cyto-reductive surgery at Westmead Hospital between 1980 and 1993. These patients had 5-year relapse-free and overall survival rates of 52 and 55%, respectively. The median follow-up was 7.5 years. Fifty-eight of the 78 women fulfilled the criteria as defined by the Princess Margaret Hospital's intermediate risk' category. These patients had both a relapse-free and overall survival rate of 62% at 5 years (P = 0.001 as compared with the remaining 20 women). Mild gastrointestinal upset was common during radiotherapy. Five women did not complete treatment. Late toxicity (grade 3 or more, using the Radiotherapy Oncology Group (RTOG) system) occurred in eight women, and five women required surgery for intestinal complications (6.4%). There were no deaths due to late side effects. In conclusion the results are consistent with those of other series in the treatment of epithelial ovarian cancer by adjuvant WART. When compared to a similar-stage disease treated with cisplatin-based chemotherapy, there is no evidence to support the exclusive use of chemotherapy.

Lack of improved survival plus increase in thromboembolic complications in patients with clear cell carcinoma of the ovary treated with platinum versus nonplatinum-based chemotherapy

BACKGROUND

This study was conducted to evaluate survival rates for patients with clear cell ovarian carcinoma who had platinum-based chemotherapy versus nonplatinum-based chemotherapy and the risk of thromboembolic complications.

METHODS

One hundred and eleven evaluable patients with clear cell ovarian carcinoma who underwent primary surgery and postoperative therapy were retrospectively evaluated. Median follow-up was 21.3 months (range, 3-280 months). Patients treated with platinum-based chemotherapy and nonplatinum-based chemotherapy were evaluated according to stage, age, grade, extent of surgery, and development of thromboembolic complications. Patient populations were compared using the chi-square test. Estimated 5- and 10-year survivals for each group were calculated using the method of Kaplan and Meier. Differences in survival rates were calculated using the log rank test. The frequency of thromboembolic complications in the clear cell ovarian carcinoma group was compared with its frequency in a matched-control group of 109 patients with epithelial nonclear cell ovarian carcinoma.

RESULTS

Seventy-one patients were treated with nonplatinum-based chemotherapy and 40 patients were treated with platinum-based chemotherapy. There was no statistically significant difference in the characteristics of patient populations treated with platinum-based chemotherapy or nonplatinum-based chemotherapy. The estimated 5-year survival for clear cell ovarian carcinoma patients treated with platinum-based chemotherapy did not differ significantly from the estimated 5-year survival for patients with clear cell ovarian carcinoma treated with nonplatinum-based chemotherapy (36% vs. 32%; P = 0.23). Twelve patients with clear cell ovarian carcinoma developed thromboembolic complications remote from primary surgery, whereas in a matched-control group of patients with nonclear cell ovarian carcinoma treated with platinum-based chemotherapy, no patients developed a thromboembolic complications (P = 0.0004). Eight of 40 patients (20%) with clear cell ovarian carcinoma treated with platinum-based chemotherapy developed thromboembolic complications, whereas 4 of 71 patients (6%) treated with nonplatinum-based chemotherapy developed thromboembolic complications (P = 0.03). Multivariate logistic regression analysis demonstrated that the development of a thromboembolic complication was significantly related to clear cell ovarian carcinoma and platinum-based chemotherapy and had a significant (P = 0.009) negative impact on survival.

CONCLUSIONS

Platinum-based chemotherapy did not appear to improve survival compared with nonplatinum-based chemotherapy of patients with clear cell ovarian carcinoma. The combination of platinum-based chemotherapy and clear cell ovarian carcinoma significantly increases the risk for thromboembolic complications and has a significant negative impact on survival.

Evaluation of whole abdominal irradiation in ovarian carcinoma with a four orthogonal fields technique

PURPOSE

The purpose of this study is to evaluate the toxicity and the results of abdominopelvic irradiation with a four orthogonal field's technique in patients with ovarian carcinoma.

METHODS AND MATERIALS

Between May 1981 and December 1990, 167 patients with ovarian carcinoma have been treated with whole abdominal irradiation: 62 patients with no or minimal residual disease < 2 cm after initial surgery (group 1) and 105 patients with no residual disease or macroscopic residual disease < 2 cm assessed by second-look surgery after incomplete debulking surgery and cisplatin-based polychemotherapy (group 2). Irradiation was performed by a four orthogonal field's technique. Thirty grays were given with a 25 MV photon beam (1.5 Gy/fraction/day, 20 fractions over 30 days). Boosts were performed in 50 cases (median dose of 15 Gy).

RESULTS

With a median follow-up of 68 months, the 5-year actuarial survival rate was 50% in the entire group, 67% in group 1, 40% in group 2, and 84% in T1, 61.5% in T2, 38% in T3. Five-year actuarial survival was analyzed according to the residuum: (a) after initial surgery (no residual disease: 70%, residual disease: 36.5%), (b) after second-look surgery: 76% in patients with a negative second look, 66% in patients with microscopic residual disease, 22% in patients with macroscopic residual disease and secondary surgical reduction, and 10% in patients with small unresectable nodules. Nine percent of the patients failed to complete irradiation acute side effects related. Five percent required surgery for bowel obstruction.

CONCLUSION

The abdominopelvic irradiation with this four orthogonal field's technique was associated with tolerable acute toxicity and a low risk of serious late complications. Similar late results to have been reported whole abdominal irradiation with chemotherapy in patients with negative or microscopic residual disease after surgery. Randomized trials comparing these two adjuvant treatments are warranted.

Role of radiotherapy in the treatment of cancer of the ovary

The initial management of carcinoma of the ovary is surgical. The need for further treatment is determined by a consideration of tumor stage, grade, and the presence of residual disease. Approximately one-third of patients are suitably managed by primary post-operative radiotherapy directed to the entire abdomen and pelvis with curative intent. Patients are mainly derived from stages I and II. Stage III patients are also included if the tumor is of low grade and there is no pelvic residuum. The dose which can be safely delivered to the upper abdomen is limited by normal tissue tolerance. Curative radiation is inappropriate for patients with upper abdominal disease and/or more than small volume residuum in the pelvis. These patients are best managed with chemotherapy. Suitably selected patients have a ten-year relapse-free survival of 68% following radiotherapy. Acute gastrointestinal symptoms are common during the treatment, but are usually amenable to symptomatic management. Long term morbidity is infrequent, and with modern techniques the incidence of treatment-related small bowel obstruction is around 5%. Radiotherapy to the abdomen and pelvis has also a potential role as consolidative treatment in patients with advanced disease, following a favourable response to chemotherapy.

Integrating radiation therapy into the management of ovarian cancer

Several studies during the last 15 years have elucidated the role of postoperative external beam radiation therapy as curative management of some subsets of patients with ovarian cancer. Despite this, the use of radiation therapy in patients with ovarian cancer has remained a controversial subject. Substantially improved cure rates have not been realized during the past decade despite the early promise of high response rates to cisplatin chemotherapy. Thus, it is important that all currently effective therapies be used for maximum therapeutic gain. This article will review the evidence that radiation therapy is curative in ovarian cancer and highlight the criteria, including stage and grade of disease and tumor residuum, by which patients suitable for such therapy are selected. The rationale for the use of whole abdominopelvic irradiation rather than pelvic or lower abdominal treatment will be discussed, as will the optimal radiation technique and its attendant morbidity. Limited data pertinent to the controversy over the use of radiation therapy versus chemotherapy in early disease, will be reviewed. The possible benefits of consolidation abdominopelvic radiation therapy after chemotherapy in highly selected patients with well-differentiated microscopic residual disease at second-look laparotomy or with no residual disease but high a risk for relapse will be considered.

Clinical surveillance of gynecologic cancer patients

A survey of gynecologic oncologists was used to determine the optimum follow-up plan for asymptomatic, disease-free patients previously treated for a gynecologic malignancy. Ninety-four (91%) of 103 questionnaires were completed and returned. The majority of respondents recommended a clinic visit for these patients every 3 months for the first year after the completion of therapy, every 3 or 4 months for the second year, every 6 months for the following 3 years, and then annually after this initial 5-year period. Breast, abdominal, lymph node, and pelvic examinations, as well as a pap smear and stool guaiac, were done at each of these clinic visits. A yearly chest X ray was performed by the majority of the survey respondents for the first 3 years following initial treatment. Determinations of serum CA-125 and ovarian germ cell tumor markers were done at each follow-up appointment during the first 5 years after therapy if they were previously elevated. The patients' smoking habits were discussed with them by the majority of respondents. Mammograms were performed periodically before age 50 and then yearly after age 50 by most respondents. Serum cholesterol determinations were accomplished every 5 years or more frequently if indicated. Calcium supplementation was recommended for postmenopausal patients. The majority of respondents did not recommend routine vitamin supplementation or surveillance sigmoidoscopy.

Stage II carcinoma of the ovary: an analysis of survival after comprehensive surgical staging and adjuvant therapy

Ninety-three women with FIGO stage II epithelial ovarian carcinoma underwent comprehensive surgical staging and were randomized prospectively to therapy consisting of either intraperitoneal radioactive phosphorus or oral melphalan. No patient had gross residual disease at the time of randomization. Ten of the forty-five women treated with melphalan experienced severe bone marrow depression at some time during therapy and two women expired from leukemia. Four of the forty-eight women treated with intraperitoneal phosphorus required surgical reexploration for intestinal obstruction or bowel injury. Twenty-one women died of their disease. Survival was not statistically different between the two treatment arms. The 5-year actuarial survival was 78%.

Epithelial ovarian cancer: the role of radiotherapy

Although several studies during the last 10-15 years have served to clarify the role of postoperative external beam radiotherapy in patients with ovarian cancer, the subject remains controversial. This paper will review the following topics: 1. Stage I Ovarian Cancer. 2. The rationale for selecting whole abdominopelvic radiotherapy over other forms of radiotherapy, such as pelvic or lower abdominal radiotherapy. 3. The choice of radiation technique. 4. The evidence that radiotherapy is curative in ovarian cancer. 5. The toxicity of abdominopelvic radiotherapy. 6. The criteria by which patients are selected for abdominopelvic radiotherapy. 7. Radiotherapy versus chemotherapy in early disease. 8. Consolidation radiotherapy after chemotherapy in advanced disease.