Radiation therapy in stage III ovarian cancer following surgery and chemotherapy: prognostic factors, patterns of relapse, and toxicity: a preliminary report

Utility of adjuvant whole abdominal radiation therapy in ovarian clear cell cancer (OCCC): a pragmatic cohort study of women with classic immuno-phenotypic signature

BACKGROUND

To evaluate the initial experience and clinical utility of first-line adjuvant intensity-modulated whole abdominal radiation therapy (WART) in women with ovarian clear cell cancer (OCCC) referred to an academic center.

METHODS

Progression-free and overall survival was analyzed in a pragmatic observational cohort study of histologically pure OCCC patients over-expressing HNF-1ß treated between 2013 and end-December 2018. An in-house intensity-modulated WART program was developed from a published pre-clinical model. Radiation dose-volume data was curated to American Association of Physics in Medicine (AAPM) Task Group 263 recommendations. A dedicated database prospectively recorded presenting characteristics and outcomes in a standardized fashion.

RESULTS

Five women with FIGO (2018) stage IA to IIIA2 OCCC were treated with first-line WART. Median age was 58 years (range 47-68 years). At diagnosis CA-125 was elevated in 4 cases (median 56 kU/L: range 18.4-370 kU/L) before primary de-bulking surgery. Severe premorbid endometriosis was documented in 3 patients. At a median follow-up of 77 months (range 16-83 mo.), all patients remain alive and progression-free on clinical, biochemical (CA-125), and ¹⁸Fluoro-deoxyglucose (FDG) PET/CT re-evaluation. Late radiation toxicity was significant (G3) in 1 case who required a limited bowel resection and chronic nutritional support at 9 months post-WART; 2 further patients had asymptomatic (G2) osteoporotic fragility fractures of axial skeleton at 12 months post-radiation treated with anti-resorptive agents (denosumab).

CONCLUSIONS

The clinical utility of intensity-modulated WART in OCCC over-expressing HNF-1β was suggested in this small observational cohort study. The hypothesis that HNF-1β is a portent of platinum-resistance and an important predictive biomarker in OCCC needs further confirmation. Curating multi-institutional cohort studies utilizing WART by means of "Big Data" may improve OCCC care standards in the future.

The differential diagnosis and bone marrow evaluation of new-onset pancytopenia

New-onset pancytopenia can be caused by a wide variety of etiologies, leading to a diagnostic dilemma. These etiologies range from congenital bone marrow failure to marrow space-occupying lesions, infection, and peripheral destruction, to name a few. Bone marrow examination, in addition to a detailed clinical history, is often required for an accurate diagnosis. The purpose of this review is to provide a brief overview of many of the causes of new-onset pancytopenia in adults and children, with emphasis on bone marrow findings and recommendations of additional testing and clinical evaluation when needed, with the overall aim of aiding the pathologist's role as a consultant to the patient's treating physician.

Intraoperative radiation therapy in recurrent ovarian cancer

PURPOSE

To evaluate disease outcomes and complications in patients with recurrent ovarian cancer treated with cytoreductive surgery and intraoperative radiation therapy (IORT).

METHODS AND MATERIALS

A retrospective study of 24 consecutive patients with ovarian carcinoma who underwent secondary cytoreduction and intraoperative radiation therapy at our institution between 1994 and 2002 was conducted. After optimal cytoreductive surgery, IORT was delivered with orthovoltage X-rays (200 kVp) using individually sized and beveled cone applications. Outcomes measures were local control of disease, progression-free interval, overall survival, and treatment-related complications.

RESULTS

Of these 24 patients, 22 were available for follow-up analysis. Additional treatment at the time of and after IORT included whole abdominopelvic radiation, 9; pelvic or locoregional radiation, 5; chemotherapy, 6; and no adjuvant treatment, 2. IORT doses ranged from 9-14 Gy (median, 12 Gy). The anatomic sites treated were pelvis (sidewalls, vaginal cuff, presacral area, anterior pubis), para-aortic and paracaval lymph node beds, inguinal region, or porta hepatitis. At a median follow-up of 24 months, 5 patients remain free of disease, whereas 17 patients have recurred, of whom 4 are alive with disease and 13 died from disease. Five patients recurred within the radiation fields for a locoregional relapse rate of 32% and 12 patients recurred at distant sites with a median time to recurrence of 13.7 months. Five-year overall survival was 22% with a median survival of 26 months from time of IORT. Nine patients (41%) experienced Grade 3 toxicities from their treatments.

CONCLUSION

In carefully selected patients with locally recurrent ovarian cancer, combined IORT and tumor reductive surgery is reasonably tolerated and may contribute to achieving local control and disease palliation.

The prognostic significance of peritoneal seeding and size of postsurgical residual in patients with stage III epithelial ovarian cancer treated with surgery, chemotherapy, and high-dose radiotherapy

OBJECTIVE

The aim of this study was to retrospectively analyze the prognostic importance of age, histologic type and grade, ascites, lymph node status, size and type of postoperative residual disease, and radiation dose on disease-specific (DSS) and progression-free survival (PFS) in stage III epithelial ovarian cancer patients who had been treated with radical surgery, postoperative chemotherapy, and high-dose radiotherapy.

METHODS

Consolidation radiotherapy including whole abdominal radiation, pelvic, and upper abdominal boosts was employed in 46 patients who showed no evidence of residual or progressive disease after completion of multiagent chemotherapy. The median follow-up for all patients was 36 months and 103 months for patients at risk. The prognostic impact of pretreatment and treatment parameters on DSS and PFS was tested in univariate and multivariate analyses.

RESULTS

The 5-year DSS and PFS rates for all patients were 38 and 33%, and for patients with 0-< or =2 cm residual tumor 65 and 61%, respectively. In univariate analysis, initial peritoneal seeding (both: P = 0.02), ascites (P = 0.03; 0.01), size of residual (0-< or =2 cm vs >2 cm), and residual miliary subdiaphragmatic (MDS) and localized peritoneal seeding (LPS) in the upper abdomen (P = 0.0002; 0.0003) were significantly correlated with DSS and PFS. Dose of radiation (< or =30 vs >30 Gy) correlated with DSS only (P = 0.02). In multivariate analysis size of residual disease (0-< or =2 cm vs >2 cm and/or MDS or LPS) remained the only independent prognostic factor for DSS and PFS (both; P = 0. 001).

CONCLUSION

Patients with localized peritoneal seeding who were rendered free of disease elsewhere had an outcome equally poor as that of patients with gross residuals (>2 cm) in the upper abdomen. If our findings can be confirmed, attempted resection of all localized seeding in patients who are otherwise cytoreducible to no or minimal residual disease may be considered in combination with Taxol-containing regimens as are now being utilized for patients with gross disease.

Consolidation radiotherapy after carboplatin-based chemotherapy in radically operated advanced ovarian cancer

OBJECTIVE

The aim of the study was to evaluate the effect of additional radiotherapy after chemotherapy on the relapse-free and overall survival rates of patients with advanced ovarian cancer.

METHODS

Between 1985 and 1992 64 patients with radically operated ovarian cancers (4 stage IC, 2 stage II, 54 stage III, and 4 stage IV) were enrolled in a randomized study. Radical surgery comprised total abdominal hysterectomy and bilateral salpingo-oophorectomy, omentectomy, and pelvic and paraaortic lymphadenectomy. All patients received adjuvant chemotherapy with carboplatin IV 400 mg/m2, epirubicin IV 70 mg/m2 on day 1 and prednimustine orally 100 mg/m2 on days 3 to 7 at 1-month intervals. Thirty-two patients without residual disease were randomized to whole abdominal radiation (30 Gy, administered over 4 weeks). An additional 21.6 Gy were delivered to the pelvis and 12 Gy to the paraaortic region up to the diaphragm for total doses of 51.6 and 42 Gy, respectively. Cancer-related survival was calculated with the Kaplan-Meier and Cox proportional hazards methods.

RESULTS

The relapse-free and overall survival rates of patients who received adjuvant chemoradiotherapy were significantly higher than those of patients who received adjuvant chemotherapy only (68% vs 56% at 2 years and 49% vs 26% at 5 years, P = 0.013, and 87% vs 61% at 2 years and 59% vs 33% at 5 years, P = 0.029). The differences were most pronounced in patients with stage III disease (77% vs 54% at 2 years and 45% vs 19% at 5 years, P = 0. 0061, and 88% vs 58% at 2 years and 59% vs 26% at 5 years, P = 0. 012). Toxicities were acceptable.

CONCLUSION

Sequential combination of platinum-based chemotherapy with open-field abdominal radiotherapy is a promising adjuvant regimen for patients with advanced ovarian cancer.

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.

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.