Treatment of recurrent ovarian cancer: a retrospective analysis of women treated with single-agent carboplatin originally treated with carboplatin and paclitaxel

Defining and targeting wild-type BRCA high-grade serous ovarian cancer: DNA repair and cell cycle checkpoints

Introduction: Molecular analyzes including molecular descriptor/phenotype interactions have led to better characterization of epithelial ovarian cancer patients, including a definition of a BRCA wild-type (BRCAwt) phenotype. Understanding how and when to use agents targeted against dependent BRCAwt pathways or other molecular events at disease progression is an important translational and therapeutic direction in ovarian cancer research. Areas covered: In this overview, we provide definitions and descriptions of a BRCAwt genotype and phenotype. We discuss novel investigational drugs that hold promise for the treatment of BRCAwt ovarian cancer, including inhibitors of poly(ADP-ribose) polymerase, ribonucleotide reductase, DNA protein kinase-catalytic subunit, ataxia-telangiectasia-mutated kinase (ATM), ataxia-telangiectasia mutated and Rad3-related kinase (ATR), CHK 1/2, cyclin kinases, glutaminase-1, WEE1 kinase, as well as tumor microenvironment and angiogenesis inhibitors. This article explores the known and the emerging areas of clinical research on patients with BRCAwt ovarian cancer. Expert opinion: Discovery of molecular changes tied to annotated disease information, along with an expanding array of pathway targets and targeted therapeutic agents, creates optimism and opportunity for women with ovarian cancer. Using precision oncology approaches, clinical researchers are, and will be, poised to select more effective treatments for ovarian cancer patients.

Predicting 6- and 12-Month Risk of Mortality in Patients With Platinum-Resistant Advanced-Stage Ovarian Cancer: Prognostic Model to Guide Palliative Care Referrals

OBJECTIVE

Predictive models are increasingly being used in clinical practice. The aim of the study was to develop a predictive model to identify patients with platinum-resistant ovarian cancer with a prognosis of less than 6 to 12 months who may benefit from immediate referral to hospice care.

METHODS

A retrospective chart review identified patients with platinum-resistant epithelial ovarian cancer who were treated at our institution between 2000 and 2011. A predictive model for survival was constructed based on the time from development of platinum resistance to death. Multivariate logistic regression modeling was used to identify significant survival predictors and to develop a predictive model. The following variables were included: time from diagnosis to platinum resistance, initial stage, debulking status, number of relapses, comorbidity score, albumin, hemoglobin, CA-125 levels, liver/lung metastasis, and the presence of a significant clinical event (SCE). An SCE was defined as a malignant bowel obstruction, pleural effusion, or ascites occurring on or before the diagnosis of platinum resistance.

RESULTS

One hundred sixty-four patients met inclusion criteria. In the regression analysis, only an SCE and the presence of liver or lung metastasis were associated with poorer short-term survival (P < 0.001). Nine percent of patients with an SCE or liver or lung metastasis survived 6 months or greater and 0% survived 12 months or greater, compared with 85% and 67% of patients without an SCE or liver or lung metastasis, respectively.

CONCLUSIONS

Patients with platinum-resistant ovarian cancer who have experienced an SCE or liver or lung metastasis have a high risk of death within 6 months and should be considered for immediate referral to hospice care.

Adjunct Histamine Blockers as Premedications to Prevent Carboplatin Hypersensitivity Reactions

OBJECTIVE

The objective of this study was to evaluate the impact of premedications given as an adjunct to carboplatin on the incidence of hypersensitivity reactions in women with ovarian cancer. Medications of interest include a histamine1 (H1 ) and histamine2 (H2 ) blocker in addition to dexamethasone.

METHODS

This was a retrospective chart review evaluating the addition of an H1 and H2 blocker in addition to dexamethasone as standard premedications on the incidence of carboplatin hypersensitivity reactions (CHRs) in women with ovarian cancer.

MAIN RESULTS

The odds ratio for premedication use was 0.46 with a 95% confidence interval (0.17-1.27), suggesting that patients with premedication use had approximately half the risk of CHR compared with patients without premedication. The overall incidence of CHRs decreased from 7.9% at baseline to 3.2% after the addition of premedications. The incidence of CHRs was 5.2% in 58 patients with recurrent or progressive disease compared with 2.1% in 96 newly diagnosed patients. Lifetime dose greater than 3377 mg, number of cycles more than six, and progressive or recurrent disease were predictive factors of CHR in women with ovarian cancer.

PRINCIPAL CONCLUSIONS

Total lifetime exposure to carboplatin remains the greatest predictive factor of CHR in women with ovarian cancer. Although data analysis indicates the addition of premedications for all ovarian cancer patients receiving carboplatin did not result in a statistically significant reduction in CHRs, a patient benefit in CHR reduction was observed. A prospective study is needed to confirm these findings.

Olaparib in the management of ovarian cancer

Alterations in the homologous repair pathway are thought to occur in 30%–50% of epithelial ovarian cancers. Cells deficient in homologous recombination rely on alternative pathways for DNA repair in order to survive, thereby providing a potential target for therapy. Olaparib, a poly(ADP-ribose) polymerase (PARP) inhibitor, capitalizes on this concept and is the first drug in its class approved for patients with ovarian cancer. This review article will provide an overview of the BRCA genes and homologous recombination, the role of PARP in DNA repair and the biological rationale for the use of PARP inhibitors as cancer therapy, and ultimately will focus on the use of olaparib in the management of ovarian cancer.

Survivin siRNA increases sensitivity of primary cultures of ovarian cancer cells to paclitaxel

PURPOSE

This aim of this study was to use ovarian cancer cells shed in ascitic fluid to establish primary cultures and subsequently use it to detect drug resistance to paclitaxel. Survivin siRNA was used to down regulate survivin expression and effect on paclitaxel resistance was also evaluated.

METHODOLOGY

Ascitic fluid along with corresponding primary tumor tissue was collected from twenty untreated epithelial ovarian cancer patients. Ten primary cultures were established from ascites obtained from untreated ovarian cancer patients in MCDB 105 and M199 medium (ratio 1:1). Knockdown of survivin was done using siRNA and sensitivity to paclitaxel was evaluated by MTT assay.

RESULTS

Grape-like clusters of ovarian cancer cells present in ascites attached and gave a characteristic cobble stone appearance. Treatment with survivin siRNA resulted in a fivefold decrease in survivin expression in primary cultures. Survivin siRNA treatment significantly increased the sensitivity of the primary ovarian cancer cell cultures to paclitaxel.

CONCLUSION

Ascitic cancer cells reflect the molecular profile of tumor and can be used to diagnose resistance to chemotherapy. This study also establishes that high survivin expression is also responsible for resistance to paclitaxel.

Taxane-sensitivity of ovarian carcinomas previously treated with paclitaxel and carboplatin

PURPOSE

The aim of the present study was to investigate, in ovarian carcinoma cases, the predictive association between the treatment-free interval (TFI) after an initial paclitaxel plus carboplatin (TC) therapy and the subsequent effectiveness of a second-line taxane-containing chemotherapy.

METHODS

Patients with a TFI < 6 months from the first-line TC therapy were treated with a combination chemotherapy using docetaxel and irinotecan; patients with a TFI ≥ 6 months were retreated with the same regimen as the initial TC therapy. The clinical data of these patients were retrospectively analyzed for this study.

RESULTS

The response rate of those with a TFI equal to 6-12 months was greater than that of those with a TFI < 6 months (p = 0.014) and less than that of those with a TFI > 12 months (p = 0.012). The progression-free survival of the cases with TFI equal to 6-12 months was longer than that of those with TFI < 6 months (p = 0.012) and shorter than that of those with TFI > 12 months (p = 0.0011). Overall survival of cases with a TFI equal to 6-12 months was longer than that of those with TFI < 6 months (p = 0.012) and shorter than that of those with TFI > 12 months (p = 0.0005).

CONCLUSIONS

The effectiveness of using a second-line taxane-containing chemotherapy was shown to be predictable by the TFI after the first-line taxane-containing chemotherapy, implying that the theory of 'taxane-sensitivity' may be applied for second-line chemotherapy in the same way as that of 'platinum-sensitivity'.

WT1 peptide immunotherapy for gynecologic malignancies resistant to conventional therapies: a phase II trial

OBJECTIVE

The aim of the present study was to analyze the long-term survival effects of WT1 peptide vaccine, in addition to its anti-tumor effects and toxicity.

METHODS

A phase II clinical trial was conducted during the period of 2004-2010 at Osaka University Hospital, Osaka, Japan. The patients who had gynecologic malignancies progressing against previous treatments received WT1 peptide vaccine intradermally at 1-week intervals for 12 weeks. The vaccination was allowed to further continue, unless the patient's condition became significantly worse due to the disease progression.

RESULTS

Forty out of 42 patients, who met all the inclusion criteria, underwent WT1 peptide vaccine. Among these 40 patients, stable disease was observed in 16 cases (40 %). Skin toxicity of a grade 1, 2 and 3 occurred in 25 cases (63 %), 9 cases (23 %) and a single case (3 %), respectively, and liver toxicity of grade 1 in a single case (3 %). The overall survival period was significantly longer in cases positive for the WT1 peptide-specific delayed-type hypersensitivity (DTH) reaction after the vaccination, compared to those negative for the DTH reaction (p = 0.023). Multivariate Cox proportional hazards analysis demonstrated that the adjusted hazard ratio for the negative DTH reaction was 2.73 (95 % CI 1.04-7.19, p = 0.043).

CONCLUSION

WT1 peptide vaccine may be a potential treatment, with limited toxicity, for gynecologic malignancies that have become resistant to conventional therapies. Larger scale of clinical studies is required to establish the efficacy of the WT1 peptide vaccine for gynecologic malignancies.

Recurrent endometrial carcinoma: prognosis for patients with recurrence within 6 to 12 months is worse relative to those relapsing at 12 months or later

OBJECTIVE

We evaluated association of prognosis of endometrial carcinoma patients and treatment-free intervals (TFIs).

STUDY DESIGN

We compared the effectiveness of second-line chemotherapy performed for patients with TFIs of 6-12 months and 12 or more months following a first-line chemotherapy based on taxane (paclitaxel) and carboplatin, with or without the anthracycline (TC).

RESULTS

Progression-free and overall survivals were significantly shorter in patients with TFIs of 6-12 months than those with TFIs of 12 or more months. Among the patients who received similar second-line chemotherapy, response rates of 15 patients with TFIs of 12 or more months and 7 patients with TFIs of 6-12 months were 67% and 43%, respectively. Progression-free survival was significantly worse in those with TFIs of 6-12 months (median, 7 months) than those with TFIs of 12 or more months (median, 12 months).

CONCLUSION

Our small retrospective analysis suggests that recurrent endometrial carcinomas with TFIs of 6-12 months can be regarded as being partially sensitive to TC-based chemotherapy.

Phase II study of the combination carboplatin plus celecoxib in heavily pre-treated recurrent ovarian cancer patients

Background

Cyclooxygenase-2 overexpression is associated with poor outcome and resistance to platinum-based chemotherapy in ovarian cancer. We evaluated the antitumor activity and safety of the combination carboplatin plus the COX-2 inhibitor celecoxib in recurrent heavily-treated OC patients.

Methods

Patients were administered oral celecoxib (400 mg/day) in combination with intravenous carboplatin (AUC5, q28). A Simon's two-stage design was employed.

Results

45 patients were enrolled: 23 (51.1%) presented platinum-resistance, and 27 (60%) had received at least 3 prior regimens for recurrence. The response rate was 28.9% with 3 complete and 10 partial responses (median duration of response = 6 months). Only one (0.4%) G4 non-febrile neutropenia was observed; G3 neutropenia, anemia, or thrombocytopenia, were observed in 2.5%, 1.7%, and 1.7% of the cycles, respectively. G3-4 vomiting was reported in only 1.7%, and 0.4% of the cycles were associated with G3 dyspepsia or diarrhea or constipation. Only one patient experienced G3 hypertension associated to G2 hypersensitivity reaction. No differences in baseline versus post-treatment Quality of Life scores were observed. Median progression free survival and overall survival were 5 and 13 months, respectively.

Conclusions

Celecoxib combined with carboplatin showed promising activity and it is well tolerated in heavily-treated recurrent ovarian cancer patients.

Trial registration number

NCT01124435 (ClinicalTrials.gov Identifier) and 935/03 (study ID numbers).

A randomized phase II study of carboplatin plus pegylated liposomal doxorubicin versus carboplatin plus paclitaxel in platinum sensitive ovarian cancer patients: a Hellenic Cooperative Oncology Group study

BACKGROUND

Platinum-based combinations are the standard second-line treatment for platinum-sensitive ovarian cancer (OC). This randomized phase II study was undertaken in order to compare the combination of carboplatin and pegylated liposomal doxorubicin (LD) with carboplatin and paclitaxel (CP) in this setting.

METHODS

Patients with histologically confirmed recurrent OC, at the time of or more than 6 months after platinum-based chemotherapy, were randomized to six cycles of CP (carboplatin AUC5 + paclitaxel 175 mg/m2, d1q21) or CLD (carboplatin AUC5 + pegylated LD 45 mg/m2, d1q28).

RESULTS

A total of 189 eligible patients (CP 96, CLD 93), with a median age of 63 years, median Performance Status (PS) 0 and a median platinum free interval (PFI) of 16.5 months, entered the study. Discontinuation due to toxicity was higher in the CP patients (13.5% versus 3%, P = 0.016). The overall response rate was similar: CP 58% versus CLD 51%, P = 0.309 (Complete Response; CR 34% versus 23%) and there was no statistical difference in time-to-progression (TTP) or overall survival (OS; TTP 10.8 months CP versus 11.8 CLD, P = 0.904; OS 29.4 months CP versus 24.7 CLD, P = 0.454). No toxic deaths were recorded. Neutropenia was the most commonly seen severe toxicity (CP 30% versus CLD 35%). More frequent in CLD were severe thrombocytopenia (11% versus 2%, P = 0.016), skin toxicity and Palmar-plantar erythrodysesthesia (PPE) grade 1-2 (38% versus 9%, P< 0.001), while grade 3 neurotoxicity and alopecia were higher in CP (7% versus 0%, P = 0.029, 20% versus 5%, P = 0.003). PS and PFI were independent prognostic factors for TTP and OS.

CONCLUSIONS

The combination of pegylated LD with carboplatin is effective, showing less neurotoxicity and alopecia than paclitaxel-carboplatin. It thus warrants a further phase III evaluation as an alternative treatment option for platinum-sensitive OC patients.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry: ACTRN12609000436279.

Management of recurrent ovarian carcinoma: current status and future directions

The majority of patients who present with epithelial ovarian cancer respond well to the initial treatment, but will ultimately experience a recurrence of their disease. Chemotherapy can palliate symptoms of disease recurrence, and there is some evidence that it also can improve survival. Recurrent ovarian carcinoma is divided into two subsets of patients: those with platinum-sensitive disease and those with platinum-resistant disease. Management for these two groups has diverged in the last few years, as evidence accrues that the response to treatment and duration of treatment-free interval after completion of front-line therapy impacts the prognosis and the treatment choice for these patients. Recent randomized trials have demonstrated a benefit for platinum combination re-treatment in patients with platinum-sensitive disease. Additionally, there are multiple single-agent trials evaluating novel agents for patients with platinum-resistant as well as platinum-sensitive disease. This review will discuss the role of chemotherapy in recurrent disease, describe the various agents used in this setting, and touch on the role of biologic agents in recurrent epithelial ovarian carcinoma.

Recurrent low-grade serous ovarian carcinoma is relatively chemoresistant

PURPOSE

Previous studies have suggested that low-grade serous ovarian carcinoma is more chemoresistant to first-line or neoadjuvant chemotherapy than high-grade serous carcinoma. The purpose of this study was to further characterize this chemoresistance in recurrent low-grade serous ovarian carcinoma.

METHODS

From a 1990-2007 search of the departmental databases at our institution, we identified recurrent low-grade serous ovarian carcinoma patients; abstracted chemotherapy response information from the medical records of those whose disease was: 1) histologically-confirmed, 2) measurable or evaluable, and 3) treated with chemotherapy; and retrospectively reviewed these data. Response was determined based on modified RECIST. Time to progression and overall survival were also calculated.

RESULTS

We identified 58 evaluable patients with recurrent low-grade serous ovarian carcinoma who received 108 separate chemotherapy regimens ("patient-regimens"), which produced 4 responses-(1 complete and 3 partial; overall response rate, 3.7%). The overall response rate for the platinum-sensitive cohort was 4.9%, and for the platinum-resistant cohort, 2.1%. Stable disease was observed in 65 (60.2%) of 108 patient-regimens. Median overall survival was 87.1 months. The median time to progression was 29.0 weeks (34.7, platinum-sensitive cohort; 26.4, platinum-resistant cohort) (P=0.32).

CONCLUSIONS

Compared with high-grade ovarian cancers, recurrent low-grade serous ovarian carcinoma appears relatively chemoresistant. Whether the latter's high rate of stable disease owes more to the tumor's biology or the influence of chemotherapy remains unclear. Based on these findings, phase II trials of novel targeted agents in recurrent low-grade serous ovarian carcinoma are warranted.

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.

[Evaluation of second-line chemotherapies most often used in recurrent epithelial ovarian cancer]

INTRODUCTION

Second-line chemotherapies result in a progression-free interval of 2,3-42 months.

AIM

The authors evaluated the efficacy of second-line paclitaxel-carboplatin, topotecan, and cisplatin-epirubicin-etoposide combinations.

METHODS

Paclitaxel-carboplatin (175 mg/m2 and AUC 5) in 3-week intervals and topotecan (1.5 mg/m2/d1-3) in 3-week intervals was given to 13 and 16 patients. The triple combination of cisplatin-epirubicin-etoposide was applied in 48 patients in 4-week courses, with doses of 33 mg/m2/d1-3, 60 mg/m2/d1, and 100 mg/m2/d1-3., respectively. The progression-free interval was calculated by the product limit method of Kaplan-Meier.

RESULTS

A significantly better progression-free interval was observed in treatments with paclitaxel-carboplatin and cisplatin-epirubicin-etoposide compared to the topotecan chemotherapy (5 and 5.5 months vs. 4 months, respectively, p = 0.0324 and p = 0.0087). A better progression-free interval was found in the platinum-sensitive tumors compared to the platinum-resistant ones by the above mentioned combinations (6 and 3.5 months, 7 and 4 months, and 6.5 and 3.5 months, respectively).

CONCLUSION

The lower priced cisplatin-epirubicin-etoposide combination resulted in a slightly better efficacy compared to the 2 other treatments both in platinum-sensitive and platinum-resistant tumors.

Extreme drug resistance is common after prior exposure to paclitaxel

OBJECTIVE

The platinum-free interval (PFI) is an important entity in the treatment of women with epithelial ovarian cancer. The purpose of this study was to determine on clinical samples whether a taxane-free interval (TFI), as defined by in vitro extreme drug resistance assay, existed in women previously exposed to platinum and taxane chemotherapy.

METHODS

Records were examined from 2003 to 2006 to find all patients with epithelial ovarian cancer who had previous exposure to platinum and taxane therapy. Further examination was done to find all patients who underwent secondary cytoreduction and had their tumor submitted for extreme drug resistance assay.

RESULTS

Thirty-four women meeting the above criteria were found. The mean PFI was 25 months (median 18). The mean TFI was 27 months (median 20). Over 44% of the patients have been exposed to more than just a course of platinum and a course of a taxane. In patients having a PFI of >or=12 months, 38.8% had extreme drug resistance (EDR) to carboplatin and 41.9% EDR to cisplatin. Conversely, in patients having a TFI of >or=12 months, 89.7% had EDR to paclitaxel and 82.8% EDR to docetaxel.

CONCLUSIONS

While only a small percentage have EDR to carboplatin and cisplatin after a PFI of >or=12 months, almost 90% of patients with a TFI>or=12 months showed EDR to paclitaxel in vitro.

Determination of the optimal combination chemotherapy regimen for treatment of platinum-resistant ovarian cancer in nude mouse model

OBJECTIVE

The primary objective of this study was to evaluate the potential to increase the in vivo activity of liposomal doxorubicin when administered in combination with other chemotherapeutic agents such as topotecan, docetaxel, gemcitabine, capecitabine, or celecoxib in an ovarian cancer xenograft mouse model to identify new treatment options for recurrent platinum-sensitive/resistant ovarian cancer.

METHODS

This was a five-arm study in two xenograft ovarian cancer mouse models, ES-2 (platinum-sensitive), and OVCAR3 (platinumresistant), to evaluate the combination of liposomal doxorubicin with the common chemotherapeutic agents. Each cell line had five mice for each treatment arm, five vehicle control mice, and five liposomal doxorubicin alone control mice. Experiments were done in duplicate.

RESULTS

The percentage tumor reduction ranged from 52% to 74.1% for the single-agent treatment arms. Tumor growth inhibition and regression (response) was improved on the combination treatment arms ranging from 76.1% to 100%. We observed increased activity in the liposomal doxorubicin plus topotecan arm, with a 27.3% improvement in response, compared with either agent alone.

CONCLUSIONS

The addition of liposomal doxorubicin demonstrated increased antitumor activity compared with either agent used alone. The most active combination treatment arm was liposomal doxorubicin with topotecan which is consistent with recent clinical study reports of enhanced activity with the combination of topoisomerase I and topoisomerase II agents. Additional studies are warranted to evaluate the efficacy and safety to optimize the combination of liposomal doxorubicin and topotecan for the treatment of recurrent or refractory ovarian cancer.

Duration of second or greater complete clinical remission in ovarian cancer: exploring potential endpoints for clinical trials

OBJECTIVE

To explore benchmarks for future consolidation strategies, we evaluated a strictly defined (normal CA-125 and normal CT) second-complete-remission (CR) ovarian cancer population for 1) the median progression-free survival (PFS), 2) the frequency with which second remission exceeds first, and 3) the proportion of patients in remission at given time points.

METHODS

Retrospective sampling was carried out at Memorial Sloan-Kettering (10/1993-12/2000) and the Royal Marsden Hospital (1/1995-4/2003) for the following: histological confirmation and elevated CA-125 at diagnosis; primary surgery; first-and second-line platinum-based chemotherapy with CR; and no maintenance therapy.

RESULTS

In 35 patients 1) the duration of first PFS was 17.8 months (95% CI, 13.2-24.5 months) and second PFS was 10.8 months (95% CI, 9.6-12.2 months); 2) the number of patients with second response longer than first was 3/35 (9%); 3) the proportion of patients remaining in second complete remission was 100% (3 months), 100% (6 months), 83% (9 months), 34% (12 months), 23% (15 months) and 8.6% (18 months), respectively.

CONCLUSION

1) The median PFS from second complete remission is short. 2) A second response is rarely longer than the first even in this second CR population. 3) The number of patients with a second response longer than the first, or the proportion of patients remaining in complete remission at given time points could be evaluated as an outcome measure in future studies.

A phase I study evaluating the safety and pharmacokinetics of weekly paclitaxel and carboplatin in relapsed ovarian cancer

This phase I study sought to determine the toxicity profile, pharmacokinetics, and antitumor activity of giving carboplatin every 3 weeks and paclitaxel weekly in patients with relapsed ovarian cancer. Eligible patients with relapsed epithelial ovarian cancer and prior treatment with platinum- and paclitaxel-based therapy were treated with an escalating regimen of carboplatin (day 1) at an area under the curve (AUC) of 4–6 and 1-h infusions of paclitaxel (days 1, 8, and 15) at 50–80 mg/m2 cycled at 3-week intervals. Pharmacokinetic studies were performed on the first day of cycles 1 and 2. All patients had a platinum-free interval of greater than 6 months from the most recent platinum treatment. A total of 77 cycles were administered to 16 patients, with a similar median number of cycles per patient at each dose level varying from 4.6 to 5.3. Febrile neutropenia and grade 4 thrombocytopenia were the dose-limiting toxicities at dose levels 3 and 4 after the third cycle, with no mucositis, nausea, vomiting, or peripheral neuropathy observed greater than grade 2. The maximum tolerated dose of carboplatin was an AUC of 5 and 80 mg/m2 for paclitaxel. Pharmacokinetic analysis showed a marginal statistical difference with regard to reduced systemic paclitaxel concentration after cycle 2 compared with cycle 1 (P= 0.06). Of nine patients evaluable for a radiographic response, the response rate was 66.6% with a complete response of 33.3%. All five patients with nonmeasurable disease achieved a biochemical response. The combination of carboplatin given every 3 weeks at an AUC of 5 and 1-h weekly paclitaxel at 80 mg/m2 is a feasible and reasonably well-tolerated regimen and may have significant antitumor activity in relapsed ovarian cancer patients.

Impact of pattern of recurrence on clinical outcome of ovarian cancer patients: Clinical considerations

Recurrence of disease represents a clinical challenge in ovarian cancer patients. The aim of this study was to analyse the distribution and pattern of recurrence and their association with clinical outcome in a large series of ovarian cancer patients. This study was conducted on 328 primary untreated ovarian cancer patients. For each relapse, information on date of clinical/instrumental recurrence, and pattern of disease presentation were retrieved. In stage III-IV cases (n = 270), diffuse abdominal carcinomatosis occurred in 62.1% of cases, while recurrences presented as a single lesion or multiple nodules occurred in 9.9% and 26.7% of cases, respectively. Pattern of recurrence as carcinomatosis was shown to be associated with unfavourable outcome even when stratified according to platinum free interval (PFI) duration. In multivariate analysis, pattern of recurrence and PFI duration retained an independent prognostic role for post-relapse survival. Duration of PFI and type of recurrence may independently influence post-relapse survival in ovarian cancer patients.

Rapid desensitization for hypersensitivity reactions to chemotherapy agents

PURPOSE OF REVIEW

Hypersensitivity reactions (HSRs) to chemotherapy agents have limited their use for fear of inducing severe reactions or death. Alternative regimens may be limited by tumor sensitivity and the need to provide first-line therapy. Rapid desensitizations allow patients to be treated with medications to which they have presented a HSR. The purpose of this review is to highlight the indications and recent developments in chemotherapy rapid desensitization protocols.

RECENT FINDINGS

Intravenous and oral rapid desensitization protocols are available for taxenes, platinums, doxorubicin, monoclonal antibodies and others. Candidate patients present mild to severe type I hypersensitivity, mast cell/IgE-dependent reactions, as seen with platinums. Anaphylactoid reactions, such as those with taxenes, can be treated with the same protocols. Repeat desensitizations in outpatient settings are well tolerated and allow patients to remain in clinical studies/trials. Breakthrough symptoms during desensitizations are less severe than the initial reaction and no deaths have been reported. Cancer remissions are similar to those for nondesensitized patients.

SUMMARY

The use of rapid desensitization protocols for cancer patients with HSRs to chemotherapy depends on their demonstrated tolerability and efficacy in selected populations. Education of nurses, pharmacists, and oncology and allergy specialists is needed to improve their universal application as standard of care.

Topotecan as second-line therapy for ovarian cancer: dosage versus toxicity

In this issue of The Oncologist, Armstrong et al. present an analysis of the use of topotecan (Hycamtin; GlaxoSmithKline, Philadelphia, http://www.gsk.com) in the second-line treatment of both ovarian cancer and small cell carcinoma of the lung. This cytotoxic agent has clearly been demonstrated to be a useful drug in a population of patients with both of these conditions. However, the description of the nature of the toxicity, as stated in the manuscript, must be questioned along with comments made regarding the relative toxicity of alternative cytotoxic agents frequently used in similar settings. The purpose of this discussion absolutely is not to negate the unquestioned, demonstrated usefulness of topotecan as second-line therapy in ovarian cancer but rather to point out that the U.S. Food and Drug Administration-approved dose level of 1.5 mg/m(2) per day x 5 days can cause substantial and highly clinically relevant bone marrow toxicity. Whether this toxicity, which can result in a level of fatigue that may cause responding patients to discontinue treatment, should simply be labeled "excessive" rather than "cumulative" appears to be a matter of semantics rather than an important distinction. Whether delivery of a lower dose of topotecan (1 mg/m(2)-1.25 mg/m(2) per day x 5 days) will essentially eliminate concern for the development of severe clinically relevant marrow toxicity is uncertain, but the risk will certainly be substantially reduced.

Gemcitabine in epithelial ovarian cancer treatment: current role and future perspectives

Newer agents and combinations are needed in order to improve current results in ovarian cancer treatment. Gemcitabine is a novel agent that has shown consistent activity as a single agent in the treatment of platinum-resistant ovarian cancer and a favorable toxicity profile. Because of its clinical and preclinical synergism with platinum analogs, gemcitabine has been combined with carboplatin as a convincing approach in the treatment of platinum-sensitive recurrent ovarian cancer patients. Further combination of gemcitabine and other agents, including paclitaxel, is also feasible and has been actively studied in order to establish the role of gemcitabine in the management of treated and untreated ovarian cancer patients.

Randomized phase II trial of carboplatin versus paclitaxel and carboplatin in platinum-sensitive recurrent advanced ovarian carcinoma: a GEICO (Grupo Espanol de Investigacion en Cancer de Ovario) study

BACKGROUND

The aim of this study was to determine whether the response rate for the paclitaxel-carboplatin combination is superior to carboplatin alone in the treatment of patients with platinum-sensitive recurrent ovarian carcinoma.

PATIENTS AND METHODS

Patients with recurrent ovarian carcinoma, 6 months after treatment with a platinum-based regimen and with no more than two previous chemotherapy lines, were randomized to receive carboplatin area under the curve (AUC) 5 (arm A) or paclitaxel 175 mg/m(2) + carboplatin AUC 5 (arm B). The primary end point was objective response, following a 'pick up the winner' design. Secondary end points included time to progression (TTP), overall survival, tolerability and quality of life (QoL).

RESULTS

Eighty-one patients were randomized and included in the intention-to-treat analysis. The response rate in arm B was 75.6% [26.8% complete response (CR) + 48.8% partial response (PR)] [95% confidence interval (CI) 59.7% to 87.6%] and 50% in arm A (20% CR + 30% PR) (95% CI 33.8% to 66.2%). No significant differences were observed in grade 3-4 hematological toxicity. Conversely, mucositis, myalgia/arthralgia and peripheral neurophaty were more frequent in arm B. Median TTP was 49.1 weeks in arm B (95% CI 36.9-61.3) and 33.7 weeks in arm A (95% CI 25.8-41.5). No significant differences were found in the QoL analysis.

CONCLUSIONS

Paclitaxel-carboplatin combination is a tolerable regimen with a higher response rate than carboplatin monotherapy in platinum-sensitive recurrent ovarian carcinoma.

Critical evaluation of secondary cytoreduction in recurrent ovarian cancer

OBJECTIVE

The optimal strategy for salvage therapy in patients who suffer from ovarian cancer recurrence after a disease-free interval is not established. The objective of this paper is to analyze the existing published data on salvage surgery in this setting.

METHODS

A retrospective review of the English literature was done looking at studies addressing the role of secondary cytoreductive surgery in recurrent ovarian cancer. A number of parameters were collected from these studies and analyzed, including patients' characteristics, outcome of secondary cytoreduction, perioperative complications, postoperative therapy, and survival. In a parallel analysis, we reviewed the outcome of patients treated with salvage chemotherapy without surgery in similar clinical settings.

RESULTS

Optimal cytoreduction was achievable in 38-87% of the study populations reviewed with acceptable perioperative complications and mortality. The attempt to analyze the impact of secondary cytoreduction on survival was limited by (1) the inter-investigator differences in defining optimal cytoreduction, (2) the heterogeneity of the patients included, (3) and the lack of information on postoperative therapy. All the studies suggest that patients left with no gross residual disease after secondary cytoreduction seem to benefit from prolonged survival in the range of 44-60 months. Current data reveal that the use of combination chemotherapy without surgery for salvage treatment of recurrent ovarian cancer can be associated with prolonged median survival reaching up to 35 months.

CONCLUSION

The available data suggest a benefit for secondary surgical cytoreduction in recurrent ovarian cancer. This needs to be considered in the light of recent data reporting prolonged survival with the use of combination salvage chemotherapy without surgery. Currently, it is not known if a salvage strategy combining surgery and multiagent chemotherapy regimens will have a survival benefit over chemotherapy alone. Hopefully, current ongoing prospective trials will answer this question.

Carboplatin hypersensitivity: a 6-h 12-step protocol effective in 35 desensitizations in patients with gynecological malignancies and mast cell/IgE-mediated reactions

OBJECTIVES

The incidence of hypersensitivity reactions (HR) is increased in patients treated with multiple courses of carboplatin. The purposes of this investigation were to evaluate the effectiveness of a 12-step desensitization protocol and to characterize the immune mechanism of carboplatin HR.

METHODS

We analyzed 10 consecutive patients who had documented HR to carboplatin and in whom continued treatment with carboplatin was considered advantageous. The patients were treated with carboplatin using a 6-h, 12-step desensitization protocol with a 30-min premedication regimen. Skin tests were performed on five patients.

RESULTS

Ten patients successfully completed 35 planned courses of desensitizations to carboplatin, 31 of which were without reactions. Four patients had symptoms during their first (n = 3) and third (n = 1) desensitizations but tolerated the re-administration of infusions without further reactions. For subsequent courses, the protocol was modified for two patients who had extracutaneous symptoms during desensitization and was unchanged for the patient who had mild urticaria. These three patients tolerated subsequent courses of desensitizations without reactions. The fourth patient with symptoms during desensitization no longer required carboplatin due to progressive disease. Of the five patients who were skin tested to carboplatin, four had positive wheal and flare reactions. In one patient, the skin test response to carboplatin became negative after desensitization.

CONCLUSION

The 6-h, 12-step desensitization protocol is safe and effective for treating patients with carboplatin HR. Positive skin tests to carboplatin suggest a mast cell/IgE-mediated mechanism. Conversion of the positive skin test to a negative response after desensitization supports antigen-specific mast cell desensitization.