The chemotherapy of ovarian carcinoma

The role of cytoreductive surgery for non-genital tract metastatic tumors to the ovaries

OBJECTIVE

The aim of this study was to investigate prognostic factors of patients with metastases to the ovaries from non-genital organs.

STUDY DESIGN

From September 1994 to December 2006, 158 patients with pathologically confirmed metastatic tumors to the ovaries at Samsung Medical Center (SMC) were included in this study. The data were obtained from the patients' medical records and pathology reports.

RESULTS

The primary tumor origin was mostly stomach (73 cases) and colon (61 cases). Krukenberg tumor (pathologically proven signet ring cell carcinoma) was found in 34 cases: stomach (25), colon (2), appendix (1), and unknown (6). Residual disease after surgery was >2 cm in 65 (41.1%) cases and <2 cm in 93 (58.9%) cases. The overall 5-year survival was 7.2% and the median survival time was 15 months. The median survival times according to the primary tumor site showed significant differences (p=0.002) and were as follows: stomach 12 months, colon 17 months. The median survival in cases with residual disease <2 cm vs. >2 cm was 26 months vs. 15 months (p=0.017) and the median survival with vs. without adjuvant chemotherapy was 16 months vs. 10 months (p=0.001). However, age, bilateral tumors, chronology of diagnosis and mass size did not affect survival.

CONCLUSION

Cytoreductive surgery and post-operative adjuvant chemotherapy had a beneficial effect on survival in selected patients.

Current management strategies for ovarian cancer

Epithelial ovarian cancer originates in the layer of cells that covers the surface of the ovaries. The disease spreads readily throughout the peritoneal cavity and to the lymphatics, often before causing symptoms. Of the cancers unique to women, ovarian cancer has the highest mortality rate. Most women are diagnosed as having advanced stage disease, and efforts to develop new screening approaches for ovarian cancer are a high priority. Optimal treatment of ovarian cancer begins with optimal cytoreductive surgery followed by combination chemotherapy. Ovarian cancer, even in advanced stages, is sensitive to a variety of chemotherapeutics. Although improved chemotherapy has increased 5-year survival rates, overall survival gains have been limited because of our inability to eradicate all disease. Technologic advances that allow us to examine the molecular machinery that drives ovarian cancer cells have helped to identify numerous therapeutic targets within these cells. In this review, we provide an overview of ovarian cancer with particular emphasis on recent advances in operative management and systemic therapies.

Activity and pharmacodynamics of 21-Day topotecan infusion in patients with ovarian cancer previously treated with platinum-based chemotherapy. New York Gynecologic Oncology Group

PURPOSE

Twenty-one-day topotecan infusion was administered as second-line therapy in patients with previously treated ovarian cancer (based on our prior favorable phase I experience) to determine its activity, time to progression, and pharmacodynamics.

PATIENTS AND METHODS

Ovarian cancer patients with measurable lesions and one prior platinum-containing regimen were eligible. Topotecan 0.4 mg/m(2)/d 21-day continuous ambulatory intravenous infusion, with appropriate dose modifications for toxicity, was administered every 28 days. Weekly blood levels of topotecan and topoisomerase-1 (topo-1) levels in peripheral-blood mononuclear cells (PBMCs) were determined for pharmacodynamic correlation.

RESULTS

Twenty-four patients were entered onto the study (six cisplatin-refractory, five relapsing within < 6 months and 13 relapsing > 6 months after platinum-based therapy). A total of 128 cycles of topotecan (median, four cycles per patient; range, one to 12 cycles) were administered. The major toxicity was neutropenia (29% grade 3 in all cycles and 4% grade 4). One episode of grade 4 thrombocytopenia (4%) occurred. Fifty-two percent of the patients had anemia that required transfusions. Eight of 23 patients with measurable disease (35%; 95% confidence interval [CI], 15% to 54%) had partial responses (PRs) lasting longer than 1 month. Two of these patients had minor residual computed tomographic changes but had clinical complete remissions that lasted up to 53 weeks while they were not undergoing further therapy. One patient with nonmeasurable disease had a PR (by CA-125 criteria) that lasted 6 months, for an overall response rate of 38% in nine of 24 patients (95% CI, 18% to 57%). The median time to progression was 26 weeks. Pharmacodynamic analysis demonstrated a statistically significant decrease in free PBMC topo-1 level at weeks 2 and 3 of drug administration. There was a strong statistical correlation between the decrease in free topo-1 levels and increasing area under the curve (AUC) for topotecan. This was confirmed in a pharmacodynamic model.

CONCLUSION

Twenty-one-day infusion is a well-tolerated method of administering topotecan. Pharmacodynamic studies demonstrate correlations between (1) the week of infusion and the PBMC topo-1 level, (2) the AUC of topotecan and the decrease in topo-1 levels, and (3) the change in topo-1 level and the neutrophil nadir. The objective response rate of 35% to 38% (95% CI, 15% to 57%) in this small multicenter study is at the upper level for topotecan therapy in previously treated ovarian cancer. Prolonged topotecan administration therefore warrants further investigation in larger, randomized studies comparing this 21-day schedule with the once-daily-for-5-days schedule.

Expression of O6-alkylguanine-DNA-alkyltransferase in situ in ovarian and Hodgkin's tumours

The cellular expression of O6-alkylguanine-DNA-alkyltransferase (ATase) may be an important factor in determining tumour sensitivity to certain alkylating agents. In a comparative study, we have examined the inter- and intracellular distribution of ATase in tumour biopsies of a series of patients with Hodgkin's disease and ovarian cancer using a rabbit antihuman ATase antiserum. The antibody recognises the ATase protein on western blots of cell-free extracts of a number of ovarian tumours with ATase activities varying from 20 to 420 fmol/mg protein as determined by in vitro assay and there was a linear correlation between ATase activity and the intensity of the band on western blots (r = 0.993). Immunohistochemical staining was seen in all of the ovarian tumours examined and was confined to the nucleus. This is in contrast to the Hodgkin's tissue, where staining was much reduced and present in both nuclei and cytoplasm. The results suggest that in ovarian tumours the general resistance to nitrosourea chemotherapy may be related to the high cellular expression of ATase protein: this is in contrast to the more chemosensitive Hodgkin's disease. This raises the possibility that it might be feasible to predict sensitivity or resistance to these alkylating agents by immunohistochemical staining of tumour or tissue specimens.

Phase I evaluation of thio-TEPA in combination with cisplatin for advanced gynecologic malignancies

Thirty-five patients with advanced gynecologic malignancies were entered into a phase I study evaluating thio-TEPA in combination with cisplatin (50 mg/m2) intravenously every 4 weeks. Thirty-four patients were evaluable for toxicity and response, and one was evaluable for toxicity only. Median age was 53 years (range 28-72), and performance status less than or equal to 2. Prior treatment included chemotherapy in 21 patients, radiation in 15, hormonal therapy in 3, and immunotherapy in 1. Thio-TEPA was given to three or more patients at each of the following dose levels: 15, 20, 25, 30, 40, 50, and 60 mg/m2. Thio-TEPA's primary toxicity was myelosuppression; at 50 mg/m2, grade 3 or 4 granulocytopenia occurred in 13 of 17 cycles, and grade 3 or 4 thrombocytopenia occurred in 8 of 17 cycles. The maximum tolerated dose (MTD) of thio-TEPA was 40 mg/m2; in 35 cycles at this dose, grade 3 or 4 granulocytopenia occurred in 19, and grade 3 or 4 thrombocytopenia occurred in 10 cycles; median granulocyte nadir was 1100 (range 110 to 3600) and median platelet nadir was 90,000 (range 10,000 to 289,000). Fifteen patients received three or more cycles at one dose level; cumulative myelosuppression was observed in 11. Two cases of partial alopecia occurred at 40 and 60 mg/m2 thio-TEPA. Responses were as follows: complete response, 5; partial response, 7; stable disease, 14; progressive disease, 8. In 16 patients with ovarian cancer (15 of whom had previously received cisplatin), there were 4 complete responses and 5 partial responses (overall response rate of 56%). The thio-TEPA dose recommended in combination with cisplatin (50 mg/m2) in phase II trials is 40 mg/m2. Cumulative hematologic toxicity may occur with this regimen.

Glutathione and glutathione S-transferases in a human plasma cell line resistant to melphalan

We report the development of a melphalan-resistant HS-Sultan human plasma cell line. The melphalan-resistant [MEL(R)] cell line was 16.7-fold more resistant to melphalan in vitro than the parent cell line [MEL(S)]. The wild type and MEL(R) HS-Sultan cell lines formed localized plasmacytomas when injected into nude mice. A dose-response effect of melphalan against the drug-sensitive plasmacytomas was present in vivo. A dose of 10 mg/kg of melphalan, which caused a 90% regression of MEL(S) plasmacytomas, had no effect on the MEL(R) plasmacytomas in vivo. In contrast to previous reports, there was no increase in the levels of glutathione (GSH) in the MEL(S) and MEL(R) plasmacytomas, suggesting that the association of elevated glutathione levels and melphalan resistance may not be common to all drug-resistant lines. In the MEL(R) plasmacytomas, there was a 1.5-fold induction of a pi type glutathione S-transferase (GST) as evidenced by isoelectric focusing (IEF) and Western blotting. This GST isoenzyme was purified and, although immunochemically similar to the pi type isoenzymes induced in other drug-resistant cell lines, was noted to have different functional characteristics. These data suggest that, depending on cell type and the drug studied, functionally different GST isoenzymes may be induced and they could be of importance in the development of drug resistance.

High-dose chemotherapy with autologous bone marrow transplantation in patients with refractory ovarian cancer

Eleven patients with persistent ovarian cancer after remission-induction chemotherapy were treated with high-dose cyclophosphamide and etoposide followed by autologous bone marrow transplantation (ABMT). Six complete responses (CR), of which five were pathologically confirmed, were achieved in eight patients who had microscopic or residual disease less than or equal to 2 cm at the start of high-dose chemotherapy. The median duration of response was 15 months with two sustained CRs after respectively 43 and 75 months. None of the three patients with residual disease greater than 2 cm responded. The median survival measured from the start of the ABMT regimen was for all patients 23 months. These results suggest that high-dose systemic chemotherapy followed by ABMT is a therapeutic option in patients with refractory ovarian cancer deserving further investigation.

Intraperitoneal chromic phosphate therapy after second-look laparotomy for ovarian cancer

Between 1973 and 1985, 118 patients in clinical remission after initial surgery and postoperative chemotherapy for epithelial ovarian carcinoma underwent second-look laparotomy at the University of North Carolina. No evidence of disease (NED) was found in 57 of these patients; 43 patients received 15 mCi of radioactive chromic phosphate (32P) suspension given intraperitoneally in the immediate postoperative period. In 29 other patients, only microscopic or minimal residual disease (nodules less than 2 cm in size) was found, seven received 32P alone, ten received 32P and further chemotherapy, and 12 received chemotherapy alone. The 4-year postsecond-look survival of the patients with NED at second-look was 89% for those receiving 32P and 67% for those who had not. The respective figures for patients with minimal residual disease at second-look are 59% versus 22%. Irrespective of treatment, a group at high risk for failure after negative second-look laparotomy has been identified; those with an initial International Federation of Gynecology and Obstetrics (FIGO) stage greater than I and histologic grade greater than 1. A comparison of our data with 18 previously published series, indicates that use of postsecond-look intraperitoneal 32P can improve the progression-free interval, and possibly overall survival, of patients with NED or minimal residual disease without adding significant complications.

Randomized trial of the addition of cis-platin (DDP) and/or BCG to cyclophosphamide (CTX) chemotherapy for ovarian carcinoma

A prospective randomized trial has compared cyclophosphamide (CTX) with CTX plus cis-diamminodichloroplatinum (DDP) as the initial chemotherapy for advanced ovarian carcinoma. A secondary randomization compared the addition of BCG treatment to either chemotherapy. The addition of DDP had no measurable impact on survival, but a small survival trend favoring BCG-treated patients was noted (P less than 0.08). Toxicity from BCG treatment was insignificant, but the addition of DDP increased both early nausea and vomiting and later hematologic toxicity. There were three long-term complete remission patients, and these all came from the group of six patients with pretreatment residual disease less than 2 cm. A univariate analysis of pretreatment prognostic factors indicated significantly better prognosis (P less than 0.02) for patients with no palpable tumor, platelet count less than 400,000/mm3, residual tumor less than 2 cm, resting pulse less than 91/min. and LDH less than 250 U/L. The authors conclude that for patients with large (greater than 2 cm) residual disease, there is no compelling evidence that initial combination therapy is superior to aggressive single alkylating agent treatment.

Sequential multi-agent chemotherapy and whole abdominal irradiation for stage III ovarian carcinoma

Modern therapy for stage III ovarian carcinoma patients usually involves one or more laparotomies with maximal resection of tumor, and intensive multi-agent chemotherapy. However, with long-term follow-up only 10-15% of patients remain free of disease. In the hope of improving outcome, we have treated 17 women with sequential multimodality therapy, including initial surgical resection (if possible), cyclophosphamide-adriamycin +/- cis-platinum, second-look surgery, and whole abdominal irradiation. Seven patients are currently alive without disease, with median follow-up of 52 months since initiation of radiation and 60 months since initiation of chemotherapy. Disease-free survival correlated with residual tumor at the start of radiotherapy: none (4/4); microscopic, less than or equal to 5 mm (3/4); greater than 5 mm or no surgery (0/9). Survival also correlated with tumor grade: grade 1 (2/2); grade 2 (2/3); grade 3 (3/11). Hematological tolerance of radiotherapy was dependent upon the number of chemotherapy cycles: ten of 11 patients receiving less than or equal to eight cycles completed radiotherapy without excessive delay, compared with only one of five receiving greater than eight cycles. There were no treatment-related deaths and only one patient required laparotomy for bowel obstruction. We conclude that intensive multimodal treatment may be tolerated moderately well if the amount of chemotherapy is limited, and that further studies are justified.

Treatment of stages II, III and IV primary surface epithelial ovarian cancers by maximum bulk tumour reduction and combined chemotherapy with cyclophosphamide, doxorubicin and cisplatin

Forty-six patients with Stages II, III and IV ovarian cancer received treatment with cyclophosphamide, doxorubicin and cisplatin. Patient response to therapy was assessed 6 weeks after the cessation of therapy. Thirty-three patients (72%) were in complete response and six (13%) had a partial response to treatment. No relationship was found between the age of the patient, histologic type or grade of tumour and survival, although stage and initial debulking were important. Treatment had to be discontinued in 11 patients because of progression of the disease or serious side-effects. The probability of survival beyond 24 months for all patients was 71% and the mean survival overall was 32 months.

The molecular basis for the differential sensitivity of B and T lymphocytes to growth inhibition by thymidine and 5-fluorouracil

Cultured leukemic lymphocytes originating from patients with T, B and non-T, non-B (null) leukemia were tested for their sensitivity to thymidine and 5-fluorouracil. T cells were found to be 5-7 fold more sensitive to thymidine growth inhibition than B-cells. At 10(-3) M concentration of thymidine, T cells showed a progressive (up to 75%) decline in the populating trypan blue-excluding cells, after 72 h. At this concentration of thymidine B cells showed slight inhibition at 24 and 48 h, then at 72 h the surviving cell level returned almost to the level of unperturbed cells. Thymidine at 10(-5) M concentration, caused 40% cell growth inhibition of T cells, however, at this concentration it had little or no effect on B cells. 5-fluorouracil effects on B and T lymphocytes are opposite to that of thymidine. B cells were on an average 5-7 times more sensitive to 5-FU than T cells. 5-FU at 10(-6) M caused up to 45% inhibition of B-cell growth but at this concentration it had no effect on the growth of T cells. B-, T- and null-lymphocytes sensitivity to thymidine and 5-FU was correlated with the level of the catabolic enzyme thymidine phosphorylase. B cells had, on average, 5-fold more thymidine phosphorylase than T or null cells. Furthermore, the enzyme from the B-cell line (HR1K) chromatographed differently on DEAE-Sephadex than the normal peripheral blood lymphocytes enzyme. The normal enzyme from peripheral blood lymphocytes when adsorbed to DEAE-Sephadex was eluted at a salt concentration of 0.3 M KCI, Enzyme activities of HR1K did not adsorb to the DEAE-Sephadex column but were adsorbed to a phosphocellulose column. Enzyme from normal and leukemic lymphocytes showed similar molecular weights of 130,000 dalton as determined by gel filtration.

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.

Treatment of advanced ovarian cancer with combination chemotherapy using cyclophosphamide, adriamycin and cis-platinum

Fifty-four patients with advanced ovarian cancer have been treated with combination chemotherapy using cyclophosphamide, adriamycin and cis-platinum. The toxicity of the regimen was manageable but few patients were prepared to tolerate more than 6 months of treatment. Those in complete clinical remission at that time were offered second-look laparotomy and if apparently free of disease, therapy was discontinued. Forty-seven patients could be assessed of whom 33 had had no previous therapy. Twenty-two of these were clinically free of disease after completion of chemotherapy of whom 12 had no detectable disease at second-look laparotomy. Of 14 patients who had failed previous therapy only one remains clinically free of disease. The results in the untreated patients demonstrate the primary importance of bulk reduction at initial laparotomy. The use of the regimen in patients who have failed on previous treatment or in patients with bulk disease seems to be palliative and the toxicity should be assessed in this context.

Pathologic data of prognostic significance for remission induction in advanced ovarian carcinoma

Sixty-eight patients with "advanced ovarian carcinoma" were entered into an ongoing phase-II trial for remission induction with cis-platinum (DDP) 80 mg/m2 i.v. on day 1 followed by forced saline diuresis, melphalan (L-PAM) 12 mg/m2 i.v. on day 2 and hexamethylmelamine (HMM) 130 mg/m2 p.o. X 14 days from days 8-21 in six monthly cycles following operative resection and/or staging. Fifty-one patients were evaluable for response, ten had not completed six courses and could not be assessed, two patients died early (one probably of toxicity), and five patients refused treatment and follow-up. Thirty-Two patients had serous, endometrioid or undifferentiated carcinomas of the ovary. Of these, 11 (35%) achieved a pathologically proven complete remission (CR), five (16%) were NED after second-look (residual disease in ovary or removed omentum with all other biopsies and cytology washings negative), eight (32%) achieved a partial remission (PR), and three (12%) had progressive disease. None of the seven patients with clear-cell carcinoma and none of the three patients with Mullerian tumor of the ovary responded. Six of nine patients with tumors of uncertain origin or proven metastasis to ovary did not respond to treatment. These preliminary results indicate that advanced ovarian carcinomas form a heterogeneous group of recognizable neoplastic diseases with striking variation in response to treatment.

Chemotherapy in advanced ovarian cancer

The chemotherapy of advanced ovarian cancer is reviewed. Treatment with single agents results in low remission rates and few complete remissions. The results have been improved with modern combination chemotherapy, which includes cisplatin, although a longer follow up is needed for definite conclusions to be made concerning survival. Toxicity and drug resistance remain important problems. The future prospects of treatment with emphasis on intraperitoneal chemotherapy are discussed.

Treatment of advanced ovarian carcinoma with hexamethylmelamine, doxorubicin, and cis-platinum (HAC): results in both untreated and previously treated patients

Twenty-two patients with advanced (FIGO stages III and IV) adenocarcinoma of the ovary were treated with 28-day cycles of hexamethylmelamine, doxorubicin, and cis-dichlorodiamine-platinum (II) (HAC). After 45 months, there were 21 evaluable patients. The median survival was 16 months. Response was achieved in 82% (9/11) who had received no prior chemotherapy, and in 50% (5/10) previously treated. HAC therapy was readily administered on an outpatient basis, with comparatively low major toxicities, primarily hematologic, neurologic, and gastrointestinal. These results indicate that HAC therapy is an effective regimen for patients with advanced ovarian carcinoma, regardless of their prior treatment status.

Chemotherapeutic Efficacy of 5-Fluorouracil with Concurrent Thymidine Infusion against Transplantable Colon Tumors in Rodents

The therapeutic efficacy of 5-fluorouracil (FU) given concomitantly with thymidine (TdR) versus that of FU alone at an equitoxic dose was evaluated when these agents were given by 72-h continuous i.v. infusion or as an i.v. push dose through the tail vein to Fischer rats bearing a transplantable colon carcinoma or to BALB/c or C57BL/6J mice bearing murine colon tumors no. 26 or 38, respectively. In the presence of TdR, the dose of FU maximally tolerated by normal rats and mice was reduced by approximately half. In tumor-bearing rats, infusion of FU alone (150 mg/kg X 72 h) was as effective as concurrent infusion of FU (100 mg/kg X 72 h) with TdR (5 g/kg X 72 h), as evaluated in terms of tumor-free survivors (7/22 and 6/20, respectively). In addition, both regimens were more effective than an i.v. push dose of FU (200 mg/kg) or FU (80 mg/kg) and TdR (2 g/kg), which resulted in 2/18 and 0/18 tumor-free survivors, respectively. No significant differences in tumor growth inhibition were seen using either murine colon tumor, whether FU or the FU with TdR combination was administered as an i.v. push dose or as an infusion. Quantitation of the levels of TdR and thymine (T) in rat plasma obtained during infusion of various doses of TdR showed dose-dependent levels of TdR and T, indicating conversion of TdR to T in vivo. These data showed that, under the conditions employed, TdR did not modify significantly the antitumor activity of FU against rodent colon tumors. The toxicity of FU, however, could be enhanced by the coadministration of TdR, probably due, in part, to a reduced degradation of FU resulting from competition by T.

Treatment of women with disseminated or recurrent advanced ovarian cancer with melphalan alone in combination with 5-fluorouracil and dactinomycin or with the combination of cytoxan, 5-fluorouracil and dactinomycin

The purpose of this study was to determine the efficacy of single and multiple drug chemotherapeutic regimens in the treatment of patients with advanced or recurrent, Stage III and IV, ovarian epithelial carcinoma. Patients were randomly assigned to one of four treatment regimens postoperatively, or at the time of recurrence: Regimen I--Melphalan (MEL) 0.2 mg/kg/day for five days every four weeks; regimen II--MEL as in Regimen I plus 5-fluorouracil (FU) 15 mg/kg/day for five days every four weeks; regimen III--MEL and FU as in regimen II plus dactinomycin (AC) 0.5 mg daily for five days every four weeks; and regimen IV--Cytoxan (CY) 7 mg/kg/day, FU 8 mg/kg/day and AC 0.5 mg/day for five days every four weeks. Four hundred and twenty-seven patients were in the study, 314 of whom are evaluable for progression-free interval (PFI), survival, and toxicity: 102 in regimen I, 80 in regimen II, 83 in regimen III, and 49 in regimen IV. Of these, 293 were considered evaluable for response. Because of excessive toxicity, entry of patients to regimen IV was discontinued midway through the study. The overall toxicity was quite high but was most severe in regimen II and IV where 16 toxicity deaths were recorded. The complete and partial response rate with Melphalan alone was 29.2%. This response rate was not enhanced by the addition of FU or FU and AC and not substantially different than the response rate of AC, FU, and CY.

Advanced ovarian adenocarcinoma. A prospective clinical trial of melphalan (L-PAM) versus combination chemotherapy

Eighty patients with advanced ovarian adenocarcinoma were treated in a prospective, randomized trial comparing a four-drug combination--hexamethylmelamine, cyclophosphamide, methotrexate and 5-fluorouracil--with the oral alkylating agent, melphalan. Treatment with the four-drug combination was associated with a significantly increased overall response rate (75 vs. 54 per cent) (P less than 0.05), more complete remissions (33 vs. 16 per cent) and longer median survival (29 vs. 17 months) (P less than 0.02) but more severe toxicity than occurred with melphalan. Patients with minimal residual disease had a significantly higher overall response rate than patients with extensive residual disease (84 vs. 53 per cent) (P less than 0.05). Patients with advanced disease who achieved a complete remission documented by peritoneoscopy or laparotomy (or both) have a median survival that will exceed three years. The four-drug regimen is more effective than melphalan in the management of advanced ovarian adenocarcinoma.

Treosulfan (dihydroxybusulphan) in the management of ovarian carcinoma

Of 36 patients with ovarian carcinoma treated with treosulfan (dihydroxybusulphan) 30-5 per cent had a complete response for a mean of 19-0 months and 33-3 per cent had a partial response. Treosulfan may have a role in the management of ascites associated with ovarian neoplasm.

Advances in the staging and treatment of ovarian cancer

The age adjusted death rate for ovarian cancer has remained unchanged for the past 20 years. Recent data obtained by staging ovarian cancer patients with lymphangiography and peritoneoscopy demonstrated that many patients with apparently localized disease actually have occult dissemination within the abdomen. These new staging techniques plus the determination of the histologic grade of anaplasia may permit a more precise determination of a patient's prognosis and therefore better design of therapeutic stategy. Radiotherapeutic techniques are being adapted to attempt to treat some areas of occult disease. Numerous single chemotherapeutic agents are capable of producing objective tumor responses. Preliminary data suggest that combination chemotherapy can increase the objective response rate above that seen with single agents. Longer follow-up is necessary to determine whether combination chemotherapy can prolong survival.

Chemotherapy of advanced ovarian carcinoma: a prospective randomized comparison of phenylalanine mustard and high dose cyclophosphamide

Twenty-four fully staged, previously untreated patients with advanced ovarian carcinoma were prospectively randomized to either intensive intravenous cyclophosphamide or conventional oral Melphalan therapy. The median durations of initial remissions (5 and 6 mo) and the median durations of survival (15 and 14 mo) were similar for the two regimens but the toxicity of the intensive regimen was excessive. Followup indicates that long term disease free survivals are possible in those patients who achieve complete remissions on chemotherapy alone as three of the four patients achieving complete remission in the present study remain free of disease with a median survival in excess of 30 mo. High dose intensive alkylating agent therapy in the manner used in the present study fails to enhance the response to chemotherapy and produces unacceptable toxicity.