Neoadjuvant chemotherapy for the management of ovarian cancer

Preoperative serum CA-125 level as a predictor for the extent of cytoreduction in patients with advanced stage epithelial ovarian cancer

BACKGROUND

Ovarian cancer is the seventh most common cancer in women worldwide and the eighth most common cause of cancer death. Due to the lack of effective early detection strategies and the unspecific onset of symptoms, it is diagnosed at an advanced stage in 75% of cases. The cancer antigen (CA) 125 is used as a prognostic marker and its level is elevated in more than 85% of women with advanced stages of epithelial ovarian cancer (EOC). The standard treatment is primary debulking surgery (PDS) followed by adjuvant chemotherapy (ACT), but the later approach is neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). Several studies have been conducted to find out whether preoperative CA-125 serum levels influence treatment choice, surgical resection and survival outcome. The aim of our study was to analyse experience of single institution as Cancer comprehensive center with preoperative usefulness of CA-125.

PATIENTS AND METHODS

At the Institute of Oncology Ljubljana a retrospective analysis of 253 women with stage FIGO IIIC and IV ovarian cancer was conducted. Women were divided into two groups based on their primary treatment. The first group was the NACT group (215 women) and the second the PDS group (38 women). The differences in patient characteristics were compared using the Chi-square test and ANOVA and the Kaplan-Meier method was used for calculating progression-free survival (PFS) and overall survival (OS).

RESULTS

The median serum CA-125 level was higher in the NACT group than in the PDS group, 972 IU/ml and 499 IU/ ml, respectively. The PFS in the NACT group was 8 months (95% CI 6.4-9.5) and 18 months (95% CI 12.5-23.4) in the PDS group. The median OS was lower in the NACT group than in the PDS group, 25 months (95% CI 20.6-29.5) and 46 months (95% CI 32.9-62.1), respectively.

CONCLUSIONS

Preoperative CA-125 cut off value of 500 IU/ml is a promising threshold to predict a successful PDS.

Surgical training in gynecologic oncology: Past, present, future

The purpose of this paper is to review the surgical care related to training in gynecologic oncology, from past, present and future perspectives. A marked decline in the incidence of cervical cancer as well as improvements in radiation therapy have led to a reduction in the numbers of radical hysterectomies and exenterations being performed. Utilization of neoadjuvant chemotherapy is reducing the extent of cytoreductive operations, including intestinal surgery. The incorporation of sentinel lymphatic mapping has reduced the number of pelvic, paraaortic and inguinal lymphadenectomies being performed. Coupled with these changes are other factors limiting time for surgical training including an explosion in targeted anticancer therapies and more individualized options beyond simple cytotoxic therapy. With what is likely to be a sustained impact on training, gynecologic oncologists will still provide a broad range of care for women with gynecologic cancer but may be quite limited in surgical scope and rely on colleagues from other surgical disciplines. Enhancement of surgical training by off-service rotations, simulation, attending advanced surgical training courses and/or a longer duration of training are currently incorporated into some programs. Programs must ensure that fellows take full advantage of the clinical materials available, particularly those related to the potential deficiencies described. Changing required research training to an additional elective year could also be considered. Based on the perspectives noted, we believe it is time for our subspecialty to reevaluate its scope of surgical training and practice.

The Impact of Percent Reduction in CA-125 Levels on Prediction of the Extent of Interval Cytoreduction and Outcome in Patients With Advanced-Stage Cancer of Müllerian Origin Treated With Neoadjuvant Chemotherapy

OBJECTIVE

To investigate the role of CA-125 percent reduction after neoadjuvant chemotherapy in predicting the extent of the interval debulking surgery (IDS) and outcomes in patients with advanced-stage müllerian carcinoma.

METHODS

Patients who received neoadjuvant chemotherapy for advanced-stage müllerian carcinoma from 2000 to 2013 were identified. Percent reduction in CA-125 was categorized into 2 groups: ≥ 90% (CA ≥ 90%) and <90% (CA < 90%) reduction from prechemotherapy to preoperative CA-125.

RESULTS

Of the 115 patients identified, 73% had CA ≥ 90% and 27% had CA < 90%. Optimal and complete IDS were achieved in 87% and 38%, respectively. Compared with the CA < 90% group, the CA ≥ 90% group was more likely to have complete IDS (P = 0.035), less likely to have a bowel resection (P < 0.001), and more likely to have no viable tumor/microscopic disease with treatment effect (P < 0.001). No difference in overall survival (OS; P = 0.81) and progression-free survival (PFS; P = 0.60) was noted between the groups. In multivariable analysis, CA ≥ 90% was not a predictor of PFS (hazard ratio [HR], 1.08; 95% confidence interval [CI], 0.65-1.79; P = 0.77) or OS (HR, 1.45; 95% CI, 0.73-2.9; P = 0.29). Patients with preoperative CA-125 < 20 had significantly longer OS (P = 0.05) and PFS (P = 0.005) than did those with preoperative CA-125 ≥ 20. In multivariable analysis, preoperative CA-125 < 20 was a predictor of PFS (HR, 0.37; 95% CI, 0.20-0.66; P < 0.001) but not OS (HR, 0.64; 95% CI, 0.34-1.21; P = 0.17).

CONCLUSIONS

A reduction in CA-125 of at least 90% is associated with complete IDS, favorable pathologic response, and fewer bowel resections. A preoperative CA-125 < 20 suggests improved outcome. These findings are helpful for treatment planning and patient counseling.

Emerging role of cancer stem cells in the biology and treatment of ovarian cancer: basic knowledge and therapeutic possibilities for an innovative approach

In 2013 there will be an estimated 22,240 new diagnoses and 14,030 deaths from ovarian cancer in the United States. Despite the improved surgical approach and the novel active drugs that are available today in clinical practice, about 80% of women presenting with late-stage disease have a 5-year survival rate of only 30%. In the last years a growing scientific knowledge about the molecular pathways involved in ovarian carcinogenesis has led to the discovery and evaluation of several novel molecular targeted agents, with the aim to test alternative models of treatment in order to overcome the clinical problem of resistance. Cancer stem cells tend to be more resistant to chemotherapeutic agents and radiation than more differentiated cellular subtypes from the same tissue. In this context the study of ovarian cancer stem cells is taking on an increasingly important strategic role, mostly for the potential therapeutic application in the next future. In our review, we focused our attention on the molecular characteristics of epithelial ovarian cancer stem cells, in particular on possible targets to hit with targeted therapies.

Latest research and treatment of advanced-stage epithelial ovarian cancer

The natural history of ovarian cancer continues to be characterized by late-stage presentation, metastatic bulky disease burden and stagnant mortality statistics, despite prolific drug development. Robust clinical investigation, particularly with modifications to primary treatment surgical goals and adjuvant therapy are increasing median progression-free survival and overall survival, although the cure rates have been affected only modestly. Maintenance therapy holds promise, but studies have yet to identify an agent and/or strategy that can affect survival. Recurrent disease is largely an incurable state; however, current intervention with selected surgery, combination and targeted therapy and investigational protocols are impacting progression-free survival. Ovarian cancer is a diverse and genomically complex disease, which commands global attention. Rational investigation must balance the high rate of discovery with lagging clinical investigation and limited patient resources. Nevertheless, growth in our armamentarium offers unprecedented opportunities for patients suffering with this disease. This Review presents and reviews the contemporary management of the disease spectrum termed epithelial 'ovarian' cancer and describes the direction and early results of clinical investigation.

Clinical course of patients treated for advanced ovarian carcinoma without surgical intervention

OBJECTIVE

To describe the clinical course and outcome of patients with non-surgically-treated advanced ovarian cancer attending a single institute.

METHODOLOGY/PRINCIPAL FINDINGS

We reviewed the medical charts of all patients with advanced epithelial ovarian cancer who underwent chemotherapy at a tertiary medical center between January 2005 and December 2010 but were never operated. Data on patient characteristics, disease course, and outcome were collected from patient files. Sixteen patients met the inclusion criteria. Eight (50%) were diagnosed with apparent FIGO stage IIIC disease, and 8 with stage IV. Five patients (31%) achieved a complete clinical response, and 11 (69%) achieved a partial response. Among the complete responders, the median disease-free interval was 8 months (range 7-11 months). In all of them, the disease recurred and second-line chemotherapy was administered. Of them, four (80%) achieved a second complete response. Partial responders had up to four lines of chemotherapy, with continued disease progression. The median overall survival of the whole group was 19.5 months, and of the complete responders, 28 months.

CONCLUSIONS/SIGNIFICANCE

Most patients with advanced ovarian carcinoma who will not undergo surgery respond only partially to first-line chemotherapy. Having no surgery is associated with a short disease-free interval.

Overcoming challenges of ovarian cancer stem cells: novel therapeutic approaches

Understanding the genetic and molecular mechanisms of ovarian cancer has been the focus of research efforts working toward the greater goal of improving cancer therapy for patients with residual disease after initial treatment with conventional surgery and neoadjuvant chemotherapy. The focus of this review will be centered on new therapeutic strategies based on Cancer Stem Cells studies of chemoresistant subpopulations, the prevention of metastasis, and individualized therapy in order to find the most successful combination of treatments to effectively treat human ovarian cancer. We reviewed recent literature (1993-2011) of novel treatment approaches to ovarian cancer stem cells. As the focus of ovarian cancer investigation has centered on the cancer stem cell model and the complexities that it presents in the development of effective treatments, the future of treating ovarian cancer lies in utilizing individualized treatment systems that include enhancing existing treatments, aiming for novel therapy targets, managing the plasticity of stem cells to induce cellular differentiation, and regulating oncogenic signaling pathways.

Is neo-adjuvant chemotherapy a "waiver" of extensive upper abdominal surgery in advanced epithelial ovarian cancer?

BACKGROUND

The goal of this study was to explore the necessity of extensive surgical procedures in patients who received neoadjuvant chemotherapy (NAC).

METHODS

We analyzed the surgical outcomes and frequency of extensive procedures required for maximal cytoreductive surgery after NAC and primary debulking surgery (PDS) in 256 women with advanced epithelial ovarian cancer.

RESULTS

NAC was performed in 116 of 256 women (45.3%). In NAC group, complete cytoreduction rate and optimal cytoreduction rate were 60.3 and 92.2%, respectively. Although the NAC group comprised patients with higher risk of suboptimal cytoreduction, complete cytoreduction rate was similar to that of PDS group (57.9%, P = .69). Moreover, blood loss and surgical complexity significantly reduced in NAC group (P = .011 and .017). Extensive upper abdominal surgery (EUAS) was performed in 70 of 116 patients (60.3%) in the NAC group. The frequency of EUAS was similar between NAC and PDS group (P = .60). Among NAC group, gross upper abdominal metastasis requiring EUAS was found in 51 patients (44%, 95% confidence interval = 35.3-53.1%).

CONCLUSIONS

A significant proportion of patients who received NAC still have gross metastatic tumors requiring EUAS. Gynecologic oncologists should be familiar with EUAS and be ready to perform any required procedures together with multidisciplinary teams, even in the patients who have received NAC.

Interaction between preoperative CA-125 level and survival benefit of neoadjuvant chemotherapy in advanced epithelial ovarian cancer

OBJECTIVE

This study aims to determine whether neoadjuvant chemotherapy (NAC) has survival benefit in selected patients with advanced epithelial ovarian cancer (EOC) who have high risk of suboptimal cytoreduction which is represented by high serum CA-125 level.

METHODS

We retrospectively reviewed records of 314 patients with EOC including 94 patients who received NAC. After stratification by preoperative CA-125 levels, the progression-free survival (PFS) was compared between the NAC group and the primary debulking surgery (PDS) group.

RESULTS

The NAC group had more FIGO stage IV disease (P<0.001) and higher CA-125 levels (P<0.001). Although suboptimal resection rate was higher in the PDS group (50% vs. 18%, P<0.001), however, NAC was not associated with increased PFS in multivariate Cox analysis (P=0.334). Nevertheless, after stratification according to CA-125 levels, NAC showed survival benefit in the subgroup with high CA-125 levels (>2000 U/ml; HR 0.62, P=0.037).

CONCLUSION

Our preliminary data suggests the possible interaction between CA-125 levels and survival benefit of NAC. The randomized trial data about NAC should be stratified by the reproducible and relevant criteria such as preoperative serum CA-125 level to elucidate true survival benefit of NAC in ovarian cancer.

The role of neoadjuvant chemotherapy in treating advanced epithelial ovarian cancer

The current management of advanced ovarian cancer consists of aggressive primary cytoreductive surgery (PCS) followed by combination platinum based chemotherapy. Recent studies have suggested that platinum-based chemotherapy may be of benefit in patients with advanced ovarian cancer prior to cytoreductive surgery (neoadjuvant chemotherapy, NACT). The concept of NACT has not been completely validated in the treatment of ovarian cancer. This review will discuss the role of NACT in patients with advanced epithelial ovarian cancer.

Does neoadjuvant chemotherapy increase optimal cytoreduction rate in advanced ovarian cancer? Meta-analysis of 21 studies

BACKGROUND

The purpose of the current study is to analyze the existing data regarding neoadjuvant chemotherapy (NAC) in advanced epithelial ovarian cancer (EOC) using a random-effects model and to determine whether NAC can improve the rate of optimal cytoreduction.

METHODS

Between 1989 and 2008, data of 21 studies were retrieved via a MEDLINE search. Meta-regression analysis based on a random-effects model was performed to assess the prognostic value of clinical variables.

RESULTS

The patients who received NAC had a lower risk of suboptimal cytoreduction than the patients with favorable conditions (pooled odds ratio, 0.50; 95% confidence interval, 0.29-0.86; P = 0.012 with DerSimonian-Laird model). Meta-regression analysis revealed that heterogeneity in year of publication, taxane use, and optimal cytoreduction rate influenced median overall survival significantly (P = 0.002, P = 0.007, and P = 0.012, respectively). However, the between-studies variation of the number of NAC cycles did not influence survival (P = 0.701).

CONCLUSION

The current meta-analysis showed that NAC helped the gynecologic oncologist achieve an increased rate of optimal cytoreduction.

Predictors of suboptimal surgical cytoreduction in women with advanced epithelial ovarian cancer treated with initial chemotherapy

The objective of this study was to retrospectively evaluate predictors of suboptimal surgical cytoreduction (SSC) in women with advanced epithelial ovarian cancer (EOC) treated with initial chemotherapy (IC). All women with EOC treated with IC at our hospital between January 1, 1995, and January 1, 2003, were eligible; 128 patients met inclusion criteria and underwent retrospective chart review. Eighty-four patients (66%) had an optimal surgical cytoreduction (OSC), 14 patients (11%) had an SSC, and 30 (23%) patients were treated with chemotherapy only (CO). Patients in the SSC group had more small-bowel mesentery disease on preoperative computed tomography (CT) scan compared to the OSC group (38% SSC vs 6% OSC, P = 0.024). Patients in the SSC group were also more likely to have disease on the liver surface, small-bowel surface, large-bowel mesentery, bladder peritoneum, spleen, and diaphragm that was not reported on preoperative CT but found at surgery. More patients in the SSC group had chemoresistant disease (indicated by stable or progressive disease on CT scan [56% SSC vs 17% OSC, P = 0.05]) and less of a decrease in their CA-125 values (69% SSC vs 93% OSC, P <or= 0.001) than patients in the OSC group. Many women with advanced EOC do not have OSC even if initially treated with IC. We created novel algorithms to identify patients who would likely have an SSC after IC. For those patients highly likely to have an SSC, CO may be offered as a reasonable alternative, decreasing the morbidity of an extensive surgical procedure that may not provide survival benefit.

Surgical management of women with ovarian cancer

Ovarian carcinoma remains a leading cause of cancer-related death among women. Proper treatment of ovarian cancer begins with a thorough staging operation and attempt to totally debulk tumor sites. Despite even maximal surgical efforts, most patients with ovarian cancer require systemic or intraperitoneal chemotherapy. Even though aggressive therapies are effective for the treatment of ovarian cancer, recurrence of the disease is common and often necessitates salvage surgical procedures and chemotherapy.

Initial chemotherapy followed by surgical cytoreduction for the treatment of stage III/IV epithelial ovarian cancer

OBJECTIVE

The purpose of this study was to evaluate differences in morbidity, progression-free interval, and survival in women with advanced epithelial ovarian cancer treated with initial chemotherapy versus initial surgery.

STUDY DESIGN

All women with epithelial ovarian cancer who were treated surgically at our hospital between January 1, 1995, and January 1, 2003, were eligible; the cases of 200 patients met the criteria and underwent retrospective chart review.

RESULTS

Ninety-eight patients (49%) had initial chemotherapy, and 102 patients (51%) had initial surgery. Patients who received initial chemotherapy were more likely to have stage IV disease (initial chemotherapy, 27%, vs initial surgery, 8%; P = .042) and grade 3 disease (initial chemotherapy, 73%, vs initial surgery, 61%; P = .025). Optimal cytoreduction was achieved more often in patients who received initial chemotherapy (initial chemotherapy, 86%, vs initial surgery, 54%; P < .001). Only optimal cytoreduction (P = .022), and not treatment choice (P = .089), had an impact on median survival.

CONCLUSION

Initial chemotherapy is a reasonable alternative to initial surgery for the treatment of selected patients with advanced epithelial ovarian cancer.

Is there a role for neoadjuvant chemotherapy in the treatment of stage IV serous endometrial carcinoma?

Serous endometrial carcinoma (SEC) is an uncommon variant of endometrial carcinoma that is notorious for its aggressive clinical course. Similar to its ovarian counterpart, it has a propensity for early intraabdominal and lymphatic spread. We present two cases of advanced SEC, who were left with no residual tumor after neoadjuvant chemotherapy. After three courses of chemotherapy, both patients underwent interval debulking surgery, resulting in no residual disease. The documentation of chemosensitivity might enable the clinician to select a subpopulation of patients with widespread SEC that might benefit from interval debulking surgery.

Diagnostic open laparoscopy in the management of advanced ovarian cancer

OBJECTIVE

Optimal primary cytoreductive surgery (OPCS) plus adjuvant chemotherapy (AC) represents the standard management for patients with advanced ovarian cancer (AOC). Recently, some authors have suggested the use of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in patients with unresectable AOC. This study has been started to evaluate the role of diagnostic open laparoscopy (DOL) in predicting who are the best candidates to OPCS.

METHODS

All patients newly diagnosed as affected by AOC were submitted to DOL in order to establish the possibility of OPCS considered as no residual tumor left after operation. Patients considered not susceptible of OPCS were submitted to three cycles of NACT, administered every 3 weeks (Carboplatin, targeted AUC = 6, plus paclitaxel 175 mg/mq), followed by IDS and adjuvant chemotherapy.

RESULTS

From January 2000 to March 2004, 87 patients with AOC underwent DOL. Fifty-three patients (61%) were judged operable and therefore submitted to primary cytoreductive surgery (Group A). Optimal debulking rate in this group of patients was 96%. Thirty-four patients were judged affected by disease not cytoriducible to absent residual tumor and therefore scheduled for NACT-IDS-AC (Group B). Twenty-five patients were judged with partial clinical response and were therefore scheduled for IDS and AC. Optimal debulking rate (no residual tumor ) in Group B patients was 80%. No major perioperative complications, due to laparoscopy, occurred. All Group B patients received the first cycle of chemotherapy the day after DOL. In 34 patients (39%), an explorative laparotomy was avoided. With a median follow-up of 22 months (range 2-49 months), the proportions surviving were 87% and 60% in Group A and Group B patients, respectively.

CONCLUSION

DOL could be considered a valid diagnostic tool in evaluating the extent of disease in AOC. Our data suggest that the use of DOL leads to decrease the rate of primary cytoreductive surgery for AOC; on the other hand, a higher optimal debulking rate (no residual tumor) at primary surgery is achieved.

Neoadjuvant chemotherapy versus primary surgery in advanced ovarian carcinoma

Background

Patients with advanced ovarian cancer should be treated by radical debulking surgery aiming at complete tumor resection. Unfortunately about 70% of the patients present with advanced disease, when optimal debulking can not be obtained, and therefore these patients gain little benefit from surgery. Neoadjuvant chemotherapy (NACT) has been proposed as a novel therapeutic approach in such cases. In this study, we report our results with primary surgery or neoadjuvant chemotherapy as treatment modalities in the specific indication of operable patients with advanced ovarian carcinoma (no medical contraindication to debulking surgery).

Patients and methods

A total of 59 patients with stage III or IV epithelial ovarian carcinomas were evaluated between 1998 and 2003. All patients were submitted to surgical exploration aiming to evaluate tumor resectability. Neoadjuvant chemotherapy was given (in 27 patients) where optimal cytoreduction was not feasible. Conversely primary debulking surgery was performed when we considered that optimal cytoreduction could be achieved by the standard surgery (32 patients).

Results

Optimal cytoreduction was higher in the NACT group (72.2%) than the conventional group (62.4%), though not statistically significant (P = 0.5). More important was the finding that parameters of surgical aggressiveness (blood loss rates, ICU stay and total hospital stay) were significantly lower in NACT group than the conventional group. The median overall survival time was 28 months in the conventional group and 25 months in NACT group with a P value of 0.5. The median disease free survival was 19 months in the conventional group and 21 months in NACT group (P = 0.4). In multivariate analysis, the pathologic type and degree of debulking were found to affect the disease free survival significantly. Overall survival was not affected by any of the study parameters.

Conclusion

Primary chemotherapy followed by interval debulking surgery in select group of patients doesn't appear to worsen the prognosis, but it permits a less aggressive surgery to be performed.

Predictors of suboptimal surgical cytoreduction in women treated with initial cytoreductive surgery for advanced stage epithelial ovarian cancer

OBJECTIVE

The purpose of this study was to determine if a suboptimal cytoreduction can be predicted preoperatively in women with advanced ovarian cancer.

STUDY DESIGN

All women with stage III/IV epithelial ovarian cancer treated with initial surgery at our hospital between January 1, 1995 and January 1, 2003 were eligible; 56 patients met inclusion criteria and underwent retrospective chart review. Statistical analysis was performed using SPSS.

RESULTS

Twenty-nine women (52%) had optimal cytoreduction (OC), and 27 (48%) had suboptimal cytoreduction (SC). Women in the SC group had higher median CA-125 values at surgery (954 SC vs 597 OC, P = .07). Three sites of disease on preoperative CT were reported more frequently in the SC patients; omentum (P = .007), parietal peritoneum (P = .096), and ascites (P = .093).

CONCLUSION

A suboptimal cytoreduction confers no survival advantage to women with advanced ovarian cancer. Thus, these patients may be the best candidates for initial chemotherapy, and identifying them preoperatively becomes important.

Stage IV ovarian cancer: a retrospective study on patient's management and outcome in a single institution

The management of stage IV epithelial ovarian carcinoma remains controversial. The aim of this study was to evaluate and compare our results to other published series. A retrospective database and casenote review was performed on all patients diagnosed with stage IV disease over a ten-year period (1992-2002). Survival analysis was performed using the Kaplan-Meier and Mantel-Haenszel methods. The study group comprised 23 women. Nine had positive pleural effusions (39.1%), and 14 had other sites of metastases (60.9%). Nine patients underwent interval debulking (39.1%), and 14 were operated on primarily (60.9%). We had six postoperative complications (26.1%) but no perioperative deaths. Optimal cytoreduction (inferior or equal to 2 cm residual disease) was obtained in 18 patients (78.3%). The overall median survival was 22.6 months. There was no statistically significant difference in overall or disease-free survival between primary surgery and interval debulking. Patients with positive pleural effusions had significantly reduced survival compared to those with distant metastases in other sites. Interestingly, there was no difference in survival between optimally and suboptimally cytoreduced patients. Debulking surgery can be performed in patients with stage IV ovarian cancer, with an acceptable level of morbidity. Optimal cytoreduction is achievable in the majority of these patients. Interval debulking should be considered in selected patients.

The potential role of neoadjuvant chemotherapy in advanced ovarian cancer

There is a multitude of evidence from retrospective analyses and meta-analyses showing that the amount of residual tumor after debulking surgery and before chemotherapy is one of the most powerful prognostic determinants in advanced ovarian cancer. This supports the important role of maximum cytoreductive surgery as one of the cornerstones in the treatment of this disease. These same analyses, however, do not suggest that patients whose tumors cannot be debulked optimally derive a significant survival benefit from upfront surgery. For these patients and those who have a poor performance status or other morbidity, making comprehensive upfront surgery contraindicated, different therapeutic approaches have to be explored. One possible way to go is to change the timing of the different therapeutic modalities: upfront chemical cytoreduction, followed by a maximal surgical effort, in turn followed by the remainder of the first-line chemotherapy or neoadjuvant chemotherapy and interval or delayed debulking surgery. The potential role of this approach and the experience with it thus far are discussed.