Why i.p. therapy cannot yet be considered as a standard of care for the first-line treatment of ovarian cancer: a systematic review

An Italian National Survey on Ovarian Cancer Treatment at first diagnosis. There's None so Deaf as those who will not Hear

Objective: Epithelial ovarian cancer (EOC) is the most lethal gynecological malignancy, crucial prognostic factors are no gross residual disease and centralization of cases. To evaluate the centralization of EOC patients, we report the results of a survey that shows the daily management of EOC patients in Italy. Methods: A 49-items electronic unblinded survey assessing demographics, practice characteristics, current opinions and approach to managing advanced EOC at first diagnosis was sent both to general gynecologists (GG) and gynecologic oncologists (GO). Differences in frequency distribution of answers between gynecologists with different expertise were evaluated using Fisher exact test. Multivariable analyses were performed applying generalized linear models. Results: 84/192 (44%) GG and 108/192 (56%) GO from all Italian regions answered to our survey. GOs declared to perform fertility sparing surgery in early EOC more frequently than GG (p=0.002). GOs can perform a frozen section and have both a gynecopathologist and a dedicated general surgeon. 89% of GOs consider as "optimal debulking" no gross residual disease and 81% achieve this at upfront cytoreduction in more than 40% of patients. Use of neoadjuvant chemotherapy decreases in higher volume centers (p<0.001) while it is lower in the group of GOs than in the GGs group (p<0.001). Conclusions: EOC patients are still treated by GGs. GOs perform more upfront surgery and achieve optimal debulking in a greater percentage of patients than GGs. In Italy an adequate centralization of cases has not yet been achieved, and this may have detrimental effects on the quality of treatment.

Pentagalloyl Glucose and Its Functional Role in Vascular Health: Biomechanics and Drug-Delivery Characteristics

Pentagalloyl glucose (PGG) is an elastin-stabilizing polyphenolic compound that has significant biomedical benefits, such as being a free radical sink, an anti-inflammatory agent, anti-diabetic agent, enzymatic resistant properties, etc. This review article focuses on the important benefits of PGG on vascular health, including its role in tissue mechanics, the different modes of pharmacological administration (e.g., oral, intravenous and endovascular route, intraperitoneal route, subcutaneous route, and nanoparticle based delivery and microbubble-based delivery), and its potential therapeutic role in vascular diseases such as abdominal aortic aneurysms (AAA). In particular, the use of PGG for AAA suppression and prevention has been demonstrated to be effective only in the calcium chloride rat AAA model. Therefore, in this critical review we address the challenges that lie ahead for the clinical translation of PGG as an AAA growth suppressor.

Toxicity of Nano-Titanium Dioxide (TiO2-NP) Through Various Routes of Exposure: a Review

Nano-titanium dioxide (TiO2) is one of the most commonly used materials being synthesized for use as one of the top five nanoparticles. Due to the extensive application of TiO2 nanoparticles and their inclusion in many commercial products, the increased exposure of human beings to nanoparticles is possible. This exposure could be routed via dermal penetration, inhalation and oral ingestion or intravenous injection. Therefore, regular evaluation of their potential toxicity and distribution in the bodies of exposed individuals is essential. Keeping in view the potential health hazards of TiO2 nanoparticles for humans, we reviewed the research articles about studies performed on rats or other mammals as animal models. Most of these studies utilized the dermal or skin and the pulmonary exposures as the primary routes of toxicity. It was interesting that only very few studies revealed that the TiO2 nanoparticles could penetrate through the skin and translocate to other tissues, while many other studies demonstrated that no penetration or translocation could happen through the skin. Conversely, the TiO2 nanoparticles that entered through the pulmonary route were translocated to the brain or the systemic circulation from where these reached other organs like the kidney, liver, etc. In most studies, TiO2 nanoparticles appeared to have caused oxidative stress, histopathological alterations, carcinogenesis, genotoxicity and immune disruption. Therefore, the use of such materials in humans must be either avoided or strictly managed to minimise risks for human health in various situations.

Recombinant Leishmania tarentolae encoding the HPV type 16 E7 gene in tumor mice model

Background: Cervical cancer, the third most prevalent cause of cancer in women worldwide, is associated with HPVs. The critical role of E7 protein in HPV-related malignancies has designated it as a strong contender for generating vaccines against HPV. Materials & methods: In this study, we developed a novel live vaccine using recombinant Leishmania tarentolae expressing E7-green fluorescent protein (GFP) fusion protein for the protection of mice against HPV-associated tumors. In order to transfect L. tarentolae with E7-GFP fusion construct, pLEXSY-neo2 system was applied. Followed by PCR, fluorescence imaging and fluorescence-activated cell sorting analysis, integration of E7-GFP gene into parasites genome was confirmed. A comparative study of six groups of C57BL/6 mice was performed to analyze antigen-specific humoral and cellular immune responses against E7 encoding live and DNA vaccines. Furthermore, the anti-tumor protective effect of L. tarentolae-E7-GFP was compared to other vaccination strategies, namely pcDNA-E7 as the DNA vaccine and pcDNA-E7/L. tarentolae-E7-GFP as the prime-boost regimen. Results: We found that E7-GFP expressing recombinant L. tarentolae induces significant levels of IgG2a and IFN-γ, while there is no significant IL-5 production compared with that of other strategies and control groups before and after challenge with TC-1 tumor cells. It is noteworthy that the designed live vaccine showed the best protection and minimum tumor size among all groups against TC-1-induced tumors. Conclusion: Overall, the results obtained revealed that the E7-GFP recombinant L. tarentolae could be a potential live vaccine for induction of immune responses in vivo.

Immunogenicity of novel nanoparticle-coated MSP-1 C-terminus malaria DNA vaccine using different routes of administration

An important aspect in optimizing DNA vaccination is antigen delivery to the site of action. In this way, any alternative delivery system having higher transfection efficiency and eventual superior antibody production needs to be further explored. The novel nanoparticle, pDNA/PEI/γ-PGA complex, is one of a promising delivery system, which is taken up by cells and is shown to have high transfection efficiency. The immunostimulatory effect of this novel nanoparticle (NP) coated plasmid encoding Plasmodium yoelii MSP1-C-terminus was examined. Groups of C57BL/6 mice were immunized either with NP-coated MSP-1 plasmid, naked plasmid or NP-coated blank plasmid, by three different routes of administration; intravenous (i.v.), intraperitoneal (i.p.) and subcutaneous (s.c). Mice were primed and boosted twice at 3-week intervals, then challenged 2 weeks after; and 100%, 100% and 50% mean of survival was observed in immunized mice with coated DNA vaccine by i.p., i.v. and s.c., respectively. Coated DNA vaccine showed significant immunogenicity and elicited protective levels of antigen specific IgG and its subclass antibody, an increased proportion of CD4(+) and CD8(+) T cells and INF-γ and IL-12 levels in the serum and cultured splenocyte supernatant, as well as INF-γ producing cells in the spleen. We demonstrate that, NP-coated MSP-1 DNA-based vaccine confers protection against lethal P. yoelii challenge in murine model across the various route of administration and may therefore, be considered a promising delivery system for vaccination.

Clinical trials and progress with paclitaxel in ovarian cancer

Paclitaxel is a front-line agent for ovarian cancer chemotherapy, along with the platinum agents. Derived from the Pacific yew tree, Taxus brevifolia, paclitaxel has covered significant ground from the initial discovery of its antineoplastic properties to clinical applications in many forms of human cancers, including ovarian cancer. Although much has been published about the unique mechanism of action of this agent, several issues remain to be resolved. Finding the appropriate dosage schedule for paclitaxel in chemo-naïve and recurrent ovarian cancer, defining the role of paclitaxel in maintenance chemotherapy, and elucidating the mechanisms of taxane resistance are areas of intense research. Newer forms of taxanes are being manufactured to avoid troublesome adverse effects and to improve clinical efficacy. These issues are reviewed in detail in this paper with an emphasis on clinically relevant evidence-based information.

Cyclophosphamide-induced leakage of gastrointestinal ammonia into the common bloodstream in rats

The kinetics of ammonia of gastrointestinal origin has been studied in rats in hematopoietic or neurovascular forms of acute lethal cyclophosphamide intoxication. Portal and caval blood ammonia, glutamine and urea, and blood markers of cytolysis were determined, and transperitoneal ammonia and glutamine fluxes were estimated after the single high-dose cyclophosphamide intraperitoneal (i.p.) administration. Within 3 hours after the administration of cyclophosphamide (200, 600, or 1,000 mg/kg), the portal ammonia level increased 1.4, 1.8, and 2.5 times, respectively; the ammonia level in v. cava caud. caudally of vv. renales inflow increased 1.5, 2.1, and 3.3 times, and cranially of vv. hepaticae, 1.8, 2.7, and 4.2 times, respectively; glutamine:ammonia and urea:ammonia ratios decreased. The rate of ammonia and glutamine accumulation in saline solution injected i.p. exceeded that in control rats dose dependently. At 18 hours after the administration of cyclophosphamide, the increased blood ammonia, glutamine and urea, and glutamine:ammonia ratio persisted. Therefore, in the rat, the high-dose i.p. administration of cyclophosphamide induces the early hyperammonemia, resulting from the enhanced transperitoneal diffusion of gastrointestinal ammonia into the blood, combined with the restriction of glutamine and urea synthesis. These alterations may contribute to neurological complications of myelosuppressive therapeutic regimens of cyclophosphamide administration.

Optimally Debulked Stage III Ovarian Cancer: Intraperitoneal or Intravenous Chemotherapy?

The optimal management of women with optimally debulked stage III ovarian cancer is contentious. There are in particular widely differing views regarding the role of intraperitoneal chemotherapy, and this has been debated widely. Being on the negative side in the debate, I will provide compelling reasons why systemic chemotherapy should remain the standard of care but argue that dose-dense weekly paclitaxel rather than the 3 weekly schedules should be adopted based on the results of the Japanese Gynecologic Oncology Group study. The pharmacokinetics of intraperitoneal paclitaxel suggests that intraperitoneal paclitaxel at day 8 with intravenous paclitaxel at day 1 is only a more complicated way of delivering dose-dense paclitaxel.

Chemotherapy for gynecologic cancers

This review highlights significant recent developments and trends in chemotherapy for major gynecologic malignancies, i.e., ovarian cancer, endometrial cancer, uterine sarcomas, gestational trophoblastic neoplasia, and cervical cancer. In ovarian cancer, chemotherapeutic options for early, advanced and recurrent disease are in the adjuvant setting as well as in the neoadjuvant setting are explored. For uterine cancer, adjuvant chemotherapy is employed for high risk epithelial subtypes with early disease, such as uterine papillary serous carcinomas, uterine carcinosarcomas and leiomyosarcomas, advanced stage cases, as well as recurrent disease. The review then proceeds to further discuss the appropriate treatment based on the International Federation of Gynecology and Obstetrics prognostic scoring system for gestational trophoblastic neoplasia. Finally, chemotherapy is utilized in cervical cancer as neo-adjuvant therapy prior to surgery or radiation, as a sensitizer concomitantly with radiation therapy or for the treatment of advanced and recurrent disease.

Trials with impact on clinical management: first line

INTRODUCTION

Advanced-stage epithelial ovarian cancer is generally managed with cytoreductive surgery and chemotherapy consisting of carboplatin and paclitaxel. Although initially responsive, most tumors recur and demonstrate progressive chemotherapy resistance. During the last 20 years, many thousands of women have participated in international front-line phase 3 trials that have contributed to our understanding of ovarian cancer biology and helped to define optimal treatment strategies. Emerging data from these trials need to be interpreted within an evolving paradigm of cancer biology, disease management, and availability of clinical resources.

METHODS

Survey of recent phase 3 trials and emerging principles of ovarian tumor biology.

RESULTS

There is no evidence that adding a third cytotoxic agent improves clinical outcomes. However, weekly dose-dense scheduling of paclitaxel appears superior to standard dosing.

CONCLUSION

Primary therapy with carboplatin and paclitaxel remains a well-tolerated standard regimen, including the option of weekly paclitaxel dosing. Data are awaited from completed trials incorporating bevacizumab. Emerging biological paradigms will contribute to individualized treatment options in the future.

Expression of Sox2 in human ovarian epithelial carcinoma

OBJECTIVES

The aim of this study was to investigate the expression of Sox2, a transcription factor, in a series of benign, borderline, and malignant ovarian tumors and to evaluate whether Sox2 expression levels correlate with clinicopathological characteristics in ovarian epithelial carcinoma.

METHODS

This study investigated immunohistochemical expressions of Sox2 in 43 species of normal ovarian epithelia, 284 species of serous epithelial lesions, and 164 species of mucinous epithelial lesions to assess their clinicopathological relevance.

RESULTS

Immunohistochemical results showed that the positive ratio of Sox2 expression gradually increased from benign and borderline to malignant ovarian tumors; 55.81% of normal ovarian epithelia, ~65% of serous and mucinous cystadenoma, ~70% of borderline serous and mucinous cystadenoma, and ~91% of serous and mucinous cystadenocarcinoma expressed Sox2, respectively. However, there was no significant correlation between Sox2 expression and the age and level of CA125 in patients with either serous or mucinous tumors. Positive correlations between Sox2 expression levels and FIGO stage or pathological stage were identified in both serous and mucinous cystadenocarcinoma samples.

CONCLUSION

The expression level of Sox2 in human ovarian tumors was directly proportional to their degree of malignancy, implying that Sox2 overexpression may be closely related to the malignant transformation of ovarian tumors.

Nanoparticles for tumor-specific intracellular drug delivery

While intraperitoneal (IP) therapy of ovarian cancer is a theoretically promising treatment option, it is not clinically well accepted due to the several challenges in IP drug delivery. Nanoparticles are promising drug carriers, which may alleviate the difficulties in IP chemotherapy. However, currently available nanoparticles need to be further improved to fulfill the following requirements: (i) they must remain non-interactive with normal cells and prevent the payload from premature leaking; (ii) once the drug carriers reach the tumor, they should enter the cells efficiently and release the drug in the cells to effectively kill the targeted cells. Our recent observation indicates that a popular nanoparticle system fails these expectations by large margin. For safe and effective IP chemotherapy, new types of carriers and/or surface modification strategies are urgently needed.

Anti-idiotypic antibody abagovomab in advanced ovarian cancer

Ovarian cancer is the fifth most common malignancy with approximately 22,000 newly diagnosed cases each year in the USA. Standard of care after cytoreductive surgery is the application of carboplatin and paclitaxel. The newly developed anti-idiotypic monoclonal antibody abagovomab demonstrated promising results in Phase I/II trials. This new type of drug is currently being tested in a Phase II/III trial in ovarian cancer patients with a complete response after standard first-line chemotherapy. Activating the cancer hosts immune system is a new strategy that is worth being pursued in the fight against ovarian cancer.