The role of secondary surgery in recurrent ovarian cancer

Surgery in platinum-resistant recurrent epithelial ovarian carcinoma

BACKGROUND

Ovarian cancer is one of the three most common malignant tumors of the female reproductive tract and ranks first in terms of mortality among gynecological tumors. Epithelial ovarian carcinoma (EOC) is the most common ovarian malignancy, accounting for 90% of all primary ovarian tumors. The clinical value of cytoreductive surgery in patients with platinum-resistant recurrent EOC remains largely unclear.

AIM

To evaluate the feasibility of secondary cytoreductive surgery for treating platinum-resistant recurrent EOC.

METHODS

This was a retrospective study of the clinical data of patients with platinum-resistant EOC admitted to the Cancer Hospital of the University of Chinese Academy of Sciences between September 2012 and June 2018. Patient baseline data were obtained from clinical records. Routine follow-up of disease progression was performed as follows. CA125 assessment and physical examination were performed every 3 wk during treatment, including gynecological examination. Imaging assessment was carried out every 12 wk by B-mode ultrasound, computed tomography, or magnetic resonance imaging. The primary outcome was progression-free survival (PFS). Secondary outcomes included overall survival (OS), chemotherapy-free interval (CFI), and complications. Follow-up ended on April 15, 2019.

RESULTS

A total of 38 patients were included. R0 resection was achieved in 25 (65.8%) patients and R1/2 in 13 (34.2%). Twenty-five (65.8%) patients required organ resection. Nine (23.7%) patients had operative complications, 36 (94.7%) received chemotherapy, and five (13.2%) had targeted therapy. Median PFS and OS were 10 (95%CI: 8.27-11.73) months and 28 (95%CI: 12.75-43.25) months, respectively; median CFI was 9 (95%CI: 8.06-9.94) months. R0 resection and postoperative chemotherapy significantly prolonged PFS and OS (all P < 0.05), and R0 resection also significantly prolonged CFI (P < 0.05). Grade ≥ 3 complications were observed, including rectovaginal fistula (n = 1), intestinal and urinary fistulas (n = 1), and renal failure-associated death (n = 1). Except for the patient who died after surgery, all other patients with complications were successfully managed. Two patients developed intestinal obstruction and showed improvement after conservative treatment.

CONCLUSION

Secondary cytoreductive surgery is feasible for treating platinum-resistant recurrent EOC. These findings provide important references for the selection of clinical therapeutic regimens.

Feasibility Study of a Network Meta-Analysis and Unanchored Population-Adjusted Indirect Treatment Comparison of Niraparib, Olaparib, and Bevacizumab as Maintenance Therapies in Patients with Newly Diagnosed Advanced Ovarian Cancer

Selecting a first-line (1L) maintenance option for ovarian cancer is challenging given the variety of therapies, differing trials, and the lack of head-to-head data for angiogenesis and poly(ADP-ribose) polymerase (PARP) inhibitors. Thus, indirect treatment comparisons (ITCs) can aid treatment decision making. This study assessed the feasibility of two ITCs, a network meta-analysis (NMA) and a population-adjusted ITC (PAIC), comparing the efficacy of the PARP inhibitor niraparib in the PRIMA trial (NCT02655016) with other 1L maintenance treatments. A systematic literature review was conducted to identify trials using the Cochrane Handbook for Systematic Reviews of Interventions to assess differences in trial design, population characteristics, treatment arms, and outcome measures. All 12 trials identified were excluded from the NMA due to the absence of a common comparator and differences in survival measures and/or inclusion criteria. The PAIC comparing PRIMA and PAOLA-1 trials was also not feasible due to differences in inclusion criteria, survival measures, and the previous receipt of chemotherapy/bevacizumab. Neither ITC met recommended guidelines for analysis; the results of such comparisons would not be considered appropriate evidence when selecting 1L maintenance options in ovarian cancer. ITCs in this setting should be performed cautiously, as many factors can preclude objective trial comparisons.

MicroRNA-378a-3p contributes to ovarian cancer progression through downregulating PDIA4

OBJECTIVE

MicroRNAs, as essential players in tumorigenesis, have been demonstrated to have a revolutionary effect on human cancer research. Ovarian cancer is the primary reason of death among gynecologic malignancies. In view of this, it is significant to identify prognostic and predictive markers for treatment of ovarian cancer. The aim of this study was to probe into the effects of miR-378a-3p and protein disulfide-isomerase A4 (PDIA4) on the biological functions of ovarian cancer cells.

METHODS

miR-378a-3p expression and PDIA4 messenger RNA expression in human ovarian cancer cells, normal human ovarian epithelial cells, and serum of both ovarian cancer patients and healthy people were detected by reverse transcription-quantitative polymerase chain reaction, and the PDIA4 protein expression was tested by Western blot analysis. Ovarian cancer OVCAR3 and SKOV3 cells were transfected or cotransfected with miR-378a-3p mimic or pcDNA3.1-PDIA4 or their negative control plasmids to explore their roles in biological functions in ovarian cancer cells. Luciferase activity and RIPA assays were implemented to validate the interaction between miR-378a-3p and PDIA4. Western blot analysis was utilized to detect phosphatidylinositol-3 kinase/serine/threonine kinase (PI3K/AKT) signaling pathway-related protein expression and their phosphate expression levels.

RESULTS

miR-378a-3p was elevated and PDIA4 was decreased in ovarian cancer cells and serum. In addition, miR-378a-3p mimic induced ovarian cancer cell growth, while miR-378a-3p inhibitor and pcDNA3.1-PDIA4 presented an inverse trend. pcDNA3.1-PDIA4 partially eliminated the capabilities of miR-378a-3p mimic on ovarian cancer progression. Meanwhile, miR-378a-3p was found to negatively regulate PDIA4, and miR-378a-3p mimic increased the phosphorylation levels of AKT and PI3K, while pcDNA3.1-PDIA4 exhibited an opposite tendency. Furthermore, pcDNA3.1-PDIA4 largely eliminated the functions of miR-378a-3p mimic on phosphorylation levels of AKT and PI3K.

CONCLUSION

This study provides evidences that miR-378a-3p activates PI3K/AKT signaling pathway by modulating PDIA4 expression, thereby playing a role in promoting the growth of ovarian cancer cells. This study provides novel directions for targeted therapy of ovarian cancer.

Ovarian Cancer Maintenance: Practice-Changing Data Calls for Changing Practice

Staying current on the rapidly evolving therapeutic landscape in oncology is challenging for clinicians. This commentary discusses exciting practice‐changing data specific to ovarian cancer.

Budget impact analysis of niraparib and olaparib for maintenance treatment of platinum-sensitive, recurrent ovarian cancer in the US

AIMS

This study aimed to evaluate the budget impact of niraparib and olaparib in patients with platinum-sensitive, recurrent ovarian cancer from a US third party payer perspective.

MATERIALS AND METHODS

A budget impact model was constructed to assess the additional per member per month (PMPM) costs associated with the introduction of niraparib and olaparib, two poly ADP-ribose polymerase ribose polymerase (PARP) inhibitors recently approved to be used in platinum-sensitive, recurrent ovarian cancer patients with and without a gBRCA mutation. The model assessed both pharmacy costs and medical costs. Pharmacy costs included adjusted drug costs, coinsurance, and dispensing fees. Medical costs included costs associated with disease monitoring and management of adverse events from the treatment. Epidemiological data from the literature were used to estimate the target population size. The analysis used 1-year time frame, and patients were assumed on treatment until disease progression or death. All costs were computed in 2017 USD. One-way sensitivity analyses were conducted to evaluate the model robustness.

RESULTS

In a hypothetical plan of 1,000,000 members, 206 patients were estimated to be potential candidates for niraparib or olaparib maintenance treatment after applying all epidemiological parameters. At listed 30-day supply WAC prices of $14,750 for niraparib and $13,482 for olaparib, budget impacts of these two drugs were $0.169 PMPM and $0.156 PMPM, respectively, most of which were contributed by pharmacy costs. Sensitivity analyses suggested that assumptions around market share, platinum-sensitive rate after first treatment, and WAC prices affected results the most.

LIMITATIONS

In this model, it was assumed that adopting niraparib and olaparib would not affect utilization of existing medications. Also, the estimated clinical parameters from clinical trials could differ from real-world data.

Diagnostic value of derived neutrophil-to-lymphocyte ratio in patients with ovarian cancer

Background

Inflammation plays an important role in the occurrence and development of cancer. Numerous studies have used the derived neutrophil‐to‐lymphocyte ratio (dNLR) to evaluate prognosis in many types of cancer. However, the relationship between dNLR and ovarian cancer and its value in the differential diagnosis of benign and malignant ovarian tumors remain unknown.

Methods

A total of 262 patients with ovarian cancer, 258 with benign ovarian disease, and 232 healthy controls were included in this study. dNLR was calculated using whole blood cell parameters. Receiver operating characteristic curves were generated to obtain sensitivity, specificity, and area under the ROC curve (AUC) to evaluate the diagnostic values of dNLR.

Results

dNLR was significantly different among the ovarian cancer, benign ovarian disease, and healthy control groups (all P < 0.001). Moreover, there were significant differences in dNLR between patients with early‐stage (I and II) and advanced‐stage (III and IV) disease (P < 0.001). dNLR was positively correlated with stage and carbohydrate antigen‐125 in ovarian cancer. A cutoff value of dNLR ≤2.11 was diagnostic in distinguishing ovarian cancer from benign ovarian disease with AUC of 0.729 (95% confidence interval [CI], 0.689‐0.767; P = 0.0001). A cutoff value of dNLR ≤1.9 was diagnostic in distinguishing ovarian cancer from healthy controls with an AUC of 0.821 (95% CI, 0.784‐0.854; P = 0.0001).

Conclusion

dNLR may be a useful indicator for distinguishing between ovarian cancer and benign ovarian disease and for identifying early and advanced ovarian cancer.

Preoperative predictors that impact the survival and outcome of patients undergoing secondary cytoreduction for ovarian cancer

This study aimed to examine the factors affecting feasibility of optimal and complete secondary cytoreductive surgery (SCRS) and to characterise the prognostic factors that correlate with improved survival in patients who underwent SCRS. This is a retrospective single-institutional cohort study of patients who underwent SCRS for recurrent epithelial ovarian cancer (EOC). One hundred and forty-eight patients met inclusion criteria. Platinum sensitivity was associated with complete cytoreduction at SCRS. Factors associated with suboptimal cytoreduction (SOC) were age >55 years, serous histology, largest tumour implant size >4 cm, and SOC at primary surgery. Overall survival analysis showed significantly longer survival with complete cytoreduction compared to optimal and SOC. Surgical outcome of SCRS was an independent predictor of survival regardless of the outcome of primary cytoreduction. Location of the largest implant, DFI and timing of chemotherapy also impact on survival.

Prediction of therapy response in ovarian cancer: Where are we now?

Therapy resistance is a major challenge in the management of ovarian cancer (OC). Advances in detection and new technology validation have led to the emergence of biomarkers that can predict responses to available therapies. It is important to identify predictive biomarkers to select resistant and sensitive patients in order to reduce important toxicities, to reduce costs and to increase survival. The discovery of predictive and prognostic biomarkers for monitoring therapy is a developing field and provides promising perspectives in the era of personalized medicine. This review article will discuss the biology of OC with a focus on targetable pathways; current therapies; mechanisms of resistance; predictive biomarkers for chemotherapy, antiangiogenic and DNA-targeted therapies, and optimal cytoreductive surgery; and the emergence of liquid biopsy using recent studies from the Medline database and ClinicalTrials.gov.

Whole-body diffusion-weighted magnetic resonance imaging in the diagnosis of recurrent ovarian cancer: a clinical feasibility study

OBJECTIVE

To assess the clinical feasibility of whole-body diffusion-weighted MRI (WB-DWI/MRI) for diagnosis and prediction of complete tumour resection in patients with suspected recurrent ovarian cancer.

METHODS

51 females clinically suspected for ovarian cancer recurrence underwent 3-T WB-DWI/MRI in addition to contrast-enhanced CT. WB-DWI/MRI was assessed for detection of tumour recurrence, prediction of tumour extent and complete resection compared with CT. Tumour presence was confirmed by pathology obtained by surgery or biopsy, or by imaging follow-up.

RESULTS

WB-DWI/MRI showed 94% accuracy for detecting ovarian cancer recurrence, compared with 78% for CT (p = 0.008). WB-DWI/MRI showed better sensitivity [% (95% confidence interval)] than CT for detecting involvement of surgically critical tumour sites including mesenteric root infiltration [92 (62-100) vs 31 (10-61)], small bowel [93 (64-100) vs 21 (6-51)], colon carcinomatosis [91 (57-100) vs 27 (7-61)] and unresectable distant metastases [90 (54-99) vs 20 (4-56)]. WB-DWI/MRI correctly predicted complete resection in 33 of 35 (94%) patients eligible for salvage surgery compared with 17 of 35 (49%) for CT (p < 0.001).

CONCLUSION

WB-DWI/MRI allowed better detection of ovarian cancer recurrence and better prediction of complete resection than CT. Advances in knowledge: WB-DWI/MRI could assist in optimizing treatment planning for recurrent ovarian cancer, particularly by improving patient selection for salvage surgery, thus giving eligible patients the highest chance on prolonged survival and refraining patients who would not benefit from extensive surgery reducing related morbidity and mortality.

Benefits of fluorine-18 fludeoxyglucose positron emission tomography in secondary cytoreductive surgery for patients with recurrent epithelial ovarian cancer

OBJECTIVE

To investigate the benefits of fluorine-18 fludeoxyglucose positron emission tomography ((18)F-FDG-PET) in patients undergoing secondary cytoreductive surgery (SCRS) for recurrent epithelial ovarian cancer.

METHODS

Patients were identified, and their clinical information was extracted by review of the gynaecologic oncology database of Peking Union Medical College Hospital. (18)F-FDG-PET scan and analysis were performed by nuclear medicine experts at our hospital.

RESULTS

The PET group and the control group of patients evaluated by conventional imaging methods differed significantly with respect to the proportion of patients who underwent complete SCRS and the number of residual lesions (p = 0.002 and 0.006, respectively). A Cox model showed that longer progression-free survival (PFS) correlated significantly with (18)F-FDG-PET evaluation [relative risk (RR) = 0.432; p = 0.001], sensitivity to platinum-based chemotherapies (RR = 0.604; p = 0.034) and resection completeness (RR = 0.679; p = 0.039). Longer overall survival (OS) correlated significantly with sensitivity to platinum-based chemotherapy (RR = 0.317; p = 0.000) and the CA-125 level after two cycles of chemotherapy (RR = 2.663; p = 0.003). Surgical safety and complications did not significantly differ between the two groups of patients.

CONCLUSION

(18)F-FDG-PET is useful for evaluating patients with recurrent epithelial ovarian carcinoma. Patients who undergo PET-guided SCRS have a greater chance of complete tumour resection and a longer PFS.

ADVANCES IN KNOWLEDGE

SCRS guided by PET results in fewer residual lesions. PET-guided SCRS is safe and can prolong PFS and OS in patients with recurrent ovarian cancer.

Current approaches and challenges in managing and monitoring treatment response in ovarian cancer

Epithelial ovarian cancer is the leading cause of death among gynecologic malignancies. Treatment of recurrent ovarian cancer remains a challenge despite advances in surgical and chemotherapeutic options. A goal of many providers is to detect recurrences as early as possible and initiate treatment though there is controversy as to whether this impacts outcome. Elevations in CA125 and radiological findings may precede symptoms of recurrence by several months. While detection of recurrences by physical exam alone is unusual, a thorough exam in conjunction with reported symptoms and elevated CA125 is sufficient to detect 80-90% of recurrences. A spiral CT scan may be used to confirm recurrence in the setting of asymptomatic CA125 elevation and a PET/CT can yield additional insight if the CT is inconclusive. Initiating chemotherapy prior to the development of symptoms, even in the setting of elevated CA125, does not impact overall survival primarily because the efficacy of available treatments in the recurrent setting is poor. More information about tumor biology and ways to predict which patients will benefit from available treatment options is required. Consequently, the approach to post-treatment surveillance should be individualized taking into account the clinical benefit of the second-line therapy, versus the costs and morbidity of the surveillance method.

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.