Bevacizumab in the treatment of ovarian cancer

Systemic treatment of newly diagnosed advanced epithelial ovarian cancer: From chemotherapy to precision medicine

Despite optimal first-line treatment based on debulking surgery and platinum-paclitaxel chemotherapy, most of the patients with advanced ovarian cancer (AOC) will eventually relapse. Over the last decades, different strategies have been assessed to improve AOC patients' outcomes in the front-line treatment. However, first line treatment landscape of AOC had not undergone major changes until the last three years. In the present review, we will navigate through the different therapeutic approaches developed in first-line AOC which range from variations in dose/administration via of conventional carboplatin-based chemotherapy to the incorporation of anti-angiogenic agents and PARP inhibitors.

A Retrospective Clinical Analysis of Hyperthermic Intraperitoneal Chemotherapy in Gynecological Cancers: Technical Details, Tolerability, and Efficacy

Objective

The aim of this study was to reveal the results of hyperthermic intraperitoneal chemotherapy (HIPEC procedure) performed during cytoreductive surgery (CRS) in patients with endometrial cancer and epithelial ovarian cancer which included mainly platinum-resistant patients.

Method

Patients who underwent CRS+HIPEC between May 2015 and January 2020 were evaluated retrospectively. Surgical complications were graded according to the Clavien-Dindo classification.

Results

A total of 33 CRS+HIPEC procedures were performed in 32 patients, two of whom had recurrent endometrial cancer. Of the 30 patients with epithelial ovarian cancer (EOC), five underwent interval CRS+HIPEC, and remaining 25 patients underwent secondary CRS+HIPEC treatment due to relapsed disease. Eighteen of the patients with relapsed disease were platinum-resistant. The overall operative mortality and severe morbidity rates were %3 and 12%, respectively. For 30 patients with EOC, during a median follow-up period of 15 months, Kaplan-Meier survival analysis revealed a 1-year OS and PFS rates of 69.7% and 30.3%, respectively. Moreover, in the subgroup analysis of the platinum-resistant cohort, median OS and PFS were 14 and five months, respectively.

Conclusion

CRS+HIPEC procedures had acceptable severe morbidity and mortality rates. In addition, patients with recurrent EOC and without a visible residual disease at the end of cytoreductive surgery had, though not statistically significant, longer OS . HIPEC administration during CRS was not associated with adverse outcomes in the platinum-resistant EOC cohort. The short-term results of the current study are promising.

Emerging Therapeutics to Overcome Chemoresistance in Epithelial Ovarian Cancer: A Mini-Review

Ovarian cancer is the fifth leading cause of cancer death among women and the most lethal gynecologic malignancy. One of the leading causes of death in high-grade serous ovarian cancer (HGSOC) is chemoresistant disease, which may present as intrinsic or acquired resistance to therapies. Here we discuss some of the known molecular mechanisms of chemoresistance that have been exhaustively investigated in chemoresistant ovarian cancer, including drug efflux pump multidrug resistance protein 1 (MDR1), the epithelial–mesenchymal transition, DNA damage and repair capacity. We also discuss novel therapeutics that may address some of the challenges in bringing approaches that target chemoresistant processes from bench to bedside. Some of these new therapies include novel drug delivery systems, targets that may halt adaptive changes in the tumor, exploitation of tumor mutations that leave cancer cells vulnerable to irreversible damage, and novel drugs that target ribosomal biogenesis, a process that may be uniquely different in cancer versus non-cancerous cells. Each of these approaches, or a combination of them, may provide a greater number of positive outcomes for a broader population of HGSOC patients.

Angiopoietins promote ovarian cancer progression by establishing a procancer microenvironment

Despite decades of research, the survival rate of ovarian cancer patients is largely unchanged. Current chemotherapeutic drugs are effective only transiently because patients with advanced disease eventually develop resistance. Thus, there is a pressing need for identifying novel therapeutic targets in ovarian cancer. Mounting evidence suggests that angiopoietins (Angpts) may play an essential role in cancer progression; however, the expression profiles and biological effects of Angpts on ovarian cancer remain largely unknown. Here, we show that, compared with their normal counterparts, expressions of Angpt1, Angpt2, and Angpt4 are increased in ovarian cancer cells and tissues and that human ovarian cancer cells also express the Angpt receptor Tie-2-receptor tyrosine kinase. We show that increased expression of Angpt1, Angpt2, or Angpt4 promotes intraperitoneal growth of ovarian cancers and shortens survival of the experimental mice. We further show, for the first time, that Angpts promote accumulation of cancer-associated fibroblasts and tumor angiogenesis in the ovarian cancer microenvironment, as well as enhance ovarian cancer cell proliferation and invasion in vivo. In addition, we establish a novel function of Angpts in promoting proliferation and invasion and inducing Tie-2 and extracellular signal-regulated kinase 1/2 activation in ovarian cancer-associated fibroblasts. Taken together, these data suggest that the Angpt-Tie-2 functional axis is an important player in ovarian cancer progression and an attractive target for ovarian cancer therapy.

Multidetector-row CT of tumour-bowel fistula: Experience at a tertiary cancer centre

AIM

To study the clinical and multidetector computed tomography (MDCT) features of tumour-bowel fistula (TBF).

MATERIALS AND METHODS

Fifty-one patients (27 women; mean age 57.4 years, range 30-77years) with TBF presenting to our institution between January 2005 and February 2012 were identified retrospectively from the radiology database. MDCT images before, at, and subsequent to diagnosis of TBF were reviewed by three radiologists in consensus; clinical presentation, management, and outcome were documented from electronic medical records.

RESULTS

Of 51 patients, small bowel (n = 22) was the most common site with gastrointestinal stromal tumour (GIST) being the most common sarcoma subtype (n = 10). TBF was treatment-associated (TTBF) in 40 patients [78%; 22 of whom had received molecular targeted therapy (MTT)], and spontaneous (STBF) in 11 patients (22%). Thirty-one patients (61%) were symptomatic at the time of TBF detection. TTBF was more often asymptomatic (19/40 versus 1/11; Fisher's exact test p = 0.03). In the TTBF group, 16 had a partial response, seven had stable disease, and 17 had progressive disease. Treatment was discontinued or changed to an alternative regimen in 27/40 patients, and 13/40 patients continued with the same regimen. TBF persisted in 27/33 patients (82%) who underwent CT follow-up. Thirty-one of the 51 patients were deceased at the time of analysis. Time from diagnosis of TBF to death was shorter with STBF (1.8 months) than with TTBF (6.4 months).

CONCLUSION

TBF is often associated with MTT and can be seen with treatment response or progression. TTBF is more frequently asymptomatic. TBF is usually managed conservatively by discontinuing treatment, but often persists on CT follow-up.

Targeting signaling pathways in epithelial ovarian cancer

Ovarian carcinoma (OC) is the most lethal gynecological malignancy. Response to platinum-based chemotherapy is poor in some patients and, thus, current research is focusing on new therapy options. The various histological types of OC are characterized by distinctive molecular genetic alterations that are relevant for ovarian tumorigenesis. The understanding of these molecular pathways is essential for the development of novel therapeutic strategies.

Novel antagonists of growth hormone-releasing hormone inhibit growth and vascularization of human experimental ovarian cancers

BACKGROUND

Antagonists of growth hormone-releasing hormone (GHRH) inhibit the proliferation of various human cancer cell lines and experimental tumors by mechanisms that include direct action on GHRH receptors in cancer cells.

METHODS

In this study, the effects of newly synthesized GHRH antagonists, MIA-313, MIA-602, MIA-604, and MIA-610, were investigated in 2 human ovarian epithelial adenocarcinoma cell lines, OVCAR-3 and SKOV-3, in vitro and in vivo. The expression of receptors for GHRH was demonstrated by Western blot analysis and ligand competition methods in the OVCAR-3 and SKOV-3 cell lines and in tumors from those cells grown in athymic nude mice. The effects of GHRH antagonists on the secretion of vascular endothelial growth factor (VEGF) by OVCAR-3 cells and on the vascularization of OVCAR-3 xenografts also were evaluated.

RESULTS

Both the pituitary and the splice variant type 1 (SV1) GHRH receptors were detected in the 2 cell lines and in tumor xenografts, and SV1 was expressed at higher levels. Cell viability assays revealed the antiproliferative effect of all GHRH antagonists that were. Maximal tumor growth inhibition was approximately 75% in both models. MIA-313 and MIA-602 decreased VEGF secretion of OVCAR-3 cells, as measured by enzyme-linked immunosorbent assay, and reduced tumor vascularization in a Matrigel plug assay, but caused no change in the expression of VEGF or VEGF receptor in the terminal ileum of mice with OVCAR-3 tumors.

CONCLUSIONS

Results from the current study indicated that a he novel approach based on GHRH antagonists may offer more effective therapeutic alternatives for patients with advanced ovarian cancer and who do not tolerate conventional anti-VEGF therapy.

'Triple negative' epithelial ovarian cancer and pathologic markers for prognosis

PURPOSE OF REVIEW

To summarize the recent evidence for 'triple negative' epithelial ovarian cancer (TNEOC), characterized by lack of expression of estrogen receptor, progesterone receptor and human epidermal growth factor receptor type 2 (HER2), and to discuss its potential pathologic markers for prognosis and targeted therapy.

RECENT FINDINGS

'Triple negative' phenotype is traditionally referred to as a specific subtype of breast cancer negative for estrogen receptor, progesterone receptor and HER2 expression. Recent studies have shown that such 'triple negative' phenotype also exists in ovarian and endometrial cancer. TNEOC accounts for about 15% of epithelial ovarian carcinoma. This specific subtype tends to exhibit more aggressive characteristics and a worse prognosis. The molecular features of TNEOC are similar to those of 'triple negative' breast cancer (TNBC), a widely studied histological subtype. Recently, a panel of specific pathologic biomarkers has been identified in TNBC. Currently, phase I and phase II trials to examine the safety and efficacy of a poly (ADP-ribose) polymerase inhibitor (olaparib) and angiogenesis inhibitors (sunitinib and bevacizumab) in TNBC are ongoing. These TNBC-associated pathologic markers could be used to screen for novel prognostic factors and therapeutic targets in TNEOC.

SUMMARY

'Triple negative' phenotype has important implications for clinical management of patients with ovarian cancer.

Addition of bevacizumab to weekly paclitaxel significantly improves progression-free survival in heavily pretreated recurrent epithelial ovarian cancer

OBJECTIVE

Weekly paclitaxel has been shown to be an effective cytotoxic regimen for recurrent epithelial ovarian cancer (EOC), and may act through inhibition of angiogenesis. Bevacizumab, a potent angiogenesis inhibitor, has also been shown to have activity in patients with EOC. Therefore, we sought to determine if the addition of bevacizumab to weekly paclitaxel led to an increased survival compared to weekly paclitaxel alone.

METHODS

A single institutional review was conducted for patients with recurrent EOC treated with weekly paclitaxel (60-70mg/m(2)) on days 1, 8, 15, and 22 of a 28day cycle and those treated with weekly paclitaxel and bevacizumab (10-15mg/kg on day 1 and 15). Response rates (RR) were calculated, and progression-free survival (PFS), and overall survival (OS) were compared using Kaplan-Meier survival analysis.

RESULTS

Twenty-nine patients treated with weekly paclitaxel and 41 patients treated with paclitaxel/bevacizumab were identified. The groups were similar in demographics, initial optimal cytoreduction, stage, histology, grade, platinum sensitivity, and median number of previous regimens (4 vs. 4, p=0.69).The overall response rate (ORR) was 63% (complete response (CR) 34% and partial response (PR) 29%) for paclitaxel/bevacizumab and 48% (CR 17% and PR 31%) for weekly paclitaxel (p=0.23). Improvement in PFS was seen in those treated with paclitaxel/bevacizumab in comparison to weekly paclitaxel alone (median PFS 13.2 vs. 6.2months, p<.01). There was a trend towards improved OS for paclitaxel/bevacizumab (median OS 20.6 vs. 9.1months; p=0.12). Toxicities were similar between the two regimens although more bowel perforations (2 vs. 0) were seen in the paclitaxel/bevacizumab group.

CONCLUSION

A significant increase in PFS with a trend towards improved OS was demonstrated in this heavily pretreated population treated with paclitaxel/bevacizumab as compared to weekly paclitaxel alone. This data should be helpful in guiding future trials to determine the optimal care for women with recurrent EOC.

Vascular endothelial growth factor (VEGF) and its receptor VEGFR-2 are highly expressed in ovarian granulosa cell tumors

OBJECTIVE

Ovarian granulosa cell tumors (GCTs) are hormonally active sex cord stromal tumors accounting for 3-5% of all ovarian cancers. These tumors are generally diagnosed at an early stage but there is a high risk of recurrence, associated with high mortality. Treatment of recurrent GCTs is difficult, and biologically targeted treatment modalities are lacking. GCTs are highly vascularized, and angiogenic factors most probably play a role in their pathology. Vascular endothelial growth factor (VEGF) is a key regulator of tumor angiogenesis, but in GCTs, the role of VEGF and its receptors VEGFR-1 (FLT1) and VEGFR-2 (KDR) remains largely unknown. Our objective is to study the expression of VEGF and its receptors in human GCTs.

METHODS

We analyzed GCTs from 106 patients for the expressions of VEGF and its receptors utilizing tumor tissue microarray, tumor mRNA, and patient serum samples.

RESULTS

We found that VEGF and its main biologically active receptor VEGFR-2 were highly expressed in primary and recurrent GCTs, when compared with normal granulosa-lutein cells. The expression of VEGF correlated positively to tumor microvessel density and to VEGFR-2 expression at the protein (P<0.05) and mRNA (P<0.05) levels. In contrast to VEGFR-2, the expression of VEGFR-1 was weak. Tumor VEGF protein expression was not prognostic for recurrence, however, we found high levels of circulating VEGF in the serum of patients with primary GCT.

CONCLUSIONS

The results suggest an important role of VEGF and VEGFR-2 in GCT pathology and support the possibility of applying novel VEGF- or VEGFR-2-targeted treatments to patients with GCT.

Therapeutic options for recurrent malignant glioma

BACKGROUND AND PURPOSE

Despite the given advances in neuro-oncology most patients with high grade malignant glioma ultimately fail locally or locoregionally. In parallel with improvements of initial treatment options, several salvage strategies have been elucidated and already entered clinical practice. Aim of this article is to review the current status of salvage strategies in recurrent high grade glioma.

MATERIAL AND METHODS

Using the following MESH headings and combinations of these terms the pubmed database was searched: "Glioma", "Recurrence", "Neoplasm Recurrence, Local", "Radiosurgery", "Brachytherapy", "Neurosurgical Procedures" and "Drug Therapy". For citation crosscheck the ISI web of science database was used employing the same search terms. In parallel, the abstracts of ASCO 2008-2009 were analyzed accordingly.

RESULTS

Currently the following options for salvage entered clinical practice: re-resection, re-irradiation (stereotactic radiosurgery, (hypo-)fractionated (stereotactic) radiotherapy, interstitial brachytherapy) or single/poly-chemotherapy schedules including new dose-intensified or alternative treatment protocols employing targeted drugs. Re-operation is associated with high morbidity and mortality, however, is an option in a highly selected patient cohort. Since toxicity has been overestimated, re-irradiation is an increasingly used option with precise fractionated radiotherapy being the most optimal technique. On average, time to secondary progression is in the range of several months. Conventional chemotherapy regimens also improve time to secondary progression; however the efficacy is only modest and treatment-related toxicities like myelo-suppression occur very frequently. Molecular targeted agents/kinases are undergoing clinical testing; however no final recommendations can be made.

CONCLUSIONS

Currently, several re-treatment options with only modest efficacy exist. The relative value of each approach compared to other options is unknown as well as it remains open which sequence of modalities should be chosen.

Vascular endothelial growth factor and its relationship to the prognosis and treatment of breast, ovarian, and cervical cancer

Tumor neovascularization is a complex process that plays a crucial role in the development of many different types of cancer. Vascular endothelial growth factor (VEGF) is a potent mitogen that is involved with mitogenesis, angiogenesis, endothelial survival, and the induction of hematopoiesis. By increasing vascular permeability in endothelial cells, it helps tumors recruit wound-healing proteins fibrin and fibrinogen from the plasma, suggesting that tumor formation is a process of abnormal wound healing dependent on the ability to generate a blood supply. The human female reproductive tract is highly dependent on VEGF for normal functions such as endometrial proliferation and development of the corpus luteum. The unique influence of female sex steroid hormones on the expression and activity of VEGF deems angiogenesis an important facet of the development of breast and ovarian cancer. Additionally, the up-regulation of VEGF by the E6 oncoprotein of the human papillomavirus suggests that VEGF plays an important role in the development of cervical cancer. Clinical trials have investigated the humanized monoclonal antibody bevacizumab as potential treatment for all three forms of cancer; the data show that in breast cancer, the use of bevacizumab may lengthen the disease-free survival for women with advanced breast cancer, but does not appear to change their overall survival. It may have a role as salvage chemotherapy for ovarian and cervical cancer, though further research is needed to establish it as a definitive form of treatment.

Ascites regression and survival increase in mice bearing advanced-stage human ovarian carcinomas and repeatedly treated intraperitoneally with CpG-ODN

Tumor cell growth, even in advanced stages of ovarian cancer, is nearly always restricted to the peritoneal cavity; therefore, repeated intraperitoneal injections of oligodeoxynucleotides containing dinucleotides with unmethylated CpG motifs (CpG-ODN) recruiting and activating innate effector cells throughout the abdominal cavity to the tumor site might control tumor cell growth and ascites formation. After a single CpG-ODN treatment, in IGROV-1 ovarian tumor ascites-bearing athymic mice, the number of tumor cells declined rapidly and markedly, and ascites volumes declined shortly after treatment (5 h), increasing thereafter at a slower rate than in controls. When administered every 7 days for 4 weeks, CpG-ODN had only a marginal effect on survival time, whereas administration 5 days/wk for 3 or 4 weeks led to a significantly increased survival time as compared with controls (P<0.005) and completely controlled ascites growth without apparent toxicity, although a disorganization of lymphoid organs was observed. Bio-plex assay of cytokine levels in peritoneal fluid of ascites-bearing mice after CpG-ODN treatment revealed an increase in interleukin (IL)-6, IL-10, IL-12, and interferon-gamma at 24 hours, which returned to control mice levels at 48 to 96 hours, whereas the high levels of angiogenic factors remained unchanged. Depletion of natural killer or monocytes/macrophages only slightly influenced the CpG-ODN-induced reduction of ascites tumor cells, indicating that the antitumor activity might not be related to a specific cell/cytokine but rather to the repertoire of cells and cytokines accumulated in the peritoneal cavity. Thus, our data suggest a relevant role for repeated activation of cells and cytokines of innate immunity in the therapy of ovarian cancer patients with malignant ascites.

Mesenchymal stem cell carriers protect oncolytic measles viruses from antibody neutralization in an orthotopic ovarian cancer therapy model

PURPOSE

Preexisting antiviral antibodies in cancer patients can quickly neutralize oncolytic measles virus (MV) and decrease its antitumor potency. In contrast to "naked" viruses, cell-associated viruses are protected from antibody neutralization. Hence, we hypothesized that measles virotherapy of ovarian cancer in measles-immune mice might be superior if MV-infected mesenchymal stem cell (MSC) carriers are used.

EXPERIMENTAL DESIGN

Antimeasles antibodies titers in ovarian cancer patients were determined. The protection of MV by MSC from antimeasles antibodies, the in vivo biodistribution profiles, and tumor infiltration capability of MSC were determined. Measles-naïve or immune tumor-bearing mice were treated with naked virus or MSC-associated virus and mice survivals were compared.

RESULTS

MSC transferred MV infection to target cells via cell-to-cell heterofusion and induced syncytia formation in the presence of high titers of antimeasles antibody, at levels that completely inactivated naked virus. Athymic mice bearing i.p. human SKOV3ip.1 ovarian tumor xenografts passively immunized with measles-immune human serum were treated with saline, naked MV, or MV-infected MSC. Bioluminescent and fluorescent imaging data indicated that i.p. administered MSC localized to peritoneal tumors, infiltrated into the tumor parenchyma, and transferred virus infection to tumors in measles naïve and passively immunized mice. Survival of the measles-immune mice was significantly enhanced by treatment with MV-infected MSC. In contrast, survivals of passively immunized mice were not prolonged by treatment with naked virus or uninfected MSC.

CONCLUSIONS

MSC should be used as carriers of MV for intraperitoneal virotherapy in measles-immune ovarian cancer patients.

Adverse effects of anticancer agents that target the VEGF pathway

Antiangiogenesis agents that target the VEGF/VEGF receptor pathway have become an important part of standard therapy in multiple cancer indications. With expanded clinical experience with this class of agents has come the increasing recognition of the diverse adverse effects related to disturbance of VEGF-dependent physiological functions and homeostasis in the cardiovascular and renal systems, as well as wound healing and tissue repair. Although most adverse effects of VEGF inhibitors are modest and manageable, some are associated with serious and life-threatening consequences, particularly in high-risk patients and in certain clinical settings. This Review examines the toxicity profiles of anti-VEGF antibodies and small-molecule inhibitors. The potential mechanisms of the adverse effects, risk factors, and the implications for selection of patients and management are discussed.

Verteporfin combination regimens in the treatment of neovascular age-related macular degeneration

BACKGROUND

Neovascular age-related macular degeneration is characterized by choroidal neovascularization that has a complex pathogenesis. Combining agents that have different mechanisms of action (i.e., verteporfin photodynamic therapy, antivascular endothelial growth factor, and/or anti-inflammatory therapies) could maximize clinical benefits through potential complementary effects. This review discusses findings from studies investigating this hypothesis.

METHODS

Articles were retrieved from PubMed using relevant search terms. Abstracts from recent scientific meetings and details of ongoing trials from clinicaltrials.gov were also included.

RESULTS

Following its approval, verteporfin was important in the management of choroidal neovascularization due to age-related macular degeneration for several years. Improved visual outcomes have now been reported with antiangiogenic agents (e.g., intravitreal ranibizumab), especially when frequently administered. Results from investigator-sponsored trials, retrospective case studies and Registries, which have provided insights into the latest findings from clinical practice in the "real-world" setting, as well as randomized controlled trials, suggest that a combination approach is generally well tolerated and may maintain improvements in visual and anatomic outcomes with fewer retreatments.

CONCLUSION

A rationale exists for investigating combination approaches to target different processes in choroidal neovascularization pathogenesis, which may optimize treatment benefits in neovascular age-related macular degeneration. Encouraging data suggest that combination strategies are not associated with major adverse events.

VEGF-A and i-NOS expression are prognostic factors in serous epithelial ovarian carcinomas after complete surgical resection

AIMS

Clinical stage at the time of diagnosis and achievement of complete macroscopic resection during initial surgery are key factors determining the outcome of ovarian cancer. However, prediction of outcome lacks accuracy and more reliable prognostic factors are required. Therefore, an analysis and evaluation of key angiogenic factors was carried out to determine their diagnostic and prognostic value in serous ovarian cancer.

METHODS

Expression levels of vascular endothelial growth factor (VEGF)-A, hypoxia-inducible factor (HIF)1-alpha and inducible nitric oxide synthase (i-NOS) were analysed by immunohistochemistry in a homogenous group of 112 patients with serous adenocarcinoma of the ovary. Vascular density as an indicator of angiogenesis was assessed using the Chalkley eyepiece method after staining for CD34. The correlation of these data with survival and established prognostic factors such as histological grade, Federation of Gynecology and Obstetrics (FIGO) stage, and residual tumour after surgery, was evaluated. Survival analyses, multivariate analyses and correlation tests were performed.

RESULTS

In the patient group with macroscopic complete tumour resection (R0) there was a significant correlation between VEGF-A and i-NOS expression. Kaplan-Meier analysis further revealed improved progression-free survival for R0 patients with VEGF-A-positive and i-NOS-negative tumours. The predictive relevance of VEGF-A regarding progression-free survival was sustained in multivariate analysis using FIGO stage, grading and resection status as fixed variables.

CONCLUSION

VEGF-A and i-NOS are prognostic markers for clinical outcome in serous ovarian cancer patients with macroscopic complete tumour resection (R0). Hence, pre-therapeutic assessment of VEGF-A as predictive factor for an antiangiogenic therapy might be of clinical value.

Current insights on the biology and clinical aspects of VEGF regulation

Vascular endothelial growth factor (VEGF) is a key molecule that orchestrates the formation and function of vascular networks. Impaired regulation of angiogenesis is implicated in a number of pathologic states. For instance, neoplasias exhibit uncontrolled angiogenesis, whereas ischemia and states of vascular insufficiency involve reduced VEGF activity. As the role of VEGF has been elucidated in these disease processes, its therapeutic role has been developed. The Food and Drug Administration has approved several anti-VEGF agents for treating colorectal, lung, and kidney cancer. VEGF-inducing agents have also been used experimentally to induce angiogenesis in patients with critical limb ischemia. As more knowledge is gathered about the biology of VEGF and its receptors, there is greater promise for therapeutic modulation of VEGF expression. The purpose of this review is to describe the various therapeutic and biologic factors that regulate the expression of VEGF.

Future directions in the management of epithelial ovarian cancer

Epithelial ovarian cancer can be a difficult malignancy to manage, partially owing to its heterogenous biology. Whilst desirable, screening designed to reduce mortality has not yet proven effective, though results of ongoing studies are awaited. In this brief review, we attempt to highlight some important issues in the current management of primary and recurrent ovarian cancer, and to place these issues in the context of cutting-edge approaches to targeted therapy and its combination with chemotherapy, as well as other novel treatment strategies. It is hoped that this will lead to further improvements in progression-free and overall survival for patients with ovarian cancer, whilst maintaining their quality of life for as much of the disease journey as possible.