Secondary cytoreduction in platinum-sensitive recurrent ovarian cancer: are we missing something?

Update on the secondary cytoreduction in platinum-sensitive recurrent ovarian cancer: a narrative review

The ovarian cancer recurrence occurs in 75% of patients with advanced FIGO stage, and its treatment is a challenge for the oncologist in gynecology. The standard treatment of recurrent ovarian cancer (ROC) usually includes intravenous chemotherapy according to platinum sensitivity. Furthermore, maintenance treatment with target therapies [e.g., anti-angiogenic drug or PARP inhibitors (PARPi)], should be provided if not precedently administrated. In this scenario, secondary cytoreductive surgery (SCS) remains a practical but controversial option for platinum-sensitive ROC (PSROC). So far, several retrospective series and a Cochrane meta-analysis had concluded that SCS could determine better survival outcomes in ROC with favorable prognostic characteristics, such as the presence of a single anatomical site of recurrence, or when patients are accurately selected for surgery based on complete resection’s predictive models. Recently, three randomized clinical trials (RCTs) investigated the role of SCS in PSROC patients selected with different criteria. All the three RCTs showed a significant statistical advantage in progression-free survival (PFS) in the SCS group, with an even more significant difference in patients with complete cytoreduction (about 7-month PFS increased). Data on overall survival (OS) are different in the two completed trials. The GOG213 study has documented a longer OS of PSROC patients who received chemotherapy alone compared to surgery plus chemotherapy. Contrarily, the DESKTOP III trial showed 7.7 months of increased OS in the surgery group vs. chemotherapy alone, with a more difference in the complete tumor cytoreduction (CTC) group (12 months). These RCTs thereby suggest that undergoing complete cytoreduction may not be the only key and that the disease biology may also matter. Few recent retrospective series investigated the role of SCS according to BRCA mutation status and the effect of SCS in patients receiving emerging PARPi. A consequence of the developments in SCS and knowledge of different molecular pathways influencing the recurrent disease is that the future research objective should be to individualize and personalize the surgical approach.

Tanshinone IIA suppresses ovarian cancer growth through inhibiting malignant properties and angiogenesis

Background

In Chinese herbal medicine, Tanshinone IIA (Tan-IIA) is one of the main compounds extracted from Salvia miltiorrhiza Bunge. Tan-IIA has been demonstrated to inhibit the growth of various tumors. However, the detailed molecular and cellular mechanisms of the antitumor effect of Tan-IIA have yet to be fully illuminated.

Methods

A2780 and ID-8 were treated with 0, 1.2, 2.4, 4.8, or 9.6 µg/mL Tan-IIA for 24 hours. Cell counting Kit-8 assay and EdU staining were used to evaluate cell proliferation. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay and flow cytometry were performed to analyze apoptosis. Western blot was carried out to determine the protein levels. Flow cytometry was used for cell cycle analysis. The levels of mRNA expression were analyzed by real-time polymerase chain reaction. The anti-tumor effect of Tan-IIA was observed in a tumor-bearing mouse model.

Results

Tan-IIA inhibited the proliferation of ovarian cancer cells in a dose-dependent manner by inducing G2/M phase arrest. It also down-regulated B-cell lymphoma 2 (Bcl-2) and up-regulated Bcl-2-associated X protein (Bax) in ovarian cancer cells to induce apoptosis, and suppressed cell migration by inhibiting focal adhesion kinase phosphorylation. Tan-IIA significantly reduced vascular endothelial growth factor (VEGF) and cyclooxygenase-2 (COX2) mRNA expression in ovarian cancer cells. In vivo, Tan-IIA significantly inhibited tumor growth by inducing apoptosis and promoting anti-angiogenesis.

Conclusions

The results of this study shed light on the molecular and cellular mechanisms for the antitumor effect of Tan-IIA.

Surgery vs. chemotherapy for ovarian cancer recurrence: what is the best treatment option

Nowadays, the best treatment option for ovarian cancer recurrence is often subjective, can vary in the different centers and depend on personal experience. Arbeitsgemeinschaft Gynaekologische Onkologie (AGO)-DESKTOP studies have identified a population of patients who could benefit from secondary surgery. The results of the Gynecologic Oncology Group (GOG)-0213 study were recently published, which showed no advantage in terms of overall survival (OS) in patients with platinum-sensitive recurrent epithelial ovarian undergoing secondary cytoreductive surgery (SCS) compared to chemotherapy alone. Aim of this narrative review is to summarize the best aspects that can make ovarian cancer recurrence patients suitable for SCS. A narrative review analyzing all the literature of the past 30 years has been performed. PubMed, Scopus, Web of Science and Ovid MEDLINE were used for research. All non-English-language articles have been excluded. The following keywords were searched: 'recurrent ovarian cancer', 'secondary surgery', 'secondary cytoreductive surgery', 'platinum-sensitive ovarian cancer', 'platinum-resistant ovarian cancer'. We divided eligible patients for secondary cytoreduction in relation to the following factors: platinum-sensitivity, AGO-score or Tian model, unresectable lesions, surgical generic contraindication, woman's personal choice. The selection of truly suitable patients for surgery seems an essential requirement for the patient's best therapeutic choice. In case of absent post-surgical residual tumor, good performance status, single recurrence, and platinum-sensitive ovarian recurrence, surgery could be performed.

Role of ultrasound in the detection of recurrent ovarian cancer: a review of the literature

Nowadays, no standard approaches for follow up in ovarian cancer (OC) patients exist. While the role of ultrasound (US) is well defined in primary diagnosis of OC, it is still controversial during follow-up of surgically treated OC. The aim of this narrative review is to evaluate the role described in literature of US imaging in the early detection of OC recurrences. A review of the English literature present in PubMed and SCOPUS of the past 30 years regarding the use of US in recurrent ovarian cancer (ROC) has been performed. The following keywords were searched: "ultrasound and recurrent ovarian cancer" and "intraoperative ultrasound and recurrent ovarian cancer". A total of 15 articles were selected. US was mainly adopted in the detection of recurrent pelvic disease after debulking surgery, after fertility sparing surgery (FSS) and as an intraoperative tool for localization of OC recurrences. If introduced as a standard follow-up procedure, US may have a central role in the early detection of pelvic OC recurrence, in ovarian localization of relapses of borderline ovarian tumor (BOT) and early stages disease treated with FSS; it may also play an important role in the intraoperative localization of previously suspected secondary lesions.

Natural compound Tan-I enhances the efficacy of Paclitaxel chemotherapy in ovarian cancer

Background

Paclitaxel is a widely used clinical first line chemotherapy drug for ovarian carcinoma. Tanshinone I (Tan-I) is one of the vital fat-soluble components, which derived from Chinese herbal medicine, Salvia miltiorrhiza Bunge. Herein, we evaluated whether Tan-I could enhance the efficacy of ovarian cancer to chemotherapy of Paclitaxel.

Methods

Ovarian cancer cells A2780 and ID-8 were exposed with Tan-I (4.8 µg/mL), Paclitaxel (0.1 µg/mL), or Tan-I combination with Paclitaxel for 24 hours. The cell proliferation was analyzed by CCK8 and EdU staining. Cell apoptosis was analyzed by the TUNEL assay and flow cytometry. The protein levels were determined by western blot. Cell migration was analyzed by Transwell and wound healing. Cell senescence was analyzed by senescence-associated b-galactosidase staining. Antitumor activity was analyzed by a subcutaneous tumor xenograft model of human ovarian cancer in nude mice. The protein expression and apoptosis level of tumor tissues were analyzed by immunohistochemistry and TUNEL staining.

Results

Tan-I treatment significantly elevated the Paclitaxel-cause reduction of A2780 and ID-8 cell proliferation and cell migration. Tan-I combination with Paclitaxel promotes apoptosis of cancer cells by promoting Bax expression and Bcl-2 expression. Besides, Tan-I treatment can notably increase Paclitaxel-inducing cell senescence by promoting DNA damage and senescence-associated proteins such as p21 and p16. Furthermore, the result of the transplanted tumor model indicated that Tan-I combination with Paclitaxel could inhibit tumor growth in vivo by inhibiting cell proliferation and inducing cell apoptosis.

Conclusions

Natural compound Tan-I enhances the efficacy of ovarian cancer to Paclitaxel chemotherapy. The results will help to supply the potential clinical use of ovarian carcinoma cells.