Radiation for persistent or recurrent epithelial ovarian cancer: a need for reassessment

Mechanical properties of CTCs in patients with diagnosed ovarian cancer

The incidence and mortality of gynecologic cancers have been constantly increasing in China over the last 2 decades, which become a major health concern for women. Survival rates of gynecologic cancers are generally not satisfactory and decrease along with the advancing stage, this is mainly due to the lack of a clear prognostic evaluation during the treatment, which brings difficulties to the treatment. Therefore, more accurate prognostic evaluation methods are urgently needed. To solve this problem, this article explores the changes in the biomechanical properties of cells. Changes in the biomechanical properties of circulating tumor cells (CTCs) were explored by nano detection technology. The reference criteria for clinical evaluation of ovarian cancer (Age, FIGO stage, Histologic type, CA-125, Ascites, Single/Double, Residual lesion, and Chemotherapy) were compared and analyzed. The results showed that the average cell height of CTCs was 4.12 ± 0.83 μm before chemotherapy and 4.87 ± 0.71 μm after chemotherapy, with an average increase of 18.203 %. The apparent Young's modulus (E) was 3.884 ± 0.045 kPa before chemotherapy and 4.514 ± 0.025 kPa after chemotherapy, which increased by 0.63 kPa. The ROC analysis of FIGO stage of ovarian cancer patients showed that Young's modulus of cells could better reflect the accuracy of the evaluation of FIGO stage of patients, with the accuracy reaching 76.7 %, which was higher than the detection accuracy of CA-125 (72.6 %). In conclusion, the mechanical properties of CTCs can indicate the FIGO stage and diagnosis of patients and predict the prognostic risk of patients.

Radiotherapy in recurrent ovarian cancer: updated results of involved-field radiation therapy

OBJECTIVE

This study aimed to update the possible clinical benefits of radiation therapy in recurrent ovarian cancer.

METHODS

The medical records of 495 patients with recurrent ovarian cancer after initially undergoing maximal cytoreductive surgery and adjuvant platinum-based chemotherapy based on the pathologic stage between January 2010 and December 2020 were analyzed: 309 and 186 patients were treated without and with involved-field radiation therapy, respectively. Involved-field radiation therapy is defined as radiation therapy only to the areas of the body involved by tumor. The prescribed doses were ≥45 Gy (equivalent dose in 2 Gy/fraction). Overall survival was compared between patients treated with and without involved-field radiation therapy. The favorable group was defined as patients who satisfied at least four of the following factors: good performance, no ascites, normal CA-125, platinum-sensitive tumor, and nodal recurrence.

RESULTS

The median age of the patients was 56 years (range 49-63) and median time to recurrence was 11.1 months (range 6.1-15.5). 217 patients (43.8%) were treated at a single site. Radiation therapy, performance status, CA-125, platinum sensitivity, residual disease, and ascites were all significant prognostic factors. The 3-year overall survival of all patients, patients treated without radiation therapy, and patients treated with radiation therapy was 54.0%, 44.8%, and 69.3%, respectively. Radiation therapy was associated with higher overall survival rates in the unfavorable and favorable patient groups. Patient characteristics showed higher rates of normal CA-125, lymph node metastasis only, lower platinum sensitivity, and higher rates of ascites in the radiation therapy group. After propensity score matching, the radiation therapy group showed superior overall survival to the non-radiation therapy group. Normal CA-125, good performance status, and platinum sensitivity were associated with a good prognosis in patients treated with radiation therapy.

CONCLUSION

Our study showed that higher overall survival was observed in patients treated with radiation therapy in recurrent ovarian cancer.

Clinical application of radiotherapy in patients with oligometastatic ovarian cancer: a sharp tool to prolong the interval of systemic treatment

BACKGROUND

With the advances of radiation technology, treatment of oligometastatic disease, with limited metastatic burden, have more chances to achieve long-term local control. Here we aim to evaluate the efficacy and safety of radiotherapy (RT) in oligometastatic ovarian cancer patients.

METHODS

A retrospective analysis collecting 142 patients (189 lesions) with oligometastatic ovarian cancer were included in the study. All pateints received radiotherapy and the curative effect and response rate were evaluated by diagnostic imaging after 1-3 months of radiotherapy with RECIST. Endpoints were the rate of complete response (CR), chemotherapy-free interval (CFI), local control (LC) rate and overall survival (OS) rate. Toxicity was evaluated by the Radiation Therapy Oncology Group (RTOG). Logistic and Cox regression were used for the uni- and multivariate analysis of factors influencing survival outcomes.

RESULTS

From 2013.1.1 to 2020.12.30, a total of 142 ovarian cancer patients (189 oligometastasis lesions) were included in the analysis. Prescribed doses to an average GTV of 3.10 cm were 1.8-8 Gy/fraction, median BED (28-115, a/b = 10 Gy), 5-28 fractions. For 179 evaluable lesions, the cases of CR, partial response (PR), stable disease (SD) and progressive disease (PD) after radiotherapy were 22,39,38 and 80 respectively. The disease control rate (DCR): CR + PR + SD was 55.31%, and the objective response rate (ORR): CR + PR was 34.08%. No patient developed grade 3 or higher side effect. The median CFI was 14 months (1-99 months), and the LC rate was 69.7%, 54.3% and 40.9% in 1 year, 2 years and 5 years respectively. GTV < 3 cm before treatment, platinum sensitivity, time from the last treatment ≥ 6 months, single lesion and BED(a/b = 10 Gy) ≥ 60 are the factors of good LC (p < 0.05). The total OS of 1 year, 2 years and 5 years were 67.1%, 52.6% and 30.3%, respectively. Single lesion (HR 0.598, 95%CI 0.405-0.884), DCR (HR 0.640, 95% CI 0.448-0.918) and ORR(HR 0.466, 95% CI 0.308-0.707) were the significant factors influencing 5-year OS.

CONCLUSION

For patients with oligometastatic ovarian cancer, radiotherapy has high LC, long chemotherapy-free interval, and survival benefits. Subgroup analysis shows that patients with single lesion and good local treatment results have higher overall survival rate, suggesting that active treatment is also beneficial for oligometastatic ovarian cancer patients.

The role of radiotherapy in ovarian cancer

Epithelial ovarian cancer accounts for around 1.9% of all malignancies and often presents late at an advanced stage. Prognosis is therefore poor. Currently the mainstay of treatment is radical cytoreductive surgery and chemotherapy but, in the past, the standard of care also included adjuvant whole abdominal radiotherapy. This is no longer standard practice, largely due to high toxicity rates and the effectiveness of platinum-based chemotherapy. Presently, a role is emerging for modern radiotherapy techniques in both the salvage and palliative settings. This review aims to examine the historical use of radiotherapy in ovarian cancer before looking forward to its potential future role.

A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review)

Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.

A Retrospective Study of Rapid Symptom Response in Bleeding Gynecologic Malignancies With Short Course Palliative Radiation Therapy: Less is More

CONTEXT

Advanced gynecologic malignancies can cause significant vaginal bleeding. Radiotherapy (RT) is often used to palliate symptoms, but limited data exist concerning the optimal dose and expected time to bleeding hemostasis in this population.

OBJECTIVES

1) To investigate the overall hemostasis response and kinetics of hemostasis in women with gynecologic malignancies receiving palliative RT. 2) To compare the efficacy of short-course RT (SCRT, less than or equal to five fractions, >3.5 Gy per fraction) vs. conventionally fractionated long-course regimens (greater than five fractions).

METHODS

We identified women receiving palliative RT for bleeding gynecologic malignancies. Initial and maximal hemostasis responses (IHR and MHR) were recorded and categorized as progressive bleeding (PD), stable disease (SD), partial response (PR), or complete response (CR). Clinical variables were correlated with response or toxicity using binary logistic regression statistical methods.

RESULTS

Thirty-three women (median age 63) were identified between 2010 and 2019. Median follow-up and survival after RT were 131 days. About 54.5% (18 of 33) received SCRT. Median time to IHR was five days (two-and-a-half days with SCRT) and 78.8% (26 of 33) responded during treatment. Median time to MHR was 13 days. About 100% achieved PR or CR at MHR. Rates of CR were similar between SCRT (83%) and conventionally fractionated schedules (87%). Average durability of hemostatic control was 5.4 months. Overall rate of rebleeding and Grade 3+ toxicity was 9.1% (3 of 33 each).

CONCLUSION

Women receiving SCRT for bleeding gynecologic malignancies achieved rapid symptom control (often during treatment) with minimal rebleeding. In a population whose median survival is four months, SCRT effectively addresses symptomatic disease while minimizing patient burden and toxicity.

Palliative Radiation Therapy for Metastatic, Persistent, or Recurrent Epithelial Ovarian Cancer: Efficacy in the Era of Modern Technology and Targeted Agents

PURPOSE

Metastatic, persistent, or recurrent epithelial ovarian cancer (MPR-EOC) remains a significant threat to patient mortality despite advances in novel targeted agents. Radiation therapy (RT) is often used as a palliative option. We report outcomes of a large series of MPR-EOC patients treated with modern palliative RT (PRT) in an era of novel systemic therapies.

METHODS AND MATERIALS

A retrospective review was conducted of women treated with PRT for MPR-EOC between 2007 and 2019 at an academic institution. Clinical response rates were recorded at <1 month, 1 to 3 months, and >3 months. Radiographic responses were categorized by RECIST 1.1 criteria. Overall response rate (ORR) was the sum of complete and partial response. Linear regression analyses of baseline characteristics were conducted for statistical testing.

RESULTS

Eighty-six patients with PMR-OC received 120 courses of palliative RT. Median follow-up was 8.6 months. Median age was 61 (range, 22-82). Thirty-six percent of women received central nervous system (CNS)-directed RT. In addition, 43% received targeted therapies before RT. Clinical ORR within 1 month and at last follow-up for non-CNS lesions was 79% and 61% (69% and 88% for CNS lesions, respectively). High-grade serous lesions were more likely to have clinical response (P = .04). Biologically effective doses (BED) >39 Gy were associated with improved clinical response in CNS lesions (P = .049). Bony sites were associated with worse clinical (P = .004) response in non-CNS lesions compared with soft tissue or nodal sites. Acute or late grade 3+ toxicities with bevacizumab were low (8.7%/4.3%).

CONCLUSIONS

PRT offers excellent rates of response for symptomatic patients with MPR-EOC within 1 month of treatment, with durable responses beyond 3 months. High-grade serous lesions were associated with improved response in all patients. Higher BED and soft tissue or nodal sites were associated with improved response in CNS and non-CNS patients, respectively. Acute or late toxicities with bevacizumab and PRT were low. Prospective investigation is warranted to determine the optimal PRT regimen.

Clinical analysis of conformal and intensity-modulated radiotherapy in patients with recurrent ovarian cancer

We aimed to provide evidence for radiotherapy treatment regimens in patients with clinically recurrent ovarian cancer. We analyzed the survival and prognostic factors in 43 patients who were treated for recurrent ovarian cancer at 58 tumor sites using three-dimensional conformal radiotherapy (3D-CRT) or intensity-modulated radiotherapy (IMRT) during January 2006-December 2017. t years 1, 2, and 3, overall survival (OS) rate was 82.4%, 68.4%, and 57.9%; local control (LC) rate was 100%, 100% and 80%; recurrence free survival (RFS) rate was 86.8%, 66.6%, and 61.1%; and disease-free survival (DFS) rate was 79.7%, 56.7%, and 46.8%, respectively. The radiotherapy technique was determined to be an independent prognostic factor for survival; the survival rate of patients was significantly improved with IMRT compared to 3D-CRT (P = 0.035). Radiotherapy dose was an independent prognostic factor; survival rate improved when patients were treated with a radiation dose ≥ 60 Gy as compared to < 60 Gy (P = 0.046). Elective nodal prophylactic radiation therapy (ENRT) did not lead to a significant improvement in survival when compared to involved-field radiation therapy (IFRT). The toxicities of 3D-CRT and IMRT were tolerable. One patient (2.3%) had grade 3 acute gastrointestinal (GI) toxicity, 2 (4.6%) grade 3 late GI toxicity, 5 (11.6%) grade 3 hematological toxicity, and 2 (4.6%) had grade 4 hematological toxicity. IMRT improved LC and OS in patients with recurrent ovarian cancer after surgery and multiple chemotherapy; toxicities were tolerable. The IMRT technique and radiotherapy dose of ≥ 60 Gy had independent prognostic significance for the survival of such patients.

Stereotactic body radiation therapy (SBRT) in recurrent, persistent or oligometastatic gynecological cancers

OBJECTIVE

SBRT is a well-tolerated technique and provides local-regional control in a variety of metastatic and recurrent tumor types. The role of SBRT in extracranial recurrent, persistent, or oligometastatic gynecological tumors is not well-studied. We therefore retrospectively analyzed a sizeable number of patients in this setting.

METHODS

We performed a retrospective review of 86 patients with 209 tumors treated at our institution with SBRT for recurrent, persistent, or oligometastatic extracranial gynecological tumors. The median follow-up was 20 months (range 1-91). The median SBRT dose was 24 Gy (range 10-50) delivered in a median of 4 fractions (range 1-6). The Kaplan-Meier curves and log rank tests were used to assess local control (LC) and overall survival (OS). Cox proportional hazards model was used to evaluate for covariates associated with LC and OS.

RESULTS

The 1- and 3-year LC were 80% and 68% respectively. The 1- and 3-year OS were 70% and 39%. 32% of the lesions demonstrated complete response, 23% partial response and 20% stable disease. SBRT achieved better local control in smaller tumors. Toxicity was typically mild with grade 1 gastrointestinal toxicity and fatigue being the most common. Only 4.3% of treatments resulted in grade 2 or greater toxicity. There was only one case of grade 3 and no grade 4 or 5 toxicities.

CONCLUSIONS

SBRT offers a high rate of local control with low incidence of toxicity, mainly grade 1 GI toxicity and fatigue, and provides effective salvage therapy for oligometastatic extracranial pelvic and extra-pelvic gynecological tumors.

Development of a nomogram to predict prognosis in ovarian cancer: a SEER-based study

Background

Ovarian cancer remains the most lethal gynecologic malignancy. In this study, we aimed to identify the specific risk factors affecting overall survival (OS) and develop a nomogram for prognostic prediction of ovarian cancer patients based on data from the Surveillance, Epidemiology, and End Results (SEER) database.

Methods

Information from the SEER database on ovarian cancer between 2004 and 2016 was screened and retrieved. Cases were randomly divided into the training cohort hand the validation cohort at a 7:3 ratio. The prognostic effects of individual variables on survival were evaluated via Kaplan-Meier method and Cox proportional hazards regression model using data from the training cohort. A nomogram was formulated to predict the 3- and 5-year OS rates of patients with ovarian cancer, and then validated both in the training cohort and the validation cohort.

Results

A total of 28,375 patients were selected from 75,921 samples (19,862 in training cohort and 8,513 in validation cohort). Cox regression analysis identified race, age laterality, histology, stage, grade, surgery, chemotherapy, radiotherapy, and marital status as independent risk factors for ovarian cancer prognosis. A nomogram was developed based on the results of multivariate analysis and validated using an internal bootstrap resampling approach, which demonstrated a sufficient level of discrimination according to the C-index (0.752, 95% CI: 0.746–0.758 in the training cohort, 0.755, 95% CI: 0.746–0.764).

Conclusions

We developed a nomogram valuable for accurate prediction of 3- and 5-year OS rates of ovarian cancer patients based on individual characteristics.

Involved-field radiation therapy for selected cases of recurrent ovarian cancer

OBJECTIVES

In our institutional experience, involved-field radiation therapy (IFRT) yields favorable outcomes in patients with recurrent epithelial ovarian cancer (EOC). This retrospective study aimed to investigate the clinical benefits of IFRT in this patient population.

METHODS

Among patients treated with IFRT for recurrent EOC between 2010 and 2017, 61 patients with 90 treatments were included. IFRT encompassed all treatable lesions identified via imaging studies with 10-15-mm margins. Prescribed doses were ≥45 Gy (equivalent dose in 2 Gy/fraction).

RESULTS

Patients were followed up for a median of 19.0 (Interquartile range, 8.6-34.9) months after IFRT. The 2-year in-field control, progression-free survival, and overall survival (OS) rates were 42.7%, 24.2%, and 78.9%, respectively. Fifty-three IFRT sessions (58.9%) were followed by systemic chemotherapy, and the median chemotherapy-free interval (CFI) was 10.5 (95% confidence interval=7.3-13.7) months. A higher carbohydrate antigen-125 (CA-125) level correlated with a worse 2-year OS (69.2% vs. 91.0%; p=0.001) and shorter median CFI (4.7 vs. 11.9 months; p<0.001). Twenty-eight (31.1%) of 90 treatments yielded a long-term CFI >12 months. For patients with a normal CA-125 level and/or platinum-sensitive tumor, IFRT prolonged CFI regardless of pre-existing carcinomatosis, gross tumor volume, and number of treatment sites.

CONCLUSION

Our early experience demonstrates the safety and feasibility of IFRT as an effective salvage therapy and enables a "chemotherapy holiday" in selected recurrent EOC settings. The CA-125 value before IFRT (within normal range) and/or platinum sensitivity could be used as selection criteria for IFRT.

[Radiotherapy for ovarian carcinoma management: Literature review]

Ovarian cancer is the fifth most common cancer in women in France with 4714 new cases in 2017. More than 70% of patients whose disease is initially locally advanced will present locoregional or distant recurrence. Therapeutic options in this situation are not consensual. They are based on chemotherapy possibly associated with an iterative cytoreductive surgery when it is bearable by the patient. The place of radiotherapy in the management of the disease is hidden in the vast majority of national or international standards. We conducted a general review of the literature to clarify the role of irradiation in the global management of ovarian cancers, particularly in recurrence.

Salvage radiation therapy for localized recurrent ovarian cancer

INTRODUCTION

To evaluate clinical outcomes for patients with localized recurrent ovarian cancer treated with salvage radiotherapy.

METHODS

In a retrospective single institutional analysis, we identified 40 patients who received salvage radiotherapy for localized ovarian cancer recurrence from January 1995 to June 2011. Recurrent disease was categorized as: pelvic peritoneal (45%, 18), extraperitoneal/nodal (35%, 14), or vaginal (20%, eight). Actuarial disease-free and overall survival estimates were calculated by Kaplan-Meier and prognostic factors evaluated by the Cox proportional hazards model.

RESULTS

Median follow-up was 42 months. Median patient age was 54 years (range, 27-78). Histologic subtypes were: serous (58%, 23), endometrioid (15%, six), clear cell (13%, five), mucinous (8%, three), and other (8%, three). At the time of salvage radiotherapy, surgical cytoreduction was performed in 60% (24) and 68% (27) had platinum-sensitive disease. Most patients (63%, 25) received salvage radiotherapy at the time of first recurrence. Relapse after salvage radiotherapy occurred in 29 patients at a median time of 16 months and was outside the radiotherapy field in 62%. 18 At 3 years, disease-free and overall survival rates were 18% and 80%, respectively. On multivariate analysis, non-serous histology (hazards ratio 0.3, 95% CI 0.1-0.7) and platinum-sensitivity (hazards ratio 0.2, 95% CI 0.1-0.5) were associated with lower relapse risk. Platinum-sensitivity was also associated with overall survival (hazards ratio 0.4, 95% CI 0.1-1.0). Four patients (10%) were long-term survivors without recurrence 5 years after salvage radiotherapy. Of the five patients with clear cell histology, none experienced relapse at the time of last follow-up.

DISCUSSION

Patients with non-serous and/or platinum-sensitive ovarian cancer had the greatest benefit from salvage radiotherapy for localized recurrent disease. Although relapse was common, radiotherapy prolonged recurrence for > 1 year in most patients and four were long-term survivors.

Radiotherapy for isolated recurrent epithelial ovarian cancer: A single institutional experience

AIM

To evaluate the efficacy and toxicity of external beam radiotherapy (RT) for isolated recurrent epithelial ovarian cancer (EOC).

METHODS

Twenty-four isolated recurrent EOC patients treated with RT at Osaka University Hospital between January 2000 and January 2017 were included in the current study. Data regarding the primary or recurrent diseases, follow-up findings, and efficacy or toxicities of RT were collected and retrospectively analyzed. Survival rates were calculated using the Kaplan-Meier method and compared using the log-rank test.

RESULTS

Their median age was 59 years. Most patients had International Federation of Gynecology and Obstetrics stage III-IV diseases at the initial diagnosis. Histologically, serous adenocarcinoma was predominant, followed by clear cell adenocarcinoma. All patients had received at least one regimen of platinum-based chemotherapy; 8 were platinum-sensitive relapse and the others were platinum-resistant. Lymph nodes were the most common sites of recurrence, and the median tumor size was 25.5 mm. The median total dose of RT administered was 54 Gy, with a median daily dose of 2 Gy. RT was well-tolerated, and no patients experienced Grade 3/4 toxicities. The in-field overall response rate was 58.3% (14/24), the median regression rate was -40.2% (range: -100 to 0) and the median survival period after RT was 17 months. The 1-year survival and local progression-free survival rates after RT were 66.7% and 45.8%, respectively.

CONCLUSION

RT showed significant antitumor effect against isolated recurrent EOC without causing severe toxicities. Prospective studies with sufficient statistical power are warranted to further evaluate the role of RT in this patient population.

Involved-field radiation therapy for recurrent ovarian cancer: Results of a multi-institutional prospective phase II trial

OBJECTIVE

To evaluate the efficacy and safety of involved-field radiation therapy (IFRT) in patients with locoregionally confined recurrent or persistent epithelial ovarian cancer.

METHODS

This study included patients with recurrent epithelial ovarian cancer eligible for IFRT either during diagnosis of the recurrence or after salvage therapies. IFRT was performed at a dose of ≥45 Gy for all tumors with 10-15-mm margins as seen on standard imaging. The primary endpoint was progression-free survival (PFS); the secondary endpoints were safety, response rate, local control, and overall survival (OS).

RESULTS

Thirty patients with a mean number of 5.7 metastatic lesions each were enrolled between 2014 and 2016. Seventeen were treated with 3-D conformal radiation therapy (RT) and 13 with intensity-modulated RT. IFRT was well tolerated in all patients, and acute toxicity ≥ grade 2 was not observed. One case of grade 3 abdominal pain was reported 10 months post-RT. The overall and complete response rates were 85.7% and 50%, respectively. After a median follow-up of 28 (range, 17-42) months, the median PFS was 7 months. The 2-year PFS rate was 39.3%. Six of the 16 patients who developed outfield disease progression after IFRT were successfully treated with repeat IFRT as salvage treatment. The 3-year local control and OS rates were 84.4% and 55.8%, respectively.

CONCLUSIONS

Although the primary endpoint was not met, IFRT might be safe and effective for in-field tumor control in patients with persistent epithelial ovarian cancer with a limited number of metastatic foci. We plan to conduct a larger scale multi-center phase II prospective study.