Clinical Stage I Carcinoma of the Cervix

Using MR imaging with a body coil parametrial invasion was determined prospectively in 169 consecutive patients considered on the basis of clinical examination to have carcinoma confined to the cervix. After radical hysterectomy correlation with histologic examination was performed for the left and right parametrium separately. The criterion for parametrial invasion was a high-signal-intensity lesion with disruption of the full thickness of the cervical stroma combined with areas of abnormal signal intensity within the parametrial region on T2-weighted images. Histologic examination showed that 18 parametria in 13 patients were invaded by tumor. MR had an overall accuracy of 93%, a sensitivity of 89%, and a specificity of 93% in demonstrating parametrial involvement. Positive and negative predictive values were 43% and 99%. The main weakness of MR was 21 false-positive tests. This represents a limitation when MR is performed with a body coil.

Impact of hospital type and treatment on long-term survival among patients with FIGO Stage IIIC epithelial ovarian cancer: follow-up through two recurrences and three treatment lines in search for predictors for survival

The purpose of this study was to investigate the impact of hospital type determined at primary treatment and find possible predictors of survival in a cohort of patients with advanced epithelial ovarian cancer (EOC) who recurred twice and received three lines of treatment during eight-year follow-up. Using the Norwegian Cancer Registry, the authors identified 174 women with FIGO Stage IIIC EOC diagnosed in 2002. First-line treatment consisted of up-front debulking surgery and chemotherapy, received in either a teaching hospital (TH, n = 84) or a non-teaching hospital (NTH, n = 90). After recurrence all patients in Norway are equally consulted at TH. Survival determined for three time intervals (TI): TI-1, from end date of first-line treatment to first recurrence or death, TI-2, from beginning of second-line treatment until second recurrence or death, and TI-3, from beginning of third-line treatment to death or end of follow-up. Extensive surgery carried out in TH followed by at least six cycles of platinol-taxan chemotherapy resulted in longer survival in the TH group during TI-1. Altogether, the majority of those who receive treatment for recurrences were primary better debulked with following platinol-taxane chemotherapy. Survival in TI-2 was influenced by platinol-sensitivity. During TI-3 the majority (96%) had good performance status and their mean age at primary diagnosis at either hospital type was 57 years. Extensive primary surgery at TH, platinol sensitivity, age, and performance status were predictors of survival in this cohort.

Improved 5-year disease-free survival for FIGO stage I epithelial ovarian cancer patients without tumor rupture during surgery

OBJECTIVE

To investigate the impact of perioperative capsule rupture on disease-free survival (DFS) and cancer-specific survival (CSS) in patients with FIGO stage I epithelial ovarian cancer (EOC I).

METHODS

This prospective population-based study enrolled all 279 patients with EOC I diagnosed in Norway between 2002 and 2004. All patients underwent primary surgery. The data were collected from notification reports to the Norwegian Cancer Registry and included medical, surgical and histopathological records. Kaplan-Meier plots were used to show differences in DFS and CSS. Cox regression analyses were used to show the effect of prognostic factors on survival, expressed as hazard ratios (HRs).

RESULTS

Significantly more patients in the capsule rupture group (Cr group) had clear cell tumors (28%) than in the FIGO stage IA and IB (AB group: 14%) groups, and the FIGO stage IC (C group: 17%; p<0.05) group. Despite adjuvant chemotherapy (AC), these patients had a poor 5-year DFS, 94% in the non-AC group and 81% in the AC group (p<0.01). After five years of follow-up, there was a lower DFS among patients in the Cr group (79%) and the C group (81%), compared with patients in the AB group (91%; p<0.05). Independent prognostic factors at the time of diagnosis were grade, histological type, ascites, adhesions, performance status, CA125 and DNA ploidy. After correcting for the four most important prognostic factors (grade, histological type, ascites, and DNA ploidy), the HR for recurrence was 4.0 (95% CI 1.3-12.7; p<0.05) for the Cr group and 1.8 (95% CI 0.5-6.1; p=0.3) for the C group, compared with the AB group.

CONCLUSIONS

Improvement was observed in the 5-year DFS for EOC I patients without tumor rupture during surgery compared with those with tumor rupture. Since AC did not improve the long-term DFS and CSS rates, it is of utmost importance that surgeons avoid tumor rupture during surgery.

The role of surgery in the second relapse of epithelial ovarian cancer. Selection criteria, morbidity and survival outcome

BACKGROUND

The aim of this study was to investigate the benefit of cytoreductive surgery (CS) and palliative surgery (PS) because of bowel obstruction in the second relapse (SR) in epithelial ovarian cancer.

METHODS

A retrospective population-based study on recorded information from 490 consecutive patients treated at the Norwegian Radium Hospital during 1985-2001 for their SR. In all, 80 had surgery, 28 and 52 of which had their tertiary surgery (TS) and secondary surgery (SS), respectively and 410 were treated with chemotherapy or other therapy.

RESULTS

Median survival time (MST) was nine months for the last group. Complete optimal cytoreduction (COC) was achieved in 56% of the patients operated with CS. At SS and TS 33% and 38%, respectively, achieved COC. MST was 46 versus seven months for 0 versus > 2 cm residual disease. MST for the CS and PS was 31 versus five months, respectively. Twenty-eight percent with CS experienced complications versus 42% with PS including two deaths. On univariate analysis initial stage, residual tumor at first relapse, residual tumor at SR, treatment-free interval from primary treatment to first relapse (TFI 0-1), type of chemotherapy at SR, WHO performance status, ascites, elevated CA 125 values, number of lesions, localization of tumor and tumor size were found to be significant prognostic factors for survival in the surgery group.

CONCLUSIONS

The combination of COC, TFI 0-1 > or = 24 months, CA 125 < or = 35, < or = 3 tumor lesions and WHO 1 performance criteria identifies a group of patients with the best overall survival in SR.

Treatment of advanced breast cancer with chemotherapeutics and inhibition of coagulation and fibrinolysis

A case of advanced breast cancer with cerebral metastasis and pleurisy is reported in which irradiation and cytostatics had failed to retard progressive growth and spread of the tumour. Adjuvant therapy with heparin combined with the fibrinolytic inhibitor tranexamic acid was followed by regression of the cerebral metastasis as well as the pleurisy. When last seen one year later, the patient was free from symptoms.

Diagnosis and treatment of borderline ovarian neoplasms "the state of the art"

The 5-year survival for women with Stage-I borderline tumours (BOT) is favourable, about 95-97%, but the 10-year survival is only between 70 and 95%, caused by late recurrence. The 5-year survival for Stage II-III patients is 65-87%. Standard primary surgery includes bilateral SOEB, omentectomy, peritoneal washing and multiple biopsies. Second cytoreductive surgery is recommended for patients with recurrent disease. Adjuvant postoperative therapy is not indicated in Stage-I diploid tumors. Occasional responses to chemotherapy have been reported in advanced BOTs but no study has shown improved survival. Recently a new theory has been developed describing a subset of S-ovarian cyst adenomas that evolve through S-BOT to low-grade carcinoma. A more correct staging procedure, classification of true serous implants and agreement on the contribution to stage of the presence of gelatinous ascites in mucinous tumours may in the future change the distribution of stage and survival data by stage for women with BOT. Independent prognostic factors in patients with epithelial ovarian BOT without residual tumour after primary surgery are DNA-ploidy, international FIGO-stage, histologic type and patient age. Studies on other molecular markers have not yet uncovered a reliable prediction of biologic behaviour, however, there is hope that future studies of genetics and molecular biology of these tumours will lead to useful laboratory tests. Future questions to be addressed in this review include the following: Have patients with borderline tumours in general been over-treated and how should these patients be treated? How to define the high-risk patients? In which group of patients is fertility-sparing surgery advisable and, do patients with borderline tumours benefit from adjuvant treatment?

The role of secondary cytoreduction in the management of the first relapse in epithelial ovarian cancer

BACKGROUND

The aim of this study was to investigate the benefit of secondary cytoreduction (SCR) in the first relapse in epithelial ovarian cancer and to attempt to define selection criteria for SCR.

PATIENTS AND METHODS

A retrospective population-based study on recorded information from 789 patients treated at the Norwegian Radium Hospital during 1985-2000 for their initial recurrence. In all, 217 had SCR and 572 were treated with chemotherapy alone.

RESULTS

Median survival time (MST) was 1.1 years for the chemotherapy group. Complete optimal cytoreduction (COC) was achieved in 35% of all 217 patients, in 49% of the patients operated with debulking intent and in 52% if bowel surgery was done with debulking intent. MST was 4.5 versus 0.7 years for 0 versus>2 cm residual disease, respectively. Residual disease after SCR, treatment-free interval (TFI) and age were found to be prognostic factors for overall survival (OS) in multivariate analysis. Localised tumour was found to be the only significant factor to predict COC.

CONCLUSIONS

SCR followed by chemotherapy gives a clear survival benefit compared with chemotherapy and should be offered when the tumour is localised. The combination of COC, TFI >24 months and age </=39 years identifies a group of patients with the best OS.

Is the watch and wait approach adequate after comprehensive surgical staging in invasive stage I epithelial ovarian cancer? The Norwegian Radium Hospital experience

OBJECTIVES

The aim of this study on stage I epithelial ovarian cancer (EOC) was to see if our different treatment policies after 1995, when lymph node staging and paclitaxel were introduced, have affected the survival, try to define risk groups for relapse and who should get adjuvant chemotherapy (AC).

METHODS

A retrospective study based on record information from all patients with invasive EOC stage I operated at the Norwegian Radium Hospital (NRH) 1984-2001, in total 252 patients.

RESULTS

Total 5-year survival was 83 and 82%, respectively, in both time periods. We found age and histology to be significant prognostic factors for overall survival (OS) (p < 0.01). From 1995 survival was significantly better for those who had been properly staged than for the others (p = 0.02), with a 5-year survival rate of 87 vs 64%. Those who did not get chemotherapy but were staged, had a significantly better overall survival than those who were not (p = 0.02), with a 5-year survival of 93 vs 77%. In the period 1995-2001 the patients who received no adjuvant treatment lived longer than those who underwent chemotherapy and/or radiotherapy (p = 0.03). In the first period 17% had no adjuvant treatment vs 58% in the last. Patients in a high-risk group getting AC had a tendency toward better survival than those who did not (p = 0.08).

CONCLUSIONS

Patients with Stage I low and medium risk EOC do not need AC if properly staged. For the high-risk group the optimal AC has not yet been established.

Primary cytoreductive surgery or neoadjuvant chemotherapy: A retrospective analysis of 214 patients with stage IIIc and IV ovarian, tubal and peritoneal cancer from the Norwegian Radium Hospital

16035

Background: We evaluated clinical prognostic factors in ovarian carcinoma for their association with upfront treatment in advanced stage ovarian cancer patients with effusions. Methods: Our study consists of a retrospective analysis of 214 patients with stage IIIc and IV primary ovarian cancer, primary peritoneal carcinoma and tubal cancer, treated at the Norwegian Radium Hospital (NRH) in the period 1998–2003. One-hundred and thirty-eight patients underwent primary cytoreduction, 51 patients received neoadjuvant chemotherapy followed by delayed debulking and 25 patients received only chemotherapy. Results: Residual disease of less than 1 cm was achieved in 31.9 % of primary surgery patients and in 47.1 % of delayed surgery patients. Standard taxane/platinum treatment was given to 79.7 % and 67.1 % patients in the surgery and neoadjuvant treatment group, respectively. Hazard ratio for relapse was significantly higher for upfront treatment with neoadjuvant chemotherapy (1.69, CI 95 % 1.12–2.55) compared to primary surgery and for suboptimal debulking surgery and/or suboptimal chemotherapy (1.66, CI 95 % 1.14–2.41) compared to optimal treatment. The incidence of disease-related death was also significantly higher for the neoadjuvant chemotherapy group (1.83, CI 95 % 1.21–2.79) and for patients treated suboptimally (1.50, CI 95 % 1.03–2.19). Median cancer-specific survival was 31 months for the primary surgery group and 15 months for the neoadjuvant treatment group. Conclusions: In this retrospective analysis, the two most important prognostic factors for advanced ovarian, tubal and peritoneal cancer with malignant pleural and/or abdominal effusion were surgical treatment as first-line therapy and combination of optimal tumor debulking (<1cm) and taxane/platinum chemotherapy. The role of neoadjuvant chemotherapy is still controversial.

No significant financial relationships to disclose.

Improved survival for stage IIIC ovarian cancer patients treated at the Norwegian Radium Hospital between 1984 and 2001

BACKGROUND

The aim of this study was to evaluate the treatment of FIGO Stage IIIC patients who were primarily treated completely or partially at the Norwegian Radium Hospital (NRH) during a 15-year period in order to discover possibilities for improvement of prognosis of advanced ovarian cancer.

MATERIALS AND METHOD

A retrospective study based on record information from all patients with epithelial ovarian cancer Stage IIIC treated at NRH from 1985-2000, in total 776 patients.

RESULTS

We found age, amount of residual tumour after surgery for primary treatment and type of chemotherapy to be the most significant prognostic factors for overall survival. During the last 5-year period primary surgery was increasingly centralised, and surgery was improved with lymph node staging and use of paclitaxel. Survival was significantly better during the last 5-year period and after macroscopic radical surgery. Also progression-free survival was better with no macroscopic tumour remaining.

INTERPRETATION

Improved survival during the last 5-year period is partly attributed to improved surgery and partly to the addition of paclitaxel. We believe that further centralisation of primary surgery for advanced ovarian cancer can contribute to a better prognosis.

Expression of matrix metalloproteinase-2 in serous borderline ovarian tumors is associated with noninvasive implant formation

OBJECTIVE

To investigate matrix metalloproteinase (MMP) proteolytic and vascular endothelial growth factor (VEGF) and receptor (VEGFR-1, VEGFR-2) angiogenetic capacity in serous borderline ovarian tumors (S-BOTs) for women with and without noninvasive implants.

METHODS

The population was made up of 99 patients with S-BOTs as the primary diagnosis between 1985 and 1995, 44 of whom had noninvasive implants and 55 without implants. MMP-2, MMP-14, the type-2 tissue inhibitor of MMPs (TIMP-2), and VEGF and receptors (VEGFR-1, VEGFR-2) were examined by immunhistochemistry.

RESULTS

Strong positive (+++) MMP-2 staining was found more frequently in women with primary S-BOTs and noninvasive implants (76%) than in those without implants (53%; p < 0.05). In contrast, staining for MMP-14 and TIMP-2 was not significantly different in the two groups. Furthermore, expression of MMP-2, MMP-14, and TIMP-2 was similar in primary tumors and in their noninvasive implants. Most tumors in both groups had no VEGF expression (84% in the noninvasive implant group and 82% in the group without implants), while moderate (++) to strong (+++) expression of VEGFR-1 and VEGFR-2 was detected in 79% and 94% of the two tumor groups, with no significant difference between the groups.

CONCLUSIONS

Enhanced MMP-2 was seen in primary S-BOT with noninvasive implants. The presence of noninvasive implants was prognostic for disease-free survival.

Improved short-term survival for advanced ovarian, tubal, and peritoneal cancer patients operated at teaching hospitals

The aim of this study was to study the impact of hospital level and surgical skill on short-term survival of advanced ovarian, tubal, and peritoneal cancer patients in a prospective population-based study. All 198 women with a diagnosis of advanced epithelial invasive ovarian, tubal, and peritoneal cancer in Norway who underwent surgery during 2002 were included in this study. The data were derived from notifications to the Norwegian Cancer Registry and from medical, surgical, and histopathologic records. The hospitals were grouped into teaching and nonteaching hospitals (NTH), and the operating physicians were classified according to specialty (specialist gynecologist, gynecologist, and surgeon). The follow-up period was from 455 to 820 days. The short-term survival at 450 days was 79% for women operated at teaching hospitals (TH) and 62% at NTH (P= 0.02). After simultaneous adjustment for seven prognostic factors and residual disease, the risk of death within 600 days at NTH was unchanged compared to TH, hazard ratio 1.83. The women operated on by specialist compared to general gynecologists had a 20% increased short-term survival (P < 0.0001). TH and specialist gynecologists achieved better short-term survival of patients operated for advanced ovarian, tubal, and peritoneal cancer. Centralization and specialization of ovarian cancer surgery might improve the outcome for this patient group.

Short-term survival of ovarian cancer patients waiting more than six weeks after surgery before chemotherapy is given

5070

Background: To investigate the impact on short-term survival of time between surgery and start of first chemotherapy cycle in patients with advanced ovarian cancer. Methods: This prospective, population-based study comprised 371 patients with epithelial ovarian, tubal or peritoneal cancer diagnosed in 2002–2003. All patients underwent primary surgery, followed at different intervals by chemotherapy. The data were derived from notifications to the Norwegian Cancer Registry and included medical, surgical and histopathological records. Kaplan-Meier plots were used to show differences in survival, and Cox regression analysis was used to show the effect of prognostic factors on survival, expressed as hazard ratios (HRs). Results: No difference in survival between patient groups was seen when time between surgery and start of chemotherapy was divided into quartiles. The group of patients with interval between surgery and chemotherapy less than six weeks had inferior survival if they had residual disease after surgery. Adjusted HR = 2.36 (95% CI, 1.22–4.57). However, in the patient groups with interval more than six weeks, there was no significant difference in survival between patients without and with residual disease. Adjusted HR = 1.35 (0.51–3.56) versus HR = 1.64 (0.76–3.57). Conclusions: The interval between surgery and start of chemotherapy had no major impact on short-term survival after ovarian cancer. Patients might be included in chemotherapy trials when interval between surgery and start of chemotherapy is more than six weeks.

[Table: see text]

No significant financial relationships to disclose.

Prognostic factors in ovarian carcinoma stage III patients. Can biomarkers improve the prediction of short- and long-term survivors?

The aim of the study was to determine if biomarker expression could help discriminate between short-term and long-term survivors in women with advanced ovarian cancer. Fifty-one patients with stage III ovarian cancer were selected for the study, which included 28 short-term survivors (death from ovarian cancer within 18 months) and 23 long-term survivors (alive for more than 5 years). There was no difference between the two groups with respect to FIGO substage, age, World Health Organization score, and first-line platinum therapy. Classic clinical pathologic parameters were examined together with p53, Bcl-2, Ki-67, PDGFRalpha, P-glycoprotein, BRCA1, and DNA ploidy. Immunohistochemistry was used for scoring biomarker expression and image cytometry for DNA ploidy. All patients had primary debulking surgery followed by first-line platinum therapy. On multivariate analysis, the presence of ascites, debulking surgery and repeat laparotomy, clear-cell histology, elevated CA125, and high Ki-67 score were all found to be of prognostic importance. The long-term survivors were characterized by primary optimal cytoreduction surgery (<1 cm residual disease), attempt at maximal tumor debulking by experienced gynecological oncologic surgeons, and the absence of ascites. Normal CA125 level before platinum therapy and negative Ki-67 expression also predicted a more favorable prognosis.

Improved short-term survival for advanced ovarian, tubal, and peritoneal cancer patients operated at teaching hospitals

The aim of this study was to study the impact of hospital level and surgical skill on short-term survival of advanced ovarian, tubal, and peritoneal cancer patients in a prospective population-based study. All 198 women with a diagnosis of advanced epithelial invasive ovarian, tubal, and peritoneal cancer in Norway who underwent surgery during 2002 were included in this study. The data were derived from notifications to the Norwegian Cancer Registry and from medical, surgical, and histopathologic records. The hospitals were grouped into teaching and nonteaching hospitals (NTH), and the operating physicians were classified according to specialty (specialist gynecologist, gynecologist, and surgeon). The follow-up period was from 455 to 820 days. The short-term survival at 450 days was 79% for women operated at teaching hospitals (TH) and 62% at NTH (P= 0.02). After simultaneous adjustment for seven prognostic factors and residual disease, the risk of death within 600 days at NTH was unchanged compared to TH, hazard ratio 1.83. The women operated on by specialist compared to general gynecologists had a 20% increased short-term survival (P < 0.0001). TH and specialist gynecologists achieved better short-term survival of patients operated for advanced ovarian, tubal, and peritoneal cancer. Centralization and specialization of ovarian cancer surgery might improve the outcome for this patient group.

Symptoms and referral of women with epithelial ovarian tumors

OBJECTIVE

To study referral to hospital units and the clinical characteristics of women with epithelial ovarian tumors in a prospective, population-based study.

METHODS

Clinical information on all women diagnosed with epithelial invasive (n=486) and borderline ovarian tumors (n=137) in Norway during 2002 was derived from notifications to the Cancer Registry of Norway and medical, surgical and histopathological records.

RESULTS

Sixty-one percent of women with invasive ovarian tumors were initially referred to gynecology units. The 38% of women referred to surgical and medical units were more likely to have symptoms as 'bowel irregularity', 'pain outside the abdominal cavity', 'persisting fatigue' and 'respiratory difficulties'. These women were older, had lower performance status and had a delay in treatment of 20 and 24 days respectively compared to 11 at gynecology units.

CONCLUSION

Greater awareness of the symptoms of ovarian cancer might lead to earlier diagnosis and treatment and thus possibly improve survival.

Paclitaxel plus platinum-based chemotherapy versus conventional platinum-based chemotherapy in women with relapsed ovarian cancer: the ICON4/AGO-OVAR-2.2 trial

BACKGROUND

Despite improvements in the treatment of ovarian cancer, most patients develop recurrent disease within 3 years of diagnosis. There is no agreed second-line treatment at relapse. We assessed paclitaxel plus platinum chemotherapy as such treatment.

METHODS

In parallel international, multicentre, randomised trials, between January, 1996, and March, 2002, 802 patients with platinum-sensitive ovarian cancer relapsing after 6 months of being treatment-free were enrolled from 119 hospitals in five countries. Patients were randomly assigned paclitaxel plus platinum chemotherapy or conventional platinum-based chemotherapy. Analysis was by intention to treat, except for toxic effects.

FINDINGS

With a median follow-up of 42 months, 530 patients have died. Survival curves showed a difference in favour of paclitaxel plus platinum (hazard ratio 0.82 [95% CI 0.69-0.97], p=0.02), corresponding to an absolute difference in 2-year survival of 7% between the paclitaxel and conventional treatment groups (57 vs 50% [95% CI for difference 1-12]), and median survival of 5 months (29 vs 24 months [1-11). 717 patients developed progressive disease or died. The progression-free survival curves show a difference in favour of paclitaxel plus platinum (hazard ratio 0.76 [0.66-0.89], p=0.0004), corresponding to an absolute difference in 1-year progression-free survival of 10% (50 vs 40% [4-15]) and in median progression-free survival of 3 months (13 vs 10 months [1-5]).

INTERPRETATION

Paclitaxel plus platinum chemotherapy seems to improve survival and progression-free survival among patients with relapsed platinum-sensitive ovarian cancer compared with conventional platinum-based chemotherapy.

Have patients with early squamous carcinoma of the vulva been overtreated in the past? The Norwegian experience 1977-1991

OBJECTIVE

To evaluate different surgical approaches in early squamous vulvar cancer.

METHODS

Review of clinical and histopathologic data and follow-up information of 216 patients with clinical FIGO stage I-II disease, primarily treated by surgery from 1977-1991.

RESULTS

Eighty-nine patients underwent radical vulvectomy with bilateral groin dissection by en bloc excision, 60 by the triple incision technique, 20 individualized vulvar surgery with uni-or bilateral groin dissection, and 47 vulvar surgery only. Groin metastases occurred in 9% stage I and 25% stage II disease. Groin involvement was not seen in stage I tumors with invasion depth < or =/=1 mm. Bilateral metastases occurred in medially located tumors of both stages, and laterally located stage II. Metastases were ipsilateral in lateral stage 1. Separate groin dissection significantly reduced morbidity. Sixty-six patients relapsed, 14 after more than 5 years. Vulvar recurrence was related to tumor diameter and the condition of the resection borders. The single most important predictor of death from vulvar cancer was the presence of inguinal femoral lymph node metastases. Conservative and individualized surgery did not compromise 5-year survival.

CONCLUSIONS

A careful selection of patients fitted for less radical surgery is essential to avoid undertreatment. Groin dissection can be omitted in tumors with diameters < or =/=2 cm and invasion depth < or =/=1 mm. At least ipsilateral groin dissection is needed in all other cases. Groin dissection should be performed through separate incisions. Modified vulvectomy is appropriate provided radicality can be obtained. Long-time follow-up is important as recurrences can be seen many years after primary therapy.

Long-term results from a phase II study of paclitaxel combined with doxorubicin in recurrent platinum refractory ovarian cancer

BACKGROUND

There is still a need for newer non-cross-resistant agents and combinations to be tried in cases of failure after first line platinum-based therapy. Several agents have demonstrated activity after failure of platinum-containing regimens. Response rate in true platinum refractory disease up to 20% but with poor long-term survival, has been reported by single drug paclitaxel. In an effort to improve response rate and survival duration obtainable with single drug paclitaxel, we have combined paclitaxel with doxorubicin for the treatment of patients refractory to cisplatin-cyclophosphamide.

PATIENTS AND METHODS

Between October 1994 and November 1996, 23 patients whereof 21 refractory to cisplatin-cyclophosphamide were enrolled for toxicity and survival analysis after receiving the combination doxorubicin 50 mg/m2 and paclitaxel 135 mg/m2 every third week for four courses. Responding patients continued on single drug paclitaxel 175 mg/m2 every third week until unacceptable toxicity or tumor progression occurred.

RESULTS

The objective response rate (CR + PR) was 33%, 95% CI (14.6-57). The median duration of response was 8.5 months (range 4.0-62.5+) and the median overall survival was 15.5 months (range 4.0-63.5+). No serious toxicity was registered.

CONCLUSION

Doxorubicin combined with paclitaxel could safely be administered using this schedule. This study shows that some patients obtaining CR can be rendered disease-free for a substantial period of time, sometimes five years or more. A median overall survival of 15.5 months with a 5-year survival probability of 15% is impressive. However, although responses can be induced in a significant number of patients, the survival figures remain poor.

[Surgery and sentinel node examination in early vulvar cancer]

BACKGROUND

Less than radical vulvectomy for primary vulvar cancer has been controversial. Less mutilating surgery without sacrificing benefits in prognosis is warranted.

MATERIAL AND METHODS

Based on relevant literature and our own experience, we give a review of surgery and sentinel node examination in early vulvar cancer.

RESULTS

Regional lymph node metastasis rarely occurs when tumour thickness is less than 1 mm. Smaller lesions (< 2 cm in diameter) should therefore be treated by wide excision only and without lymph node dissection. Other T1 lesions with deeper invasion should be radically excised with at least 2 cm margins and extend deep to the inferior fascia of the urogenital diaphragm. Complete inguinal-femoral lymphadenectomy should be performed in patients without groin metastases to avoid a small, but definite risk of recurrence, although the incidence of lymph node metastases for all clinical stage I patients is less than 10%. Lymphatic mapping with 99mTechnetium and patent blue technique is a potentially valuable intraoperative tool for assuring removal of the sentinel node most likely to have metastasis, defining the extent of the superficial inguinal lymphadenectomy and identifying uncommon anatomic variations.

INTERPRETATION

Until reliable data on the benefits of selective lymphadenectomy using intraoperative lymphoscintigraphy are available, the procedure should only be performed in an approved research setting.

Fertility preservation in gynecologic cancer

SUBJECT

Management of patients with gynecologic cancer can now often be tailored to the extent of the disease and preservation of child-bearing ability and/or sexual function may be possible for certain women with early invasive disease.

METHOD

A better understanding of the tumor-biology, and the consideration of different clinicopathologic factors, that bear prognostic significance in therapeutic modalities, will allow more and more individualization of treatment.

DISCUSSION

Management of young women with early gynecologic cancer should therefore be individualized with the risk of conservative therapy balanced against the dangers and advantages of more radical therapy. Experts in gynecologic oncology and infertility together with an informed patient and her family should make treatment decisions.

OUTCOME

This article will review the conservative surgical management of early invasive cancers of the ovary, cervix and endometrium, in order to help preserve child-bearing capacity. In addition, management of gynecologic cancers diagnosed during pregnancy will also be discussed.

Clear-cell and papillary serous cancer: treatment options

Clear-cell carcinoma (CCC) and serous papillary carcinoma of the endometrium (UPSC) are rare subtypes of endometrial carcinoma (10%). The histological diagnosis can be made on the dilation and curettage specimens in both types in a very high percentage of the cases. This is important in the planning of treatment. CCC and UPSC are associated with about 50% of all relapses occurring in endometrial carcinoma, and the 5-year survival rate is, on average, 42% and 27% respectively. Surgico-pathological stage, age, and vessel invasion are independent prognostic factors for both groups. The recurrence rate is extremely high, and the most frequent extra-pelvic sites of relapse are the upper abdomen, lungs and liver. Stage Ia patients treated with complete surgical staging alone have a low risk of relapse and need not be offered adjuvant systemic therapy or pelvic radiation. The treatment of patients with CCC and UPSC stage Ib, Ic, II and III should include radical debulking surgery and some form of adjuvant therapy, but it is not clear which type is most effective. Adjuvant pelvic radiotherapy plus intracavitary radiotherapy is usually given in early-stage disease and pelvic radio therapy/or whole abdomen irradiation plus adjuvant systemic chemotherapy (PAC) in advanced disease. However, we are urgently waiting for a large prospective randomized study to compare both modalities. Paclitaxel, alone or in combination, is currently being tested in phase II studies.

[Fertility preservation in gynecologic cancer]

Recent advances in both the staging and the understanding of the natural history of gynecologic cancers have led to new approaches to treatment. The treatment can now often be tailored to the extent of the disease, and preservation of child-bearing ability and/or sexual function may be possible for certain women with early invasive cancers of the ovary, cervix, endometrium, vagina and vulva. Better understanding of the tumour biology and clinicopathologic factors of prognostic significance will allow for individualization of treatment. Management of patients with early gynecologic cancer should be individualized with the risks of conservative therapy balanced against the dangers and advantages of more radical therapy. Specialists in gynecologic oncology and infertility together with an informed patient and her family should make treatment decisions. In this article we present an overview of the therapeutic management of early invasive cancers of the ovary, cervix and endometrium, and present guidelines that may help preserve childbearing capacity.

Tamoxifen in the treatment of recurrent ovarian carcinoma

This review examines the evidence for useful clinical activity of tamoxifen in women with ovarian carcinoma who have failed conventional cytotoxic chemotherapy. The optimised search strategy of the Cochrane Gynaecological Cancer Collaborative Review Group by Williams was used. Tamoxifen demonstrates a modest degree of effectiveness in ovarian cancer refractory to cytotoxic chemotherapy. The overall objective response rate in all trials (647 patients) was approximately 11%. There is, however, a wide variation in the objective response rates in the different trials (0-56%). Tamoxifen therapy has limited efficacy in refractory ovarian carcinoma. However, considering the mild toxicity of tamoxifen, occasional long-term palliation and lack of alternatives, the drug has a useful role in heavily pretreated patients with ovarian cancer.

Health-related quality of life and occurrence of intestinal side effects after pelvic radiotherapy--evaluation of long-term effects of diagnosis and treatment

Health-related quality of life (HRQOL) and occurrence of late intestinal side effects were assessed 3-4 years after pelvic radiotherapy for carcinoma of the endometrium and cervix. During 1988-1990, 143 women were included in a clinical trial to evaluate the effect of a low fat, low lactose diet on radiation-induced diarrhoea. Of 94 survivors, 79 (84%) answered the request. HRQOL was assessed by the EORTC QLQ-C36 and compared with population-based norms. The women scored lower than the general population on role functioning (81.5 versus 90.6 (p < 0.01)) and higher on diarrhoea (23.8 versus 9.5 (p < 0.01)). Compared with pre-treatment conditions, an increase in cases with pain in the lower back, hips and thighs was seen. Substantial pain and diarrhoea were associated with deterioration in HRQOL. In conclusion, few treatment and/or disease-related effects were detected 3-4 years after radiotherapy, with the exception of increased bowel frequency and pain in the lower back, hips and thighs.

[Controversies in surgical treatment of advanced ovarian cancer]

Cytoreductive surgery has traditionally been regarded as a cornerstone in the primary treatment of advanced ovarian cancer. Both five year survival and median survival are better for patients with small residual masses. Despite many similar reports showing the prognostic significance of postoperative residual tumour, the survival benefits of cytoreductive surgery still remain scientifically unproven and controversial. There have been no prospective controlled clinical trials. The question remains as to whether the observed survival benefits for patients subjected to primary cytoreductive surgery are an effect of surgery skills or tumour biology. The proponents of tumour biology claim that cytoreductive surgery is a selective procedure and that patients with better prognosis are selected. Therefore a randomized study between primary cytoreduction and neoadjuvant chemotherapy in patients that cannot be optimally cytoreduced seems warranted, though one problem with such a study is how to select eligible patients. During chemotherapy and after relapse several types of operations are used in ovarian cancer: secondary cytoreductive surgery, interval cytoreductive surgery, second-look surgery and palliative secondary surgery. So far interval cytoreductive surgery during chemotherapy is the only type of operation which in a prospective randomized study showed significant improvement in long-term survival. This paper discusses indirect evidence in the literature in support of or in contradiction to the primary debulking hypotheses and also indications and impact of surgical procedures during chemotherapy.

Disease control of uterine cervical cancer: relationships to tumor oxygen tension, vascular density, cell density, and frequency of mitosis and apoptosis measured before treatment and during radiotherapy

Identification of biological parameters of major importance for the control of malignant diseases can be useful for the design of optimal treatment regimes for individual patients. Tumor oxygen tension (pO2), vascular density, cell density, and frequency of mitosis and apoptosis were measured before treatment (40 patients) and after 2 weeks of radiotherapy (22 patients) in patients with uterine cervical cancer. The aim was to investigate whether one of the parameters was more important for disease control than the others. Three sets of data were considered; the pretreatment parameters, the parameters measured after 2 weeks of radiation, and the changes in the parameters during this time. The pO2 was measured polarographically; the other parameters were determined by histological analyses of tumor biopsies. Hypoxic subvolume (HSV5), ie., the fraction of pO2 readings <5 mm Hg multiplied with tumor volume, showed the strongest correlation to control. Patients with a small HSVs before treatment had a higher control probability after a median follow-up time of 50 months than patients with a large HSV5 (P < 0.001). All other parameters or changes in parameters showed impaired correlation to control compared with pretreatment HSV5. The present results suggest that pretreatment oxygenation is more important for disease control of cervical cancer than the oxygenation after 2 weeks of radiotherapy or the changes in oxygenation during this time. Moreover, vascular density, cell density, and frequency of mitosis and apoptosis before treatment or after 2 weeks of therapy are probably not as important as pretreatment oxygenation as well. Although significant correlations between disease control and some of the parameters other than pretreatment oxygenation can occur in studies based on a large number of patients, the specificity of these parameters in the prediction of control is probably not as high as for oxygenation.

Effects of paclitaxel on CA-125 serum levels in ovarian cancer patients

OBJECTIVE

As in vitro activation of ovarian carcinoma cells in terms of CA-125 secretion by taxanes has been demonstrated, we were interested in whether taxanes also modulate CA-125 expression in vivo.

METHODS

Serum CA-125 was determined immediately before and 24 h after paclitaxel-containing chemotherapy in 53 ovarian carcinoma patients. To test the quality of the analysis methods and the biological variation of untreated patients, serum CA-125 levels of two control groups were analyzed.

RESULTS

Median CA-125 concentration was 107 kU/liter 24 h after chemotherapy treatment compared with 99 kU/liter the day before paclitaxel treatment. Changes in CA-125 serum levels observed immediately after paclitaxel treatment were not correlated to treatment response. However, overall change in CA-125 serum concentration was a good predictor of response to paclitaxel containing treatment. Patients achieving a complete or partial response had a significant reduction of median CA-125 levels, whereas tumor progression was associated with increased CA-125 levels. Only for the group of patients obtaining a complete response was a decrease in the median relative CA-125 value observed.

CONCLUSION

Paclitaxel-induced modulation of CA-125 expression could not be confirmed in vivo.

Randomized study on adjuvant chemotherapy in stage I high-risk ovarian cancer with evaluation of DNA-ploidy as prognostic instrument

PURPOSE

Adjuvant chemotherapy versus observation and chemotherapy at progression was evaluated in 162 patients in a prospective randomized multicenter study. We also evaluated DNA-measurements as an additional prognostic factor.

PATIENTS AND METHODS

Patients received adjuvant carboplatin AUC 7 every 28 days for six courses (n = 81) or no adjuvant treatment (n = 81). Eligibility included surgically staged and treated patients with FIGO stage I disease, grade 1 aneuploid or grade 2 or 3 non-clear cell carcinomas or clear cell carcinomas. Disease-free (DFS) and disease-specific (DSS) survival were end-points.

RESULTS

Median follow-up time was 46 months and progression was observed in 20 patients in the treatment group and 19 in the control group. Estimated five-year DFS and DSS were 70% and 86% in the treatment group and 71% and 85% in the control group. The hazard ratio was 0.98 (95% confidence interval (95% CI): 0.52-1.83) regarding DFS and 0.94 (95% CI: 0.37-2.36) regarding DSS. No significant differences in DFS or DSS could be seen when the log-rank test was stratified for prognostic variables. Therefore, data from both groups were pooled for the analysis of prognostic factors. DNA-ploidy (P = 0.003), extracapsular growth (P = 0.005), tumor rupture (P = 0.04), and WHO histologic grade (P = 0.04) were significant independent prognostic factors for DFS with P < 0.0001 for the model in the multivariate Cox analysis. FIGO substage (P = 0.01), DNA ploidy (P < 0.05), and histologic grade (P = 0.05) were prognostic for DSS with a P-value for the model < 0.0001.

CONCLUSIONS

Due to the small number of patients the study was inconclusive as regards the question of adjuvant chemotherapy. The survival curves were superimposable, but with wide confidence intervals. DNA-ploidy adds objective independent prognostic information regarding both DFS and DSS in early ovarian cancer.

Prospectively detected cancer in familial breast/ovarian cancer screening

BACKGROUND

Early diagnosis and treatment are shown to improve survival of breast and ovarian cancer. Identification and medical follow-up of high-risk groups may be important for early diagnosis.

METHODS

A prospective study of 845 women from breast/ovarian- and ovarian cancer kindreds who were classified according to pre-set inclusion criteria (Table I), were offered genetic counseling and annual medical examinations of breasts and ovaries. The material consisted of three series: 1) 754 unaffected women, 2) 49 women with breast cancer, and 3) 42 women with ovarian cancer.

RESULTS

In series 1) nine ovarian cancers and 20 breast cancers, in series 2) seven ovarian cancers, and in series 3) three breast cancers were found. All but one of the ovarian cancers were 40 years or older, and 4/16 (25%) were Borderline cancer. All breast cancers were 30 years or older, and 89% were detected before spread.

CONCLUSIONS

This is to our knowledge the first prospective report of the combined breast/ovarian cancer findings in breast/ovarian cancer kindreds. A woman with both breast and ovarian cancer is the hallmark of inherited breast/ovarian cancer, and 50% of the ovarian cancers were detected in these families. Borderline ovarian cancer may represent a manifestation of this syndrome. If prophylactic oophorectomy prevents ovarian cancer, oophorectomy at age 45 would have prevented 75% of such cancers. Based on these results we revised our protocol for annual follow-up in these kindreds: 1) clinical breast examination and mammography (ultrasound/cytology if indicated) from 30 years of age, 2) gynecologic examination (including vaginal ultrasound, serum-CA125) from 35 years of age, and 3) discuss oophorectomy at 45 years of age.

Long-term follow-up of neoadjuvant cisplatin and 5-fluorouracil chemotherapy in bulky squamous cell carcinoma of the cervix

Fifteen patients with bulky (designated as > 3 cm largest diameter) FIGO stage Ib or IIa squamous cervical cancer were treated with cisplatin (100 mg/m2 on day 1) and 5-fluorouracil (1000 mg/m2 continuously on days 1-5) administered intravenously at 21-day intervals for a total of two or three courses before planned radical hysterectomy. A complete clinical response was noted in four patients and a partial response in ten patients, which represents a 93% overall response rate. One patient had stable disease (two courses of chemotherapy), and none had progressive disease. Median tumor volume was 78.5 cm3 and 2.5 cm3 at diagnosis and after neoadjuvant chemotherapy, respectively (p < 0.001). This indicates that chemotherapy resulted in a 97% median reduction of tumor volume. Median overall and disease-free survival was not reached, and the actuarial five-year survival rate was 73% and 67%, respectively. There was no grade 4 toxicity. Myelosuppression was acceptable; however, two patients experienced significant ototoxicity, and in two patients serum creatinine increased. All patients with major toxicity received two cycles of chemotherapy only. The improved local control and survival in our series are in accordance with other results reported, but need to be confirmed in a randomized prospective trial.

Three per cent of Norwegian ovarian cancers are caused by BRCA1 1675delA or 1135insA

Our aim was to determine the prevalence of two Norwegian BRCA1 founder mutations in ovarian cancer patients, to identify carriers and their families for medical follow-up, and to study histopathological factors. Of a cohort of 727 ovarian cancer patients, 615 gave informed consent to testing. 2.9% (18/615) of the tested patients were found to be carriers of BRCA1 1675delA (n = 13) or 1135insA (n = 5). The total frequency of the mutations was 4.7% (8/171) in patients below 50 years of age, and zero (0/144) in patients above 70 years of age. In patients below 70 years of age, the frequency of 1675delA and 1135insA mutations was 2.8% and 1.0%, respectively. Out of 13 patients with 1675delA mutation, 4 had breast cancer. 14/16 (87.5%) families fulfilled clinical criteria for familial breast-ovarian cancer. Median age of onset of ovarian and breast cancer was 51 years and 37 years, respectively. Mutation carriers tended to have tumours with unfavourable prognostic factors. This is, to our knowledge, the highest reported frequency of founder mutations in a national ovarian cancer cohort (less than in the Ashkenazis). It seems justified to offer such testing to ovarian cancer patients below 70 years of age in Norway, identify their risk of breast cancer and offer medical follow-up to the families.

Intraperitoneal treatment and dose-intense therapy in ovarian cancer

BACKGROUND

There has been a longstanding controversy regarding the role of high-dose chemotherapy in patients with advanced ovarian cancer. Based on retrospective studies, it has been suggested that there will be improved results when doses of platinum compounds in particular are increased. High-dose therapy can be administered using an intraperitoneal route of drug delivery or with haematologic support in the form of autologous bone marrow transplantation (ABMT) or peripheral blood stem cell transfusions (PBSCT).

METHODS

Experienced clinical investigators reviewed published data available on high-dose chemotherapy and intraperitoneal drug delivery. In addition, ongoing clinical trials of ABMT or PBSCT were also reviewed.

RESULTS

Prospective randomised trials have failed to demonstrate that doubling the dose of platinum compounds increases survival in patients with advanced ovarian cancer. Intraperitoneal chemotherapy with cisplatin or paclitaxel remains an area of investigation and prospective randomised trials in previously untreated patients as well as part of consolidation therapy in patients achieving a complete remission are in progress. Phase II trials of high-dose chemotherapy with ABMT or PBSCT in previously treated patients with advanced ovarian cancer have produced higher response rates than achieved with conventional doses although there has been no proven impact upon survival. Prospective randomised trials in previously untreated patients are in progress. Until the completion of these trials, high-dose chemotherapy with ABMT or PBSCT and intraperitoneal chemotherapy should be considered investigational.

Surgery during chemotherapy and at relapse of ovarian cancer

During chemotherapy and after relapse several types of operations are used in ovarian cancer: secondary cytoreductive surgery, interval cytoreductive surgery, second-look surgery, and palliative secondary surgery. The role of these operations has been difficult to define because there is considerable variation in the patterns of behaviour of tumours among those with persistent or recurrent disease. The definitions, indications and impact of these procedures are reviewed.

Intergroup collaboration in ovarian cancer: a giant step forward

The rather slow evolution of so-called "optimal chemotherapy" for ovarian cancer is the result of suboptimal randomised clinical trials, not having the statistical power to identify truly superior regimens, and of the lack of systematic comparisons of new agents with relevant control arms. There is little doubt that we need international collaboration to move the field forward in a timely and coherent manner. European and transatlantic collaboration represents the beginning of the process and point to the success that can await us if the drive to work together remains strong. A similar organisation as for breast cancer (Breast International Group, BIG) needs to be established for ovarian cancer.

TP53 alterations in relation to the cell cycle-associated proteins p21, cyclin D1, CDK4, RB, MDM2, and EGFR in cancers of the uterine corpus

In the present study, TP53 alterations have been analysed and compared with the expression of the proteins p21, cyclin D1, cdk4, RB, EGFR, and MDM2 in 53 cancers of the uterine corpus. TP53 gene mutations analysed by CDGE/DGGE and direct sequencing showed a TP53 gene mutation in 18 per cent of the cases. TP53 gene mutations were not significantly related to overexpression or down-regulation of any of the proteins. Immunohistochemically, there was an increased protein level of TP53 in 77 per cent, p21 in 36 per cent, cyclin D1 in 45 per cent, cdk4 in 77 per cent, EGFR in 8 per cent, and MDM2 in 32 per cent of the cases. Expression of RB protein was normal in all cancers. Significant association of protein expression was seen between TP53 and MDM2 (p=0.005) and p21 and MDM2 (p=0.001). Furthermore, there may be an association between TP53 and p21 (p=0. 038) and cyclin D1 and cdk4 (p=0.045). The results revealed increased levels of TP53 protein in all MDM2-positive cases that did not show TP53 mutations, indicating TP53 protein stabilization and inactivation by complex formation with MDM2. In summary, the high number of cases showing an increased level of TP53 and cdk4 proteins suggests that these proteins play an important role in the neoplastic process in cancers of the uterine corpus.

p53 protein expression in squamous cell carcinoma of the vulva

BACKGROUND

The objective of the study was to evaluate the pathogenetic and prognostic value of p53 protein expression in squamous cell carcinoma of the vulva.

METHODS

The clinical data in charts of 167 patients with International Federation of Gynecology and Obstetrics (FIGO) Stages I-III primary tumors who were treated by surgery were reviewed. Samples from the primary tumor were immunostained for p53 protein. p53 overexpression was defined as immunoreactivity in > 5% of nuclei.

RESULTS

p53 overexpression was observed in 92 tumors (55%). p53 overexpression did not correlate with age at diagnosis, FIGO stage, histologic grade, vessel invasion, tumor thickness, tumor greatest dimension, DNA ploidy, or inguinal lymph node metastasis. In the whole group a significantly reduced 5-year corrected survival was observed in patients with p53 overexpression compared with p53 negative patients (P = 0.04). In the different FIGO stages, disease-related survival was not influenced by p53 overexpression in 37 patients with Stage I disease (P = 0.60) or in 86 patients with Stage II disease (P = 0.96). In 44 patients with Stage III disease, p53 overexpression was significantly associated with poorer prognosis (P = 0.004). Independent prognostic factors for corrected survival in the entire group of 167 patients were: vascular invasion, groin metastasis, tumor greatest dimension, and p53 overexpression. In patients with FIGO Stage III disease p53 overexpression was not an independent prognostic factor.

CONCLUSIONS

p53 protein overexpression appears to be involved in the pathogenesis of vulvar squamous cell carcinoma. p53 protein overexpression was significantly associated with disease-related survival. p53 prognostic impact was observed only in patients with advanced disease.

Carboplatin/5-fluorouracil treatment of recurrent cervical carcinoma: a phase II study with long-term follow-up

OBJECTIVE

To evaluate the response rate, progression-free (PFS) and overall survival in patients with recurrent carcinoma of the cervix (RCC) treated with carboplatin (CBDCA; cis-diamine-1, 1-cyclobutane dicarboxylate platinum II) 300 mg/m2 or according to Calverts formula, CBDCA dose [(GFR + 25) x AUC = 51 mg intravenous (iv) day 1 and 5-FU (5-fluorouracil) 1000 mg/m2 iv day 1 to 5, every 4 weeks.

METHODS

From June 1989 to October 1992, 25 patients were enrolled in this phase II study. All patients were evaluated for toxicity, response and survival data.

RESULTS

No patients obtained objective response. Eleven patients had stable disease. The median progression-free survival for these patients was 9 months (range 2 to 38), and the median survival was 17 months (range 3 - 50). For all patients the median overall survival was 11 months (range 2 - 50). Four patients survived for more than 1 year. Two of these patients survived for more than 4 years. The toxicity was tolerable with bone marrow suppression as the major problem.

CONCLUSION

Eleven patients (44%) with RCC obtained stable disease and four patients (16%) survived for more than one year. These poor results make this combination regimen insufficient and it should not be used in treating RCC.

Long-term results from a phase II study of single agent paclitaxel (Taxol) in previously platinum treated patients with advanced ovarian cancer: the Nordic experience

BACKGROUND

Owing to the wide spread perception of a possible benefit from paclitaxel in the second-line situation the Nordic Gynecologic Oncology Group (NGOG) conducted two prospective phase II studies of paclitaxel single agent treatment (175 mg/m2, three-hour i.v. infusion with standard pre-medication every third week) in patients with relapsing or progressing epithelial ovarian cancer following platinum.

PATIENTS AND METHODS

Between 1992-1994 138 patients in total were enrolled of whom 136 received paclitaxel and were included in the toxicity and survival analysis, while 112 were evaluable for response.

RESULTS

The overall response rate (CR + PR) was 28% with 16 patients achieving a CR (14%). The estimated median (range) time to progression was 4.1 (0.7-60.7) months. The projected four-year overall survival was 7%, with a median (range) of 9.6 (0.3-60.7) months. A multivariate logistic regression analysis showed that platinum resistance, and WHO performance status at baseline, independently correlated with survival at all three time points (median survival time 9.6, 18, and 24 months). Patients with platinum sensitive tumors and WHO performance status 0 had a median survival of 25.6 months compared to 7.0 months for the rest of the patients (P < or = 0.0001). No serious toxicity was registered.

CONCLUSION

Paclitaxel could safely be administered in an outpatient setting using this schedule. Patients with platinum sensitive tumors and a good performance status were most likely to survive. However, these patients are also most likely to respond to re-treatment with a platinum compound. With reference to the reasonably good tumor control and limited toxicity observed in this study, we conclude that paclitaxel single agent therapy is a viable option in the salvage situation, which in some patients can give long-lasting responses. However, although responses can be induced in a significant number of patients, the survival figures remain poor.

Therapy effect of either paclitaxel or cyclophosphamide combination treatment in patients with epithelial ovarian cancer and relation to TP53 gene status

Cell death after treatment with chemotherapy is exerted by activation of apoptosis, and the p53 protein has been shown to actively participate in this process. This recent focus on TP53 status as a possible determinant of cancer therapy response has raised the question of whether or not mutations in the TP53 gene have an influence on paclitaxel therapy. The TP53 status has been analysed at the DNA level in tumours from 45 ovarian cancer patients randomized to treatment with paclitaxel and cisplatin or cyclophosphamide and cisplatin. Therapy response was obtained for 38 patients with clinically evaluable disease after initial surgery. The positive response rate to the paclitaxel/cisplatin therapy was 85% vs 61% for the patients who received the cyclophosphamide/cisplatin regimen. A significant difference in relapse-free survival in favour of paclitaxel/cisplatin chemotherapy was found (P = 0.001). A total of 33 tumour samples (73%) had detectable sequence alterations in the TP53 gene. When relapse-free survival was estimated for all patients with TP53 alterations in their tumours, a significant better outcome for the paclitaxel/cisplatin group was found compared with the patient group receiving cyclophosphamide and cisplatin therapy (P = 0.002). We did not observe an association between TP53 tumour status and prognosis for patients who received paclitaxel/cisplatin combination treatment, indicating that the effect of this therapy is not influenced by this parameter.