Phase II trial of single-agent cetuximab in patients with persistent or recurrent epithelial ovarian or primary peritoneal carcinoma with the potential for dose escalation to rash

5577

Background: Data in other tumor types showed a correlation between severity of acneiform rash and cetuximab (Cet) response. This study evaluated if Cet dose escalation to cause Grade 2 rash correlated with anti-tumor activity and if sera-based markers could predict likelihood of response. Methods: A 2-stage design was used with 50 patients (pts) planned. Eligibility: persistent/recurrent ovarian or primary peritoneal carcinoma; up to 2 prior regimens, including 1 platinum/taxane-based regimen; ECOG PS = 2; measurable EGFR-positive tumors. Pts received an initial dose of Cet 400 mg/m2, then 250 mg/m2 weekly for two 3-week cycles. Pts who had SD and < Grade 2 rash were dose escalated in 75 mg/m2 increments every 3 weeks until Grade 2 rash or maximum 400 mg/m2. Blood, pre- and/or post-treatment, was obtained from 13 of 25 pts with measurable response and the sera evaluated for potential predictive markers of response. Results: The study was stopped due to inadequate number of responders among the first 25 pts. Median age: 58 years (range: 31–79); median number of cycles: 2 (range: 1–11). At first assessment, 4 pts remained at 250 mg/m2; 8 pts were dose-escalated to 325 mg/m2; of these, 4 were increased to 400 mg/m2. One pt achieved PR; 9 pts had best response of SD. Median PFS: 2.1 months; 4-month PFS rate: 25%; 1-year survival rate: 54.8%. Rash (96%) was the most common drug-related adverse event (2 pts with Grade 3); 1 pt had Cet-induced Grade 4 hypersensitivity. Serologic markers including cytokines, chemokines, and growth and angiogenic factors were analyzed in sera from 9 pts exhibiting PD and 4 pts with SD. In pre-treatment samples, the average values of 9 of these markers were significantly reduced in pts exhibiting SD vs PD (P=0.052 to 0.00018, t-test). Changes in marker levels after Cet treatment were not significant indicators of SD. Conclusions: Single-agent Cet showed minimal activity in these previously treated pts. However, the low number of dose-escalated pts limits complete evaluation of the hypothesis regarding response and dose escalation to rash. We did identify that pts with reduced levels of 9 serologic markers at baseline were more likely to have disease control on Cet treatment.

No significant financial relationships to disclose.

A prospective multi-center ovarian cancer screening study in women at increased risk

5510

Background: No proven ovarian cancer (OC) screening strategy exists for women who are at increased risk for the disease. A risk of ovarian cancer algorithm (ROCA) using serial CA125 values has previously shown greater positive predictive value (PPV) and sensitivity than a single CA125 in screening women at general population risk. We hypothesized that using ROCA would yield a reasonable PPV for ovarian cancer screening in a cohort at increased risk. Methods: Between 7/2001 and 9/2006, 25 sites (14 Cancer Genetics Network, 3 ovarian SPOREs, 1 EDRN, 7 others) prospectively enrolled patients. Inclusion criteria included: among self, 1° or 2° relatives in same lineage either (i) BRCA1/2 mutation, or (ii) two of OC or early onset (age = 50) breast cancer (BC), or (iii) Ashkenazi ethnicity and 1 of OC or BC. A previous diagnosis of OC excluded subjects. Subjects underwent CA125 every 3 months and the risk of having ovarian cancer based on the CA125 profile was recalculated after each test. ROCA referred subjects with risk > 1% to ultrasound (US), and risk > 10% additionally to a gynecologic oncologist. Objectives included PPV for study indicated surgery, sensitivity, and compliance. Sample size was chosen to observe 8 OC endpoints with a power of 80% to rule out PPV = 10% if the true PPV = 20%. Results: 2,343 high risk women enrolled, with 6,284 women years of screening and 19,549 CA125s obtained. There were 628 (10%/yr) referrals to US with 414 US performed. 38 women underwent study indicated surgeries. 9 OCs were identified during screening, 3 were prevalent (1 early, 2 late stage), and 6 were incident (5/6 = 83% early, 1 late). 3 of the 6 incident cases were found on prophylatic oophorectomy in early stage. ROCA detected 2 in early stage of remaining 3 incident cases, and 3 of 3 prevalent cases. The PPV was 5/38 = 13% (95% CI 4.4%, 28%) and sensitivity was 5/6 = 83%, CI (36%, 99%). There was high compliance with CA125 testing throughout study, with 84%, 85%, 85%, 82% subjects returning within 1 month of schedule for first 4 tests. Conclusions: Frequent CA125 testing using ROCA results in an acceptable PPV and high compliance in a cohort of women at increased risk for OC. A definitive screening study (= 30 incident cases) using ROCA with serial CA125 and possibly additional markers is required to define sensitivity for early stage OC.

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Rectal prolapse in women with other defects of pelvic floor support

OBJECTIVES

We describe a series of patients with rectal prolapse who had other pelvic floor defects.

STUDY DESIGN

Patients with rectal prolapse that we examined between 1990 and 2000 were reviewed.

RESULTS

During this time frame 55 patients with rectal prolapse were seen by one of us. Fifty-two of these patients had other defects of pelvic floor support and are the subject of this report. The diagnosis was established in all patients with video defecography. Thirty-nine of the patients had internal (occult) prolapse that simulated either a rectocele or an enterocele. The mean number of surgical procedures for pelvic floor support before the diagnosis of rectal prolapse was 1.5. Thirty-one patients underwent a sigmoid resection with rectopexy, 12 underwent a rectopexy alone, 3 underwent a Ripstein procedure, 2 elderly patients had physical therapy alone, and the other 4 patients had surgical correction of the rectal prolapse before being referred for repair of vaginal vault prolapse. Other procedures performed simultaneously included sacral colpopexy, sacrospinous suspension, rectopubic urethropexy, and abdominal fixation of the vagina to the uterosacral ligaments.

CONCLUSIONS

Rectal prolapse frequently coexists with other pelvic floor defects. Internal rectal prolapse may simulate a rectocele or enterocele and requires defecography to establish the diagnosis. Rectopexy (with or without sigmoid resection) is a satisfactory technique for correction and may be combined with other reconstructive procedures on the pelvic floor.

A phase I trial of a 3-day topotecan Q 21 days for recurrent epithelial cancers of the ovary, fallopian tube, and peritoneum

OBJECTIVE

This trial was undertaken to determine the dose limiting toxicity (DLT) and maximum tolerated dose (MTD) of topotecan that can be administered for 3 days q 21 days. A 3-day schedule is more convenient and less expensive than standard 5-day dosing.

METHODS

Patients with recurrent epithelial ovary, tubal, or peritoneal carcinoma were treated with escalating doses of topotecan beginning at 2.50 mg/m(2) as an outpatient days 1-3 q 21 days. Colony stimulating factors were not employed prophylactically, but could be added for grade 4 marrow toxicity.

RESULTS

Twenty patients with a median age of 61 (range 46-80) and performance status of 0 or 1 were entered. All patients had received at least one prior paclitaxel/platinum regimen; 6 had received two. Ninety-one cycles were delivered (median = 6) and 98.9% were on schedule. Grade 4 neutropenia was seen in 17 of 20 patients (85%) in cycle 1 and in 38 of 91 (41.8%) total cycles. Sixteen of 20 patients (80%) started G-CSF on cycle 2. Two of 91 (2.2%) cycles had grade 4 thrombocytopenia. Four cycles (4.4%) were associated with febrile neutropenia. Two patients experienced grade 4 neurotoxicity (DLT) at 4.25 mg/m(2). Other nonhematologic toxicity was mild.

CONCLUSIONS

Topotecan can be safely administered on schedule as an outpatient days 1-3 q 21 days. Neurotoxicity was the DLT when G-CSF was added; the MTD was 3.75 mg/m(2). There was minimal other nonhematologic toxicity. Neutropenia was predictable and easily managed with G-CSF. Febrile neutropenia was uncommon and thrombocytopenia was rare at the doses evaluated.

Adenocarcinoma of the uterine cervix metastatic to lymph nodes

OBJECTIVE

We set out to evaluate the prognostic factors in cervical adenocarcinoma metastatic to lymph nodes.

STUDY DESIGN

We performed a retrospective review of 40 patients with cervical adenocarcinoma and lymph node metastasis from 1976 to 1996.

RESULTS

Thirty-four patients had adenocarcinoma, and six had adenosquamous carcinoma. Median survival was 50 months. The median survival for patients with stage I disease was 69 months. Stage at diagnosis, treatment with radical hysterectomy, and receiving adjuvant therapy were associated with prolonged survival. A trend toward improved survival was noted with the use of concurrent radiation and chemotherapy as an adjuvant therapy.

CONCLUSIONS

Adenocarcinoma metastatic to the lymph nodes does not have a uniformly poor prognosis, especially with early-stage disease. Improved survival was observed with the use of adjuvant therapy, specifically the use of combined chemotherapy and radiation after radical hysterectomy. The optimal therapy in this setting is yet to be determined.

Metastatic placental site trophoblastic tumor: long-term remission in a patient treated with EMA/CO chemotherapy

OBJECTIVE

We document a case of long-term remission in a patient with metastatic placental site trophoblastic tumor (PSTT) and attempt to determine the response rate of metastatic PSTT to EMA/CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine) combination chemotherapy based on available reports.

METHODS

Medical records, histological slides, and radiological films were reviewed for a patient with metastatic PSTT diagnosed in 1991. Using Medline and cross-references, pertinent articles were reviewed.

RESULTS

A 31-year-old patient with PSTT metastatic to the lungs and vagina is presently alive, without evidence of recurrent cancer, more than 6 years after treatment with EMA/CO chemotherapy and surgery. The total response rate for seven patients with metastatic PSTT treated with EMA/CO chemotherapy was 71% with a complete response rate of 28%.

CONCLUSIONS

Metastatic PSTT is potentially curable. EMA/CO chemotherapy appears superior to older multiagent regimens used in treating PSTT.

Cisplatin, doxorubicin hydrochloride, and cyclophosphamide followed by radiotherapy in high-risk endometrial carcinoma

OBJECTIVE

Our purpose was to assess the effect of adjuvant platinum-based, multiagent chemotherapy followed by conventional radiotherapy on the recurrence-free interval, patterns of recurrence, and survival of women with completely resected, poor-prognosis endometrial carcinoma.

STUDY DESIGN

Surgical stage IC and II endometrial carcinomas involving the outer one third of myometrium and completely resected stage III and IV carcinomas were eligible for six cycles of cisplatin (Platinol), doxorubicin hydrochloride (Adriamycin), and cyclophosphamide (Cytoxan) (50, 50, 500 mg/m2), followed by external beam radiotherapy to pelvis, pelvis and periaortic chain, or whole abdomen, on the basis of documented disease.

RESULTS

Forty-seven women were registered between April 1, 1984, and Oct. 10, 1992; 39 were eligible for review. Six were stage I, 28 were stage III, and five were stage IV. Two tumors were grade I, eight were grade 2, and 29 were grade 3. Twenty-three were endometrioid adenocarcinomas, eight papillary serous, six adenosquamous, and two clear cell. Thirty-seven patients (94.9%) completed six courses of chemotherapy, with no deaths ascribed to treatment. Grade 3 or 4 neutropenia was experienced by 17 (44%) and sepsis by three (8%). Current median follow-up is 27.3 months. Fifteen patients (38.5%) have recurrence, and 14 have died after a median interval of 26.9 months. The 2-year progression-free interval is 72.5% for nonpapillary serous histologic types and 22.5% for papillary serous cancers (p = 0.0074).

CONCLUSION

Adjuvant chemotherapy with Platinol, Adriamycin, and Cytoxan followed by radiation therapy is well tolerated and seems to confer a survival advantage to women with nonpapillary serous endometrial carcinoma with a poor prognosis compared with historic controls treated by surgery or radiotherapy.

Prognostic significance of DNA content and nuclear morphology in borderline ovarian tumors

We used the technique of image analysis to simultaneously measure DNA content and nuclear morphology of 21 borderline ovarian tumors. Aneuploidy was identified in 9 of 21 tumors and was unrelated to tumor stage or nuclear grade. Morphometric nuclear features that were measured included size, shape, texture, and average density. Nuclear size and shape were positively correlated (r = 0.507), and nuclear size and average density were negatively correlated (r = -0.772). Six tumors recurred and recurrence was significantly associated with tumor aneuploidy (P = 0.046), stage III tumors (P = 0.03), and increased nuclear texture (P = 0.07). These results suggest that measurement of DNA ploidy and nuclear morphology using image analysis can provide important prognostic information in patients with borderline ovarian tumors.

Malignant placental site trophoblastic tumor associated with placental abruption, fetal distress, and elevated CA-125

The second pregnancy of 27-year-old woman, gravida 2, para 2 was complicated by a low alpha-fetoprotein and symptoms of chronic placental abruption. She delivered by cesarean section at 35 weeks for fetal distress at which time a biopsy of the uterus revealed a placental site trophoblastic tumor (PSTT). She rapidly developed intraabdominal spread of the neoplasm which did not respond to chemotherapy and she died 10 weeks later. Her CA-125 was elevated to 5360 mu/ml and this decreased after hysterectomy. This patient is reported to highlight a very malignant course of PSTT that was associated with a live-born male infant.

Continuous infusion of low-dose 5-fluorouracil and radiation therapy for poor-prognosis squamous cell carcinoma of the uterine cervix

Ten patients with squamous cell carcinoma of the cervix metastatic to periaortic lymph nodes were treated with external-beam radiation therapy and synchronous infusion of intravenous 5-fluorouracil (5-FU) chemotherapy at doses of 350 mg/m2/day. The overall response rate was 90% with four complete responses (CR) and five partial responses (PR). The median duration of response was 11.8 months for CRs and 3.6 months for PRs. Toxicity was tolerable, with gastrointestinal symptoms and myelosuppression being noted most frequently. No patient experienced life-threatening toxicity. Median survival was 7.6 months, with only one patient being alive and free of disease at 2 years. In this pilot study we were unable to demonstrate a beneficial effect of continuous infusion of low doses of 5-FU chemotherapy concurrent with radiation therapy when compared to conventional radiotherapy in patients with advanced squamous cell carcinoma of the cervix.

Comparison of the pattern of metastatic spread of squamous cell cancer and adenocarcinoma of the uterine cervix

Retrospective review of medical records and autopsy findings in patients dying of squamous cell cancer or adenocarcinoma of the uterine cervix was undertaken to evaluate for possible differences in biologic behavior between these tumor types. Twenty-one patients with each tumor type were evaluated. Patients with adenocarcinoma were found to have a higher incidence of tumor involvement of the paraaortic lymph nodes (13/21 vs 6/20, P less than 0.05), uterine corpus (17/17 vs 12/20, P less than 0.05), and adrenal gland (7/21 vs 0/21, P less than 0.005). Presence of ascites (9/21 vs 2/21, P less than 0.05) and hydrothorax (9/21 vs 3/21, P less than 0.05) was also significantly more frequent in patients with adenocarcinoma. These findings suggest that this tumor may behave differently in regard to pattern of metastatic spread or response to therapy. The therapeutic implications of these findings deserve further study.

Claudication as a rare symptom of recurrent cervical carcinoma

Diagnosis of recurrent cervical cancer can be very difficult in the heavily irradiated pelvis. Sciatica and lymphedema are well-known symptoms of disease recurrent to the side wall. The isolated symptom of claudication is reported as an early sign of recurrence. Two patients are presented in whom claudication was the only early presenting symptom. This symptom in a patient with a history of a gynecologic malignancy should lead to an evaluation for recurrent cancer as well as the routine vascular studies.

Contribution of endocervical curettage in evaluating abnormal cervical cytology

A review of 540 patients evaluated by the Gynecologic Colposcopy Clinic for abnormal cervical cytology revealed that 372 (68.9%) had cervical intraepithelial neoplasia (CIN), microinvasive carcinoma, or frank invasive carcinoma. The repeat cytologic smear taken before biopsy was falsely negative in 26.4%. An endocervical curettage was obtained in 52.5% of patients with an adequate colposcopy who had a neo-plastic lesion and was positive in 17.9% of those sampled, including six patients with no lesion found on the ectocervix. An endocervical curettage was obtained in 88.5% of patients with an inadequate colposcopy who had a neoplastic lesion, and was positive in 48.7%. All patients with an inadequate colposcopy not having an endocervical curettage underwent conization of the cervix. Twelve patients (2.2%) were ultimately found to have invasive or microinvasive carcinoma. A positive endocervical curettage and an inadequate colposcopy were both correlated with a final diagnosis of invasion. The contribution of endocervical curettage to the outpatient work-up of abnormal cervical cytology is substantial and it should be performed in all patients in whom cone biopsy is not planned.