Intraperitoneal cisplatin chemotherapy in ovarian carcinoma patients who are clinically in complete remission

Intraperitoneal chemotherapy for ovarian cancer

PURPOSE OF REVIEW

Intraperitoneal chemotherapy for ovarian cancer is based on sound pharmacological principles and is technically feasible. There is mounting evidence, bolstered by a recent randomized trial, that in certain patients, this route of delivery may be superior to traditional intravenous chemotherapy. This review explores the background and pharmacokinetic principles of intraperitoneal chemotherapy, the recent evidence supporting an intraperitoneal approach, and some of the logistical and technical challenges involved.

RECENT FINDINGS

Intraperitoneal chemotherapy has been evaluated in several settings. Most phase I and II data came from second-line treatment of ovarian cancer, and there have been a few series, including one recent phase III trial, exploring intraperitoneal consolidation. The greatest impact among recent studies will be from a large, intergroup phase III trial evaluating intraperitoneal therapy in the front-line setting. This study will probably change the dialogue of standard treatment for optimally cytoreduced, advanced epithelial ovarian cancer.

SUMMARY

Based on recent findings, intraperitoneal chemotherapy should be considered for the front-line treatment of women with minimal residual advanced ovarian cancer. Efforts should continue to facilitate the integration of intraperitoneal treatment into mainstream practice, and future trials should be designed to address lingering controversy surrounding this route of treatment.

[Follow-up of 70 patients with advanced ovarian cancer after negative second-look laparotomy]

OBJECTIVES

To analyze the results of treatment of 70 patients with stage III and IV ovarian cancer after second look laparotomy with negative findings and to identify causes of failure and prognostic factors.

MATERIALS AND METHODS

Between 1985 and 1998, seventy patients with ovarian cancer stage III and IV were treated with surgery and at least six courses of chemotherapy with cisplatin doxarubicin and cyclophosphamide. Then a second look laparotomy was performed.

RESULTS

The actuarial survival rate without evidence of disease was 50% at 5 years. Locoregional failure was observed in 31 patients (88%) and distant metastases in 9, but they were the sole reason for unsuccessful treatment in only 4 (12%). Adverse prognostic factors were: grade 3 differentiation, primary stage IIIC and IV, and residual infiltration exceeding 2 cm after first laparotomy.

CONCLUSION

Our results are comparable with reports in the literature. The actuarial survival rate without evidence of disease at 5 years in patients with advanced ovarian cancer after second look negative laparotomy is 50%.

Consolidation and maintenance treatments for patients with advanced epithelial ovarian cancer in complete response after first-line chemotherapy: A review of the literature

Most patients with advanced epithelial ovarian cancer experience objective responses to paclitaxel/platinum-based chemotherapy, but responses are generally short-lived and the clinical outcome is still unsatisfactory. Therefore, the strategy to consolidate and to prolong the duration of response is very attractive. Different consolidation or maintenance treatments have been attempted, such as whole abdomen radiotherapy, intraperitoneal chromic phosphate, radioimmunotherapy, intraperitoneal chemotherapy, high-dose chemotherapy with haematopoietic support, prolonged administration of the first-line regimen, second-line single-agent chemotherapy, and biological agents. Clinical studies have given conflicting, inconclusive, and generally disappointing results. A recent US randomised trial appeared to show that the prolonged administration of single-agent paclitaxel (175 mg/m2 every 3 weeks) significantly improved the progression-free survival of complete responders to paclitaxel/platinum-based chemotherapy. Alternative less toxic, and probably more effective schedules of administration of chemotherapy (i.e. weekly paclitaxel) might assure a better balance between quality of life and anti-tumor activity in patients previously exposed to chemotherapy.

Intraperitoneal chemotherapy in ovarian cancer: who and when?

PURPOSE OF REVIEW

Intraperitoneal chemotherapy in ovarian cancer has been studied for several years and developed in many countries. However, despite positive results from well-conducted clinical trials, its clinical application is still controversial. A review of recent advances is presented.

RECENT FINDINGS

Intraperitoneal chemotherapy has been studied in two situations: in the first line, combined with intravenous chemotherapy, or as a consolidation treatment, after surgery and systemic chemotherapy. In the first line, two randomized studies showed an increased survival in patients with intraperitoneal chemotherapy. In patients with pathological complete remission, the theoretical principle remains valid, treating minimal disease, but definitive results from randomized studies are lacking.

SUMMARY

Intraperitoneal chemotherapy is a regional treatment for ovarian cancer. Its development is limited by the reluctance of the medical oncologist community to include this technique in the whole strategy of treatment, despite positive results. However, intraperitoneal chemotherapy should be considered in patients optimally debulked and with minimal residual disease.

Timing isn't everything: an analysis of when to start salvage chemotherapy in ovarian cancer

OBJECTIVE

Results from GOG 178 showed a prolongation of progression-free survival (PFS) with the immediate use of chemotherapy (CT) following a complete clinical response (CR) in patients with stage III-IV ovarian cancer. We wanted to evaluate our strategy of reserving second line (2nd line) chemotherapy to the time of clinical recurrence by determining PFS intervals following first, second, and third line agents and to compare these finding to results of GOG 178.

METHODS

We conducted a retrospective parallel study to GOG 178 using identical criteria for PFS definitions. Patients (pts) with stage III-IV cancer achieving a CR following surgery and five to eight cycles of platinum-based CT were identified. Patients not obtaining a CR and those with a CR who underwent second look surgery were excluded. Rather than immediately beginning consolidation CT after CR, second line agents were started at recurrence and were followed by a third line when pts progressed. Clinical-pathologic characteristics were abstracted, and time intervals including time to recurrence, time to use of second line CT, time to use of third line (3rd line) CT, and survival were recorded. Time intervals were studied by Kaplan-Meier method.

RESULTS

Of 217 reviewed pts (1991-2001), 59 eligible pts were identified. Forty-nine patients had stage III disease and ten had stage IV. At completion of surgery, 44 were optimally debulked. With a median follow-up of 51 months, the median PFS (from CR) of all patients was 20 months. At 5 years, 36% of pts remain disease-free, and 66% of pts are alive. Twenty-three pts have not received second line agents, and thirty-six have received them. For all pts, the median time from CR to start of second line chemotherapy was 21 months, and the median time to start of third line agents was 43 months. Recurrences occurred after 6 months from completion of first line (1st line) therapy in 87% of cases and after 12 months in 50%.

CONCLUSIONS

Nearly 70% of pts achieving a CR after primary therapy eventually recurred. Most recurrences occurred greater than 6 months from completion of primary chemotherapy, and the use of second line agents at the time of recurrence was effective. In this study, the median time from CR to start of third line agent at 43 months compares favorably with the median PFS of 28 months following 12 months of Taxol reported in GOG 178 and challenges the concept of consolidation chemotherapy in ovarian cancer. A randomized trial to evaluate when to institute second line agents should be performed.

Long-term survival with consolidation intraperitoneal chemotherapy for patients with advanced ovarian cancer with pathological complete remission

OBJECTIVES

The goal of this study was to evaluate the long-term outcome after consolidation intraperitoneal (IP) chemotherapy in patients with a negative second-look laparotomy (SLL) following first-line intravenous chemotherapy for advanced ovarian cancer.

METHODS

This study included patients with FIGO stage III-IV ovarian cancer who entered into four prospective trials (1984-1995) including intravenous chemotherapy based on cisplatin (six cycles) and anthracycline, early debulking surgery after three cycles of chemotherapy in the case of initial residual disease >2 cm, SLL, and IP consolidation chemotherapy. Among 218 patients, 68 with biopsy-negative SLL received every 4 weeks three consolidation cycles of IP chemotherapy (mitoxantrone, cisplatin, etoposide) via a totally implantable port. Long-term outcome of these patients is reported.

RESULTS

Mean age was 56 years (33-72 years). Overall, 51% of the patients had at least a grade 3 or 4 toxic effect. Main toxic effects were leukopenia, abdominal pain related to the catheter, and nausea and vomiting. Only 13 patients (19%) did not receive the full three cycles. The median progression-free survival (PFS) for the whole population is 34 months, 34% of the patients being estimated to be free of disease at 5 years. The median overall survival is 73 months, and the 5-year survival is 58%.

CONCLUSIONS

In this selected population treated with IP consolidation chemotherapy, prolonged survival was observed. However, the occurrence of late relapses in this most favorable patient category underlines the need to improve the consolidation therapy options in ovarian cancer.

Intraperitoneal therapy as consolidation for patients with ovarian cancer and negative reassessment after platinum-based chemotherapy

Although three large phase III trials have documented the benefit of IP chemotherapy, this therapy as consolidation has been studied in only a few pilot studies. These small studies have included patients with a variety of baseline prognostic characteristics, and only one series had a comparator group of surgically documented pathologic complete response to uniform systemic chemotherapy. No randomized trials have been done to assess the impact of IP consolidation on progression-free survival or survival in either positively or negatively reassessed patients. It is hoped that the current experience will trigger further consideration of future phase III trials to assess the value of IP consolidation after initial induction with chemotherapy (ie, chemical debulking).

Phase I and pharmacologic study of i.v. hydroxyurea infusion given with i.p. 5-fluoro-2'-deoxyuridine and leucovorin

Preclinical data suggests that the action of fluoropyrimidines may be enhanced by the addition of hydroxyurea. We developed a phase I trial to determine the maximum tolerated dose and pharmacokinetics of i.v. hydroxyurea (HU) in combination with i.p. 5-fluoro-2'-deoxyuridine (FUdR) and leucovorin (LV). Eligible patients had metastatic carcinoma confined mostly to the peritoneal cavity, and adequate hepatic, renal and bone marrow function. Patients were treated with a fixed dose of FUdR (3 g) and LV (640 mg) administered on days 1--3. HU was administered as a 72-h infusion starting simultaneously with i.p. therapy on day 1. The following dose levels were studied: 2.0, 2.5, 3.0 and 3.6 g/m(2)/day. Pharmacokinetics were studied in blood and peritoneal fluid. Twenty-eight patients were accrued. Steady-state plasma and peritoneal fluid HU levels increased with increasing dose, and steady state was achieved within 12 h of continuous dosing. The steady-state HU plasma:peritoneal fluid concentration ratio ranged from 1.06 x 10(3) to 1.25 x 10(3) and the plasma HU clearance ranged from 4.63 to 5.81 l/h/m(2). Peritoneal fluid AUC = 137,639 +/- 43,914 microg/ml x min, t(1/2) = 100.9 +/- 56.4 min and Cl = 25.29 +/- 10.88 ml/min. Neutropenia represented the dose-limiting toxicity. We conclude that i.p. FUdR and LV in combination with i.v. HU is well tolerated. The addition of systemic HU increased the incidence of myelosuppression.

Second-look laparotomy for epithelial ovarian cancer: a reappraisal

Although second-look laparotomy (SSL) has been used in the management of ovarian cancer for over three decades, its current clinical use is limited. On average, over 50% of patients with a clinical complete response are noted to have disease at the time of SLL, emphasizing our lack of accurate noninvasive methods for determining pathologic response. Although findings at SLL have some prognostic significance, there is no definitive evidence that those patients undergoing SLL have improved survival, and even 50% of patients with negative findings at SLL have recurrences. The lack of survival advantage for patients enduring SLL highlights the need to identify consistently effective salvage and consolidation regimens. Few published studies provide definitive evidence regarding efficacy of treatment. Prospective, randomized, controlled trials are needed to evaluate the various therapies available. In general, the performance of SLL should be confined to those patients enrolled in clinical trials.

Intraperitoneal chemotherapy in ovarian cancer

From a theoretical viewpoint, intraperitoneal therapy (IP) in patients with ovarian cancer, a malignancy which remains mainly confined to the peritoneal cavity, is logical. Over the past decades this approach has evolved into a therapeutic strategy for a selected group of patients. Data available at present suggest a beneficiary role (for IP therapy) as first-line treatment in patients with small residual disease and possibly following initial reduction of tumor load by systemic chemotherapy. The theoretical basis, the present status of IP therapy in different settings, pharmacology, factors limiting its clinical utility and future directions are reviewed.

A phase II trial of intraperitoneal cisplatin and etoposide as consolidation therapy in patients with Stage II-IV epithelial ovarian cancer following negative surgical assessment

PURPOSE

To determine the efficacy of three courses of intraperitoneal (i.p.) cisplatin (CDDP) and etoposide (VP-16) as consolidation therapy following pathologically negative second-look surgical reassessment for Stage IIC-IV epithelial ovarian cancer (EOC).

PATIENTS AND METHODS

Between September 1988 and April 1996, 40 patients were treated with three cycles of i.p. CDDP (100 mg/m2)/VP-16 (200 mg/m2) as consolidation therapy. Survival was compared to that of a group of 46 contemporaneous patients undergoing observation only.

RESULTS

Median age of the 36 eligible patients was 52 years (range 30-70 years). Stage distribution was II (3), III (31), and IV (2); histologic grade was 1 (2), 2 (7), 3 (25), and not recorded (2); and residual disease at completion of initial surgery was none/microscopic in 13/36 (36%) patients. Median age of the 46 patients who did not receive consolidation was 52 years (range, 27-80 years); stage distribution was II (18), III (26), and IV (2); histologic grade was 1 (5), 2 (12), 3 (28), and not recorded (1). With a median follow-up of 36 months in both groups, 14/36 (39%) of the protocol group have recurred compared with 25/46 (54%) of those undergoing observation alone. Median disease-free survival (DFS) for the observed patients is 28.5 months and has not been reached in the consolidation group. Disease-free survival distribution between the two groups was compared using the log-rank test and was found to be significant (P = 0.03). Multivariate analysis revealed that the only significant predictor of improved DFS was protocol treatment (P < 0.01).

CONCLUSION

Intraperitoneal consolidation with CDDP/VP-16 following negative second-look reassessment in patients with advanced EOC resulted in a significant increase in DFS compared to nonprotocol patients treated concurrently who underwent observation alone.

Evaluation of whole abdominal irradiation in ovarian carcinoma with a four orthogonal fields technique

PURPOSE

The purpose of this study is to evaluate the toxicity and the results of abdominopelvic irradiation with a four orthogonal field's technique in patients with ovarian carcinoma.

METHODS AND MATERIALS

Between May 1981 and December 1990, 167 patients with ovarian carcinoma have been treated with whole abdominal irradiation: 62 patients with no or minimal residual disease < 2 cm after initial surgery (group 1) and 105 patients with no residual disease or macroscopic residual disease < 2 cm assessed by second-look surgery after incomplete debulking surgery and cisplatin-based polychemotherapy (group 2). Irradiation was performed by a four orthogonal field's technique. Thirty grays were given with a 25 MV photon beam (1.5 Gy/fraction/day, 20 fractions over 30 days). Boosts were performed in 50 cases (median dose of 15 Gy).

RESULTS

With a median follow-up of 68 months, the 5-year actuarial survival rate was 50% in the entire group, 67% in group 1, 40% in group 2, and 84% in T1, 61.5% in T2, 38% in T3. Five-year actuarial survival was analyzed according to the residuum: (a) after initial surgery (no residual disease: 70%, residual disease: 36.5%), (b) after second-look surgery: 76% in patients with a negative second look, 66% in patients with microscopic residual disease, 22% in patients with macroscopic residual disease and secondary surgical reduction, and 10% in patients with small unresectable nodules. Nine percent of the patients failed to complete irradiation acute side effects related. Five percent required surgery for bowel obstruction.

CONCLUSION

The abdominopelvic irradiation with this four orthogonal field's technique was associated with tolerable acute toxicity and a low risk of serious late complications. Similar late results to have been reported whole abdominal irradiation with chemotherapy in patients with negative or microscopic residual disease after surgery. Randomized trials comparing these two adjuvant treatments are warranted.