Speed of response to platinum-based chemotherapy: implications for the management of epithelial ovarian cancer

The Role of Induction Chemotherapy in Inoperable Ovarian Cancer

Thirty patients with bulky advanced ovarian cancer surgically not resectable, received combination chemotherapy (median of 4.1 cycles; range, 3-7) including cisplatin or carboplatin, followed by a second surgical effort. Clinical CR+PR was observed in 24/30 (80 %) patients after chemotherapy. Our study deals only with these 24 patients, and the 6 patients who did not respond to chemotherapy are not part of this report. At debulking, 7/24 (29.1 %) patients had a complete macroscopic resection; 9/24 (37.5 %) patients had a partial resection (residual tumor <2 cm). These data suggest that debulking is feasible and successful after chemotherapy containing cisplatin or its derivative. Overall median survival from diagnosis was 18.9 months; the 3-year survival rate was 28 %. Median progression-free survival from diagnosis was 13.5 months. The results observed in our study indicate that the use of induction chemotherapy can play an important role in increasing the chances of optimal debulking in patients presenting with unresectable ovarian cancer.

Intervention debulking surgery in advanced epithelial ovarian cancer

OBJECTIVE

To study whether intervention debulking surgery improves survival in patients with advanced ovarian cancer who have bulky (> 2 cm) residual disease after primary surgery.

DESIGN

A prospective multicentre randomised study.

SETTING

Hospitals in the West Midlands.

SUBJECTS

Ovarian cancer patients with bulky residual disease after primary surgery who are considered well enough to receive cis-platinum based chemotherapy and further surgery.

METHODS

Eligible patients were randomised to receive combination chemotherapy alone or combined with intervention debulking surgery.

MAIN OUTCOME MEASURE

Survival was assessed using product limit method and log-rank test.

RESULTS

Seventy-nine patients were entered into the study. Thirty-seven patients were randomised to intervention debulking surgery, 25 (67%) of whom underwent intervention debulking surgery, which was performed a median of 13 weeks after primary surgery. The median survival for the intervention debulking surgery group was 15 months (95% CI 10-20 mo) and that of those randomised to chemotherapy alone, which was 12 months (95% CI 8-16 mo), were not significantly different (hazard ratio = 0.71; 95% CI 0.44-1.13).

CONCLUSION

Intervention debulking surgery may not improve survival in patients with advanced ovarian cancer.

Neoadjuvant carboplatin and ifosfamide chemotherapy for inoperable FIGO stage III and IV ovarian carcinoma

Thirty patients aged 34-69 years (median 56) with previously untreated FIGO Stage III and IV ovarian carcinoma were given carboplatin (400 mg/m2) and ifosfamide (5 g/m2) with mesna every 28 days for a median of 3 cycles, followed, where possible, by laparotomy. Objective responses were observed in 13 (43%) patients, 11 of whom proceeded to laparotomy. Nine were successfully debulked, and two of these had removal of all macroscopic disease. Three cycles of chemotherapy were found to achieve the optimum response for the least toxicity. After a minimum follow-up of 32 months, two patients who had had debulking surgery remain alive. The median response duration was 13.9 months in the debulked group compared with 3 months in those who remained inoperable, while the corresponding median survivals were 23.4 and 6.4 months. This study suggests that neoadjuvant chemotherapy given over 8 weeks may render debulking surgery feasible in a proportion of patients presenting with unresectable ovarian cancer and can result in an improved median survival.

Treatment of advanced ovarian cancer: 10 years of experience

Although the majority of the patients with advanced ovarian cancer will die of the disease, optimism is justified in view of the improved results of surgery followed by cisplatin--and carboplatin-based chemotherapy. Currently, approximately 30% of the patients reach a complete remission and a long therapy-free period with a good quality of life after treatment with 6 cycles of cyclophosphamide and cisplatin. Cisplatin-based two-, three-, and four-drug regimens probably give equal results, with respect to survival outcome, if equitoxic dosages are used. Because of its more favourable toxicity spectrum, carboplatin is likely to replace cisplatin in the near future. The group of long-term survivors includes patients with a good performance status, a well-differentiated tumour, and small tumour residuals after the initial laparotomy. Patients who relapse after a period without treatment may benefit from retreatment with cisplatin or the analogue, carboplatin, given alone or in combination with cyclophosphamide. New promising approaches are now being tested in clinical trials and may be expected to yield new ways to improve treatment results. Results of fundamental research may lead to the development of new treatment strategies in the next decade and further improve the outlook for patients with ovarian cancer.

Short-duration (three cycles) cisplatin combination chemotherapy with alkylating agent consolidation in advanced epithelial ovarian cancer

Forty-eight patients with advanced epithelial ovarian cancer were treated with a two-part cytotoxic regimen consisting of three cycles of cisplatin-based induction therapy followed by five cycles of escalating doses of cyclophosphamide, all given at 3-weekly intervals. The total cisplatin dose was 225 mg/m2. Seventeen patients with optimal primary surgery received chemotherapy only, while 17 of the 31 patients with suboptimal primary surgery underwent optimal interval cytoreductive surgery at the end of induction (cisplatin) therapy. Median survival for all patients was 15.4 months. Median survival was 15 months for patients with optimal primary surgery and 22 months for patients who had optimal secondary cytoreduction. Only 10 patients suffered WHO grade 3 or greater toxicity during therapy. This study suggests that the total dose of cisplatin can be reduced for patients with advanced ovarian carcinoma, resulting in reduced overall toxicity, without compromising response or response duration. A randomized trial to test this concept is now underway.