Adjuvant Intensity Modulated Whole-Abdominal Radiation Therapy for High-Risk Patients With Ovarian Cancer (International Federation of Gynecology and Obstetrics Stage III): First Results of a Prospective Phase 2 Study

Identification of a Prognostic Signature for Ovarian Cancer Based on Ubiquitin-Related Genes Suggesting a Potential Role for FBXO9

BACKGROUND

Ovarian cancer (OV) is associated with high mortality and poses challenges in diagnosis and prognosis prediction. Ubiquitin-related genes (UbRGs) are involved in the initiation and progression of cancers, but have still not been utilized for diagnosis and prognosis of OV.

METHODS

K48-linked ubiquitination in ovarian tissues from our OV and control cohort was assessed using immunohistochemistry. UbRGs, including ubiquitin and ubiquitin-like regulators, were screened based on the TCGA-OV and GTEx database. Univariate Cox regression analysis identified survival-associated UbRGs. A risk model was established using the LASSO regression and multivariate Cox regression analysis. The relationship between UbRGs and immune cell infiltration, tumor mutational burden, drug sensitivity, and immune checkpoint was determined using the CIBERSORT, ESTIMATE, and Maftools algorithms, based on the Genomics of Drug Sensitivity in Cancer and TCGA-OV databases. GEPIA2.0 was used to analyze the correlation between FBXO9/UBD and DNA damage repair-related genes. Finally, FBXO9 and UBD were accessed in tissues or cells using immunohistochemistry, qPCR, and Western blot.

RESULTS

We confirmed the crucial role for ubiquitination in OV as a significant decrease of K48-linked ubiquitination was observed in primary OV lesions. We identified a prognostic signature utilizing two specific UbRGs, FBXO9 and UBD. The risk score obtained from this signature accurately predicted the overall survival of TCGA-OV training dataset and GSE32062 validation dataset. Furthermore, this risk score also showed association with immunocyte infiltration and drug sensitivity, revealing potential mechanisms for ubiquitination mediated OV risk. In addition, FBXO9, but not UBD, was found to be downregulated in OV and positively correlated with DNA damage repair pathways, suggesting FBXO9 as a potential cancer suppressor, likely via facilitating DNA damage repair.

CONCLUSIONS

We identified and validated a signature of UbRGs that accurately predicts the prognosis, offers valuable guidance for optimizing chemotherapy and targeted therapies, and suggests a potential role for FBXO9 in OV.

Acute Presentation of Large Size Clear Cell Ovarian Carcinoma as Double Torsed Ovarian Tumor

We report a 46-year-old patient who presented to the emergency department with complaints of acute abdominal pain, nausea, and vomiting. An abdominal CT scan revealed a large (207 × 155 × 182 mm) thin-walled inhomogeneous tumor connected to the uterus and right ovary. Emergency surgery laparotomy was performed. Inside the abdominal cavity, a 30 × 30 cm heterogenous, dark blue tumor in the right adnexa area, torsed two times, weighing 3700 g was found. Histological examination revealed right ovary clear cell carcinoma. We emphasize the rare nature of the histology and presentation of this case report. Ovarian clear cell carcinomas are relatively rare malignancies, presenting in 5 to 10% of ovarian malignant tumors in the west.

Phase I Trial of Stereotactic MRI-Guided Online Adaptive Radiation Therapy (SMART) for the Treatment of Oligometastatic Ovarian Cancer

PURPOSE

Stereotactic body radiation therapy is increasingly used to treat a variety of oligometastatic histologies, but few data exist for ovarian cancer. Ablative stereotactic body radiation therapy dosing is challenging in sites like the abdomen, pelvis, and central thorax due to proximity and motion of organs at risk. A novel radiation delivery method, stereotactic magnetic-resonance-guided online-adaptive radiation therapy (SMART), may improve the therapeutic index of stereotactic body radiation therapy through enhanced soft-tissue visualization, real-time nonionizing imaging, and ability to adapt to the anatomy-of-the-day, with the goal of producing systemic-therapy-free intervals. This phase I trial assessed feasibility, safety, and dosimetric advantage of SMART to treat ovarian oligometastases.

METHODS AND MATERIALS

Ten patients with recurrent oligometastatic ovarian cancer underwent SMART for oligometastasis ablation. Initial plans prescribed 35 Gy/5 fractions with goal 95% planning target volume coverage by 95% of prescription, with dose escalation permitted, subject to strict organ-at-risk dose constraints. Daily adaptive planning was used to protect organs-at-risk and/or increase target dose. Feasibility (successful delivery of >80% of fractions in the first on-table attempt) and safety of this approach was evaluated, in addition to efficacy, survival metrics, quality-of-life, prospective timing and dosimetric outcomes.

RESULTS

Ten women with seventeen ovarian oligometastases were treated with SMART, and 100% of treatment fractions were successfully delivered. Online adaptive plans were selected at time of treatment for 58% of fractions, due to initial plan violation of organs-at-risk constraints (84% of adapted fractions) or observed opportunity for planning target volume dose escalation (16% of adapted fractions), with a median on-table time of 64 minutes. A single Grade ≥3 acute (within 6 months of SMART) treatment-related toxicity (duodenal ulcer) was observed. Local control at 3 months was 94%; median progression-free survival was 10.9 months. Median Kaplan-Meier estimated systemic-therapy-free survival after radiation completion was 11.5 months, with concomitant quality-of-life improvements.

CONCLUSIONS

SMART is feasible and safe for high-dose radiation therapy ablation of ovarian oligometastases of the abdomen, pelvis, and central thorax with minimal toxicity, high rates of local control, and prolonged systemic-therapy-free survival translating into improved quality-of-life.

Survival Analysis of Radiation Therapy in Ovarian Cancer: A SEER Database Analysis

RESULTS

A total of 20031 ovarian cancer patients were included, with 291 (1.45%) patients who received radiotherapy. The median overall survival (OS) in patients who received radiotherapy was shorter than which in patients without radiotherapy (23 vs. 75 months, P < 0.001). The Elderly, nonepithelial pathology, advanced American Joint Committee on Cancer (AJCC) stage, elevated level of CA125, and receiving radiotherapy were risk predictors to survival in both multivariable analyses before and after PSM. Among 11872 patients with III/IV stage, the radiotherapy group also showed a significantly worse prognosis (median OS: 19 vs. 44 months in patients without radiotherapy, P < 0.001). Consistent results were observed in stratification analyses on pathology and stage among patients with III/IV stage.

CONCLUSIONS

For patients with ovarian cancer, radiotherapy was associated with a poor prognosis regardless of pathology or stage. Considering this is a retrospective study, future studies concerning radiotherapy combination with other new agents in ovarian cancer are needed.

Radiotherapy and Its Intersections with Surgery in the Management of Localized Gynecological Malignancies: A Comprehensive Overview for Clinicians

Surgery, including minimally invasive surgery, and radiotherapy are key modalities in the treatment of gynecological malignancies. The aim of this review is to offer the multidisciplinary care team a comprehensive summary of the intersections of surgery and radiotherapy in the local treatment of gynecological malignancies. Recent advances in radiotherapy are highlighted. Relevant publications were identified through a review of the published literature. Ovarian, endometrial, cervical, vaginal, and vulvar cancer were included in the search. Current guidelines are summarized. The role of radiotherapy in adjuvant as well as definitive treatment of these entities is synthesized and put into context with surgery, focusing on survival and quality of life. Although these outcomes have improved recently, further research must be focused on the number of life years lost, and the potential morbidity encountered by patients.

Photodynamic Diagnosis and Therapy for Peritoneal Carcinomatosis: Emerging Perspectives

Simple Summary

Peritoneal carcinomatosis, the formation of wide-spread metastases throughout the abdominal cavity, remains challenging to diagnose and treat. Photodynamic diagnosis and photodynamic therapy are promising approaches for the diagnosis and treatment of peritoneal carcinomatosis, which use photosensitizers for fluorescence detection or photochemical treatment of (micro) metastases. With the aim of highlighting the potential of this theranostic approach, this review outlines the clinical state of the art in the use of photodynamic diagnosis and therapy for peritoneal carcinomatosis, identifies the major challenges, and provides emerging perspectives from preclinical studies to address these challenges. We conclude that the development of novel illumination strategies and targeted photonanomedicines may aid in achieving more efficient cytoreductive surgery. In addition to combination treatments with chemo-, and radiotherapy, such approaches hold significant promise to improve the outlook of patients with peritoneal carcinomatosis.

Abstract

Peritoneal carcinomatosis occurs frequently in patients with advanced stage gastrointestinal and gynecological cancers. The wide-spread peritoneal micrometastases indicate a poor outlook, as the tumors are difficult to diagnose and challenging to completely eradicate with cytoreductive surgery and chemotherapeutics. Photodynamic diagnosis (PDD) and therapy (PDT), modalities that use photosensitizers for fluorescence detection or photochemical treatment of cancer, are promising theranostic approaches for peritoneal carcinomatosis. This review discusses the leading clinical trials, identifies the major challenges, and presents potential solutions to advance the use of PDD and PDT for the treatment of peritoneal carcinomatosis. While PDD for fluorescence-guided surgery is practically feasible and has achieved clinical success, large randomized trials are required to better evaluate the survival benefits. Although PDT is feasible and combines well with clinically used chemotherapeutics, poor tumor specificity has been associated with severe morbidity. The major challenges for both modalities are to increase the tumor specificity of the photosensitizers, to efficiently treat peritoneal microtumors regardless of their phenotypes, and to improve the ability of the excitation light to reach the cancer tissues. Substantial progress has been achieved in (1) the development of targeted photosensitizers and nanocarriers to improve tumor selectivity, (2) the design of biomodulation strategies to reduce treatment heterogeneity, and (3) the development of novel light application strategies. The use of X-ray-activated PDT during whole abdomen radiotherapy may also be considered to overcome the limited tissue penetration of light. Integrated approaches that take advantage of PDD, cytoreductive surgery, chemotherapies, PDT, and potentially radiotherapy, are likely to achieve the most effective improvement in the management of peritoneal carcinomatosis.

Kidney-sparing whole abdominal irradiation in Wilms tumor: Potential advantages of VMAT technique

PURPOSE

To present a preliminary clinical experience and a dosimetric comparison of kidney-sparing volumetric modulated arc therapy (VMAT) with three-dimensional conformal radiotherapy (3D-CRT) for whole abdominal irradiation (WAI), in the setting of Wilms tumor (WT) treatment.

MATERIALS AND METHODS

From a total of 20 consecutive WT cases treated with adjuvant irradiation, seven were submitted to WAI with VMAT. Renal function and survival rates were evaluated, and, for comparison purposes, similar VMAT and 3D-CRT treatment plans were performed for WAI patients, and differences were dosimetrically evaluated regarding doses to the remaining kidney and other organs at risk and the planning target volume (PTV).

RESULTS

After a median follow-up time of 40.8 months (35.3-52.2), no acute significant intestinal toxicity was observed, and median creatinine clearance was 110.1 and 103.3 mL/min/1.73 m², respectively, before treatment and at last follow-up for WAI patients (P = 0.128). For comparative plans, maximum and median doses were lower for the remaining kidney with VMAT than with 3D-CRT. VMAT was associated with better PTV coverage as compared with 3D-CRT, with superior results for all the evaluated parameters (D95, D2, V100%, V98%, V95%; P = 0.018).

CONCLUSION

The use of VMAT technique is associated with lower radiation doses to the remaining kidney and better coverage to the PTV than 3D-CRT technique for WAI, with preliminary clinical experience showing a favorable toxicity profile. Long-term results from prospective studies might prove the ability of VMAT to spare renal function in the setting of WT treatment.

[Radiotherapy for ovarian carcinoma management: Literature review]

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

Adjuvant intensity modulated whole-abdominal radiation therapy for high-risk patients with ovarian cancer FIGO stage III: final results of a prospective phase 2 study

Background

To assess late toxicity, quality of life and oncological outcome after consolidative whole abdominal radiotherapy (WART) following cytoreductive surgery and carboplatin/paclitaxel chemotherapy in high risk patients with advanced ovarian cancer FIGO stage III using IMRT (Intensity modulated radiation therapy).

Methods

The OVAR-IMRT-02 study is a multi-center single-arm phase-II-trial. Twenty patients with optimally debulked ovarian cancer stage FIGO III with complete remission after chemotherapy were treated with intensity modulated WART. A total dose of 30 Gy in 20 fractions was applied to the entire peritoneal cavity. Primary endpoint was treatment tolerability; secondary objectives were acute and chronic toxicities, quality of life, rates of therapy disruption/abortion, progression-free survival (PFS) and overall survival (OS).

Results

All patients completed treatment and 10/20 patients (50%) reached the final study follow-up of 36 months. Late side effects consisted of °1-°2 lower limb edema (44.5%), with one patient (5.6%) showing °3 edema. Three patients (16.7%) showed elevated gamma-Glutamyltransferase. There were no severe late side effects regarding renal or hepatic function or any gastrointestinal toxicity greater than °2. During WART, mean global health status decreased by 18.1 points (95%-CI: 7.1–29.0), but completely normalized after 6 months. The same trend was observed for the function scale scores. Kaplan-Meier-estimated 1-, 2- and 3-year PFS was 74, 51 and 40%, respectively. 1-, 2- and 3-year OS was 89, 83 and 83%, respectively.

Conclusions

Intensity modulated WART after aggressive surgery and carboplatin/paclitaxel chemotherapy is associated with an acceptable risk of acute and late toxicity and minor impact on long-term quality of life. Together with the promising results for PFS and OS, intensity modulated WART could offer a new therapeutic option for consolidation treatment of patients with advanced ovarian cancer.

Trial registration

The study is registered with ClinicalTrials.gov (NCT01180504). Registered 12 August 2010 – retrospectively registered.

The role of radiotherapy in epithelial ovarian cancer: a literature overview

Ovarian cancer (OC) accounts for 3% of all cancer in women and for 5% of all cancer-related deaths. Epithelial Ovarian Cancer (EOC) is a radiosensitive malignancy with a poor prognosis. In the pre-chemotherapy era, radiation therapy (RT) delivered to the abdominopelvic region (whole abdominal irradiation, WAI) has historically played a role in the adjuvant and consolidation setting. Specific cluster of patients with early-stage disease and definite histologies may take advantage of RT. Platinum-based chemotherapy (CT) has replaced RT and plays a major role in most of the clinical settings. Radiation Therapy for palliation is recommended in patients with localized symptoms. Nevertheless, modern RT represents a reliable treatment option, with a mild toxicity profile, particularly effective for oligo-recurrent or progressive disease. The present literature review aims to highlight the historical role of RT in EOC, the actual lines of evidence, and the future perspectives.

Recent advances in gynecologic radiation oncology

PURPOSE OF REVIEW

Radiation has long been a primary treatment modality in locally advanced gynecologic carcinomas and a tool for palliation of metastatic disease. Here we review advances in imaging and radiation technologies and the corresponding clinical evolution of the role for radiation oncology in the treatment of gynecologic malignancies.

RECENT FINDINGS

Advances in MRI are impacting diagnosis, radiation target delineation, planning, treatment delivery, and response assessment. The combination of MRI and PET-computed tomography (PET-CT) has the potential to significantly change treatment recommendations as compared with a single imaging modality. Advances in radiation delivery including intensity modulated radiation therapy (IMRT) and stereotactic ablative radiotherapy (SABR) have expanded the role for radiation in the definitive treatment of high risk and oligometastatic ovarian cancer. Finally, global disparities in oncology resources has led to the development of resource stratified treatment guidelines for gynecologic malignancies. The use of ultrasound for brachytherapy planning may help improve access to this critical treatment modality.

SUMMARY

As imaging and radiation technologies advance, the indications for radiation in the treatment of gynecologic malignancies continues to evolve. Here we review the changing landscape of radiation oncology in the multidisciplinary management of gynecologic cancers.