Multiple Cycles of Neoadjuvant Chemotherapy Associated With Poor Survival in Bulky Stage IIIC and IV Ovarian Cancer:

Feasibility of neoadjuvant and adjuvant intraperitoneal chemotherapy in patients with advanced epithelial ovarian cancer: A single-center experience

Intraperitoneal (IP) chemotherapy is believed to prolong the survival of patients with advanced ovarian cancer after primary debulking surgery. However, there is little knowledge about IP chemotherapy in the setting of neoadjuvant chemotherapy, and there are contradictory conclusions about adjuvant IP chemotherapy. Here, we evaluated the feasibility of neoadjuvant and adjuvant IP chemotherapy in patients with advanced epithelial ovarian cancer (AEOC).We retrospectively reviewed the data of 114 patients with AEOC who received neoadjuvant chemotherapy followed by laparoscopic conservative interval debulking surgery (NACT + LIDS) in our institution from January 1, 2009 to December 31, 2017.The median overall survival (OS) was 56 months and the median disease-free interval (DFI) was 14 months for the entire study population. Neoadjuvant IP chemotherapy cycles were crucial for the treatment of no gross residual (R0) disease (hazard ratio [HR] = 0.446, 95% confidence interval [CI] = 0.245-0.811), which was independently associated with OS of the entire study population (HR = 9.589, 95% CI = 3.911-23.507). In addition, residual disease and body mass index (BMI) were the prognostic factors for DFI (HR = 6.022, 95% CI = 3.632-9.986; HR = 1.085, 95% CI = 1.012-1.163). However, adjuvant IP cycles along with BMI were the determining factors for DFI in the R0 group (HR = 0.703, 95% CI = 0.525-0.941; HR = 1.130, 95% CI = 1.025-1.247), and were associated with OS in the R0 group (HR = 0.488, 95% CI = 0.289-0.824). The OS and DFI Kaplan-Meier curves stratified by adjuvant IP chemothearpy cycles within the R0 group were statistically significant (P = .024 and P = .033, respectively).Our results showed improvement in patients with AEOC in terms of survival, thus suggesting the feasibility of neoadjuvant and adjuvant IP chemotherapy.

LAMC2 regulated by microRNA-125a-5p accelerates the progression of ovarian cancer via activating p38 MAPK signalling

AIMS

Laminin γ2 (LAMC2) is over-expressed in ovarian cancer, and its high expression facilitates cell invasion. Nevertheless, the effects of LAMC2 on other ovarian cancer cell functions and its underlying mechanism remain largely unclear. Bioinformatics analysis shows that LAMC2 is a predicted target of miR-125a-5p and miR-193a-3p. Therefore, the present study aimed to investigate the effects of LAMC2 in ovarian cancer progression and determine whether LAMC2 expression is under the regulation of miR-125a-5p or miR-193a-3p in ovarian cancer.

MATERIALS AND METHODS

Immunohistochemistry staining, western blot and qPCR were used to detect LAMC2 expression profiles. CCK-8, flow cytometry and tumour formation assays were used to assess cell proliferation, apoptosis and tumorigenesis. The interaction between miR-125a-5p/miR-193a-3p and LAMC2 were determined by the luciferase gene reporter assay.

KEY FINDINGS

The results showed that LAMC2 was over-expressed in ovarian cancer tissues and cell lines. Over-expression of LAMC2 significantly promoted cell proliferation and repressed cell apoptosis, as well as increased the expression levels of p38, p-p38, c-myc and CREB, and translocated p38 protein to the nucleus. In addition, the promotion of cell proliferation and repression of cell apoptosis mediated by LAMC2 over-expression were all weakened when p38 was downregulated. Moreover, LAMC2 expression was negatively regulated by miR-125a-5p, which inhibited the nuclear accumulation of p38 protein. Upregulation of LAMC2 significantly abolished the effects of miR-125a-5p on cell proliferation inhibition and cell apoptosis promotion, as well as tumourigenesis repression.

SIGNIFICANCE

The present study clarified that LAMC2 functioned as an oncogene in ovarian cancer through upregulating p38 under the regulation of miR-125a-5p.

In patients with advanced ovarian cancer, primary suboptimal surgery has better survival outcome than interval suboptimal surgery

Objective

It is known that optimal or complete cytoreduction is the most important factor in patients with advanced ovarian cancer. The aim of this study was to examine the results of patients who did not undergo optimal cytoreduction and to examine subgroup analysis based on neoadjuvant chemotherapy (NAC).

Material and Methods

Patients with advanced ovarian cancer and suboptimal surgery were retrospectively reviewed.

Results

A total of 99 patients with a median age of 59.0 years (range, 22-87 years) were studied. The median follow-up time was 39±32.7 months, 81 patients (81.8%) died and 18 patients (18.2%) were alive. The five-year survival rate was 27.6%. Of the patients, 37 (37.4%) were underwent surgery after NAC, 62 (62.3%) were primary. More patients with NAC died within 3 years compared with those without NAC (83.9% vs 56.0%) (p=0.015). Patients with NAC had less tumor spread (presence of visible tumor in the upper abdomen during surgery) (29.7% vs 72.6%; p<0.001) and had less overall survival times when compared with patients who underwent primary surgery [median 22.3±1.2; 95% CI: (19.9-24.7) vs (37.5±11.2); 95% CI: (15.4-59.5) months; log rank test p=0.055]. The relationship between overall survival and factors such as age, NAC, presence of metastasis in the upper abdomen, and tumor histology (serous vs. non-serous) were analyzed using univariate cox regression analysis. Of these factors, only NAC was close to significant, but it did not reach significance (p=0.055).

Conclusion

NAC reduces tumor burden before surgery in advanced ovarian cancer. The prognosis of patients who are not eligible for optimal surgery despite NAC is worse than in patients who do not receive NAC.

[Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).

The role of neoadjuvant chemotherapy in ovarian cancer

INTRODUCTION

Ovarian cancer is mostly diagnosed at advanced stage. Better survival is achieved through complete debulking surgery and chemotherapy. Historically, neoadjuvant chemotherapy (NAC) has been introduced for unresectable disease to decrease tumor load and perform a unique complete surgery. Four randomized control trials have compared primary debulking surgery to NAC, but there is still controversy about the use of neoadjuvant chemotherapy and questions about its modalities. Areas covered: We made a review of knowledge on benefits of NAC compared to primary debulking chemotherapy, in terms of survival and morbidity, methods of administration, new drugs in early and late phase trials, the selection of patients. Similar survival was observed after NAC and interval debulking surgery or primary debulking surgery. Morbidity of surgery was decreased after interval debulking compared primary debulking surgery. Conventional drugs are carboplatin and paclitaxel. Safety of bevacizumab was evaluated in phase 2 trials associated with conventional drugs. Immunotherapy trials are enrolling patients in phase 1 study. Expert commentary: NAC followed by debulking surgery is the best treatment for patients with advanced ovarian cancer.

Dioscin suppresses the viability of ovarian cancer cells by regulating the VEGFR2 and PI3K/AKT/MAPK signaling pathways

Diosgenin is a natural steroidal saponin that is extracted from a range of sources, including from fenugreek. It is a critical raw material in the synthesis of steroid hormone drugs, exhibiting antitumor, anti-inflammatory, antioxidation and a number of other significant pharmacological actions, possessing high pharmaceutical value. The aim of the present study was to investigate the effects of dioscin suppression on ovarian cancer cell growth and the mechanism of apoptosis induction by dioscin in ovarian cancer cells. The results of the present study demonstrated that dioscin decreased viability and induced apoptosis in SKOV3 human ovarian cancer cells in a dose-dependent manner. Dioscin significantly increased caspase-3 and caspase-9 activity, and increased the protein expression of Bax and cleaved poly(ADP-ribose) polymerase in SKOV3 cells. In addition, dioscin significantly suppressed vascular endothelial growth factor receptor (VEGFR)2, phosphoinositide 3-kinase (PI3K), phosphorylated AKT and phosphorylated p38 mitogen-activated protein kinase (MAPK) protein expression in SKOV3 cells. Taken together, to the best of our knowledge, the present study demonstrated for the first time that dioscin suppresses cell viability in ovarian cancer cells by regulating the VEGFR2 and PI3K/AKT/MAPK signaling pathways.

Neoadjuvant chemotherapy and chemotherapy cycle number: A national multicentre study

OBJECTIVES

Six cycles of consolidation chemotherapy have become the standard for ovarian cancer treatment regimen following primary cytoreduction, yet with neoadjuvant chemotherapy (NAC), only 3 consolidation cycles are used. This study examines the effects of number of chemotherapy cycles in women with ovarian cancer that are being treated with neoadjuvant chemotherapy. In addition, we examined the effect of number of cycles on survival on consolidation and total chemotherapy.

METHODS

All patients with stage IIIC and IV high grade serous carcinoma (HGSC) were identified at 4 major Canadian cancer centers treated with NAC. A retrospective chart review was conducted using the medical charts and registry databases.

RESULTS

403 NAC patients were identified. 47% had zero residual disease. Chemotherapy cycles were divided into <3cycles or ≥4cycles for NAC and consolidation treatments and analyzed with multivariate analysis. 139/403 (34.5%) received ≥4cycles of NAC and had a worse prognosis than <3cycles (p=0.011). 70/403 (17.4%) received ≥4cycles of consolidation treatment and there was no difference in survival (p=0.33) CONCLUSION: Women with advanced HGSC are managed with a combination of surgery and chemotherapy. This is a study of a homogenous cohort of patients with stage IIIC or IV high grade serous cancers who received NAC. ≥4cycles of NAC had a worse outcome than <3cycles likely due to poor prognostic factors or poor response. The number of consolidation cycles did not appear to make a difference in overall survival.

The Use of “Optimal Cytoreduction” Nomenclature in Ovarian Cancer Literature: Can We Move Toward a More Optimal Classification System?

Objectives

The objective of this study is to explore how cytoreductive surgical outcomes such as residual disease (RD) and use of the term “optimal cytoreduction” (OCR) have changed over time in the ovarian cancer literature.

Methods

We identified all English-language publications referring to ovarian cancer cytoreduction for a 12-year period. Publications were evaluated for how the diameter of RD was categorized and whether OCR was defined. In addition, the use of RD and OCR terminology trends over time and associations between terminology and the region of corresponding author, study type, and journal impact factor were explored.

Results

Of the 772 publications meeting inclusion criteria, the RD stratification points used to demarcate patient groups were as follows: 0 mm (45%), 5 mm (3.6%), 10 mm (65%), and 20 mm (24%). The use of 0-mm RD (odds ratio [OR], 1.1; 95% confidence interval, 1.05–1.15) and 10-mm RD (OR, 1.1; 95% confidence interval, 1.09–1.20) to delineate patient outcomes increased over time. The use of OCR terminology did not change over time but was more commonly used in clinical studies as well as those from North America. Many studies (70%) defined OCR as less than or equal to 10-mm RD, whereas 30% defined OCR differently or not at all.

Conclusions

Optimal cytoreduction terminology remains ambiguous and inconsistently used in the ovarian cancer surgical literature. On the basis of this literature review, we propose a novel classification system to categorize RD without reference to OCR while accurately and succinctly identifying meaningful clinical subgroups and minimizing bias.