Patterns of Recurrence and Clinical Outcome of Patients With Stage IIIC to Stage IV Epithelial Ovarian Cancer in Complete Response After Primary Debulking Surgery Plus Chemotherapy or Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery: An Italian Multicenter Retrospective Study

Comparison of clinical and cost outcomes between primary and interval debulking surgery in ovarian cancer

INTRODUCTION

While neoadjuvant chemotherapy with interval debulking surgery (IDS) has comparable clinical outcomes to primary debulking surgery (PDS) for advanced epithelial ovarian cancer, their economic dimension remains understudied.

METHODS

This retrospective chart review examined Stage IIIC-IV epithelial ovarian cancer patients who underwent IDS or PDS between 2011 and 2014. We compared the demographics, disease-specific, intraoperative, thirty-day clinical outcome and billing, and ten-year survival data.

RESULTS

Patients who underwent PDS (n = 36) and IDS (n = 43) had similar characteristics, including age, comorbidity, cancer stage, cell type, nationality, and 30-day median bill sizes (SGD 31,649.69 vs. SGD 35,326.02). The IDS group had lower postoperative sepsis (2.3% vs. 16.7%), gastrointestinal complications (0.0% vs. 11.1%) and suboptimal debulking (14.0% vs. 33.3%) rates, shorter median hospital stay (5 vs. 8 days) and higher rates of complete gross resection (CGR) (62.8% vs. 36.1%) (all P < 0.05). There were significant associations between thirty-day complications and mucinous adenocarcinomas (odds ratio [OR] 10.8), packed cell transfusion (OR 1.87 per unit), and suboptimal debulking (OR 6.33). Thirty-day readmission or death was significantly associated with Clavien-Dindo Grade I-II complications (OR 46.8) and suboptimal debulking (OR 8.24). While PDS and IDS groups had similar ten-year survival (37.0% vs. 16.2%), PDS conferred a significantly lower recurrence rate (66.7% vs. 83.7%, P = 0.003).

CONCLUSION

The thirty-day cost and ten-year survival of IDS and PDS are comparable. Although IDS offers lower postoperative sepsis and gastrointestinal complications, shorter hospital stays and higher CGR rates, the ten-year recurrence is higher.

Deciphering the stromal molecular landscape: the correlation between p16 and α-SMA in epithelial ovarian cancer

INTRODUCTION

The tumor microenvironment (TME) plays an essential role in promoting cancer initiation, progression and metastasis. Cancer-associated fibroblasts (CAFs) are a major constituent of the TME, but universal CAFs' markers have not yet been identified. We selected several new biomarkers [p16 and α-smooth muscle actin (α-SMA)] to investigate the molecular landscape in epithelial ovarian cancer (EOC), given to the unique TME of this malignancy.

METHODS

In total, 64 patients with a diagnosis of EOC who underwent primary debulking surgery (PDS) at the Department of Gynecology and Obstetrics of the University of Pisa were enrolled between January 2019 and June 2021. The stromal expression of α-SMA and p16 was investigated by using immunohistochemistry, and the correlations between p16 and α-SMA immunoreactivity and BRCA mutational status were analyzed.

RESULTS

Positive p16 stromal expression was found in 6 out of 38 (15,78%) patients with wild-type BRCA and in only 1 of the 22 (4,50%) patients with mutated BRCA. Conversely, positive α-SMA expression was detected in 34 of 38 patients with wild-type BRCA (89,47%) and in 21 of 22 patients (95,45%) with mutated BRCA. There was a significant difference (r = -0,32) between the negative stromal p16 expression and the positive stromal expression of α-SMA.

CONCLUSION

This study suggests a new correlation between stromal expression of p16 and α-SMA and BRCA mutational status in EOC. Further investigations are strongly warranted to improve the understanding of the landscape of this malignancy.

Enhancing the detection of clinically relevant biomarkers in advanced uterine and tubo-ovarian carcinomas through genome-wide analysis

BACKGROUND

Advanced-stage tube-ovarian cancers (TOC) and uterine cancers (UC) significantly contribute to cancer mortality. While surgery achieves clinical remission in most cases, recurrence often necessitates systemic therapy. Recent molecular phenotype studies have advanced targeted therapies. We employed whole genome sequencing (WGS) to investigate biomarkers in gynecologic malignancies.

DESIGN

Ninety-one tumor samples (45 TOC, 46 UC) were analyzed for germline mutations, somatic driver mutations, rearrangements, genome-wide signatures, and molecular phenotypes. A WGS-based high-confidence classifier for homologous recombination deficiency (HRD) was applied. Genomic profiles were correlated with clinical outcomes.

RESULTS

The HRD phenotype was identified in serous carcinoma components, with 50 % of HRD cases showing BRCA1/2 wildtype (33 %) or variants of unknown significance (17 %). HRD correlated with better overall survival in tubo-ovarian serous carcinoma and was linked to responses to platinum therapy and PARP inhibitors. Endometrioid carcinomas showed no HRD phenotype despite BRCA1/2 variants. CDK12-type genomic instability (10 %) occurred in cases with CDK12 rearrangements, and CCNE1 gain (8 %) was observed in CCNE1-amplified cases, independent of copy number. In endometrioid carcinoma, mismatch repair (MMR) deficiency single base substitution signatures, particularly SBS44, contributed to high tumor mutation burden (TMB). Ultra-high TMB was found in two cases with pathogenic POLE and POLQ mutations, exhibiting multiple SBS signatures, including MMR deficiency.

CONCLUSION

Comprehensive genomic profiling of advanced-stage TOC and UC via WGS reveals key biomarkers and therapeutic targets, enhancing diagnostic accuracy and advancing personalized medicine in gynecological cancers.

Current peritonectomy practice during debulking surgery in patients with newly diagnosed advanced ovarian cancer: a Korean Gynecologic Oncology Group Study (KGOG 4004)

OBJECTIVE

Because of the possible therapeutic benefit of removing occult tumor cells, a source of recurrence and chemoresistance, total parietal peritonectomy (TPP) is an alternative treatment for advanced epithelial ovarian/fallopian tube/primary peritoneal cancer. Interventional studies comparing TPP with selective parietal peritonectomy (SPP) are in progress. Since surgeons skilled in TPP are essential for such trials to be conducted, this nationwide survey aimed to examine current peritonectomy practice among gynecologic oncologists in Korea.

METHODS

A 17-item questionnaire, developed by a surgery committee and reviewed by the scientific review board of the Korean Gynecology Oncology Group (KGOG), was distributed to 144 KGOG members. The questionnaire was divided into 3 categories: respondent demographics, peritonectomy practice during primary debulking surgery (PDS), and peritonectomy practice during interval debulking surgery (IDS).

RESULTS

We received 88 (61.1%) valid responses. Of the valid respondents, 98.9% and 93.8% performed SPP during PDS and IDS, respectively. Only 4.9% of the respondents performed TPP during IDS. Most respondents performed peritonectomy in cases where optimal postoperative outcomes were expected. Approximately 50.6% of the respondents had performed peritonectomy independently, while the others did so in cooperation with non-gynecologic surgeons. The primary reasons for not performing TPP were concerns about morbidity and uncertainty about the clinical benefits of the procedure.

CONCLUSION

SPP is the predominant technique used in both PDS and IDS in Korea. A small percentage (4.9%) of gynecologic oncologists have performed TPP during IDS. Accordingly, a study regarding the feasibility of TPP should be conducted before proceeding with a prospective clinical trial.

The impact of varying levels of residual disease following cytoreductive surgery on survival outcomes in patients with ovarian cancer: a meta-analysis

BACKGROUND

Residual disease following cytoreductive surgery in patients with ovarian cancer has been associated with poorer survival outcomes compared with no residual disease. We performed a meta-analysis to assess the impact of varying levels of residual disease status on survival outcomes in patients with ovarian cancer who have undergone primary cytoreductive surgery or interval cytoreductive surgery in the setting of new therapies for this disease.

METHODS

Medline, Embase, and Cochrane databases (January 2011 - July 2020) and grey literature, bibliographic and key conference proceedings, were searched for eligible studies. Fixed and random-effects meta-analyses compared progression and survival by residual disease level across studies. Heterogeneity between comparisons was explored via type of surgery, disease stage, and type of adjuvant chemotherapy.

RESULTS

Of 2832 database and 16 supplementary search articles screened, 50 studies were selected; most were observational studies. The meta-analysis showed that median progression-free survival and overall survival decreased progressively with increasing residual disease (residual disease categories of 0 cm, > 0-1 cm and > 1 cm). Compared with no residual disease, hazard ratios (HR) for disease progression increased with increasing residual disease category (1.75 [95% confidence interval: 1.42, 2.16] for residual disease > 0-1 cm and 2.14 [1.34, 3.39] for residual disease > 1 cm), and also for reduced survival (HR versus no residual disease, 1.75 [ 1.62, 1.90] for residual disease > 0-1 cm and 2.32 [1.97, 2.72] for residual disease > 1 cm). All comparisons were significant (p < 0.05). Subgroup analyses showed an association between residual disease and disease progression/reduced survival irrespective of type of surgery, disease stage, or type of adjuvant chemotherapy.

CONCLUSIONS

This meta-analysis provided an update on the impact of residual disease following primary or interval cytoreductive surgery, and demonstrated that residual disease was still highly predictive of progression-free survival and overall survival in adults with ovarian cancer despite changes in ovarian cancer therapy over the last decade. Higher numerical categories of residual disease were associated with reduced survival than lower categories.

Prognostic value of HE4 in advanced-stage, high-grade serous ovarian cancer: Analysis of HE4 kinetics during NACT, predicting surgical outcome and recurrence in comparison to CA125

OBJECTIVES

To assess the prognostic value of human epididymis protein 4 (HE4) kinetics during and after neoadjuvant chemotherapy (NACT) cycles compared with cancer antigen 125 (CA-125), in predicting the surgical outcomes of interval debulking surgery (IDS) in patients with advanced-stage, high-grade serous ovarian cancer.

METHODS

This retrospective cohort study was conducted at Severance Hospital in Seoul, South Korea and involved 123 women with high-grade serous epithelial ovarian, fallopian tube, or primary peritoneal cancer who were diagnosed between April 2015 and July 2020. Three outcomes were considered: the chemotherapy response score (CRS) by omentum, residual disease after IDS, and recurrence. Other clinical, imaging, and biological parameters at baseline, during NACT cycles, and pre- and postoperative time were collected and analyzed.

RESULTS

We observed a substantial and gradual decrease in both CA-125 level (median from 1612 to 85.55 U/mL; p < 0.001) and HE4 level (514.7 to 87.7 pmol/L; p < 0.001) during NACT cycles, while pre-to-postoperative reduction was only significant for HE4 (median from 77.3 to 62.0 pmol/L (p < 0.001)). Of the total patients, 4.1% showed no response to NACT (chemoresistance) and 65.9% had a partial response. Residual disease was observed in 55 (44.7%) patients. Recurrence occurred in 90 patients (73.2%), with a median progression-free survival of 15.28 months. The percent reduction in CA-125 level- but not HE4 - during NACT was significantly associated with CRS (by omentum); the reduction in CA-125 during NACT cycles was higher when the CRS was found to be 3 and 2 (median = 96.4 [IQR = 8.3] and 93.7 [12.2] respectively) compared to score 1 (68.3 [34.1]), and the difference was statistically significant (p = 0.004). However, no significant association was observed between the percent reduction in CA-125 or HE4 levels during NACT and residual disease or recurrence. The normalization of HE4 - but not CA-125 - before surgery was predictive for surgery outcome; that is, an abnormal preop HE4 level was associated with a residual disease risk ratio of 2.72 (95% CI = 1.27-5.79).

CONCLUSION

Monitoring HE4 or CA-125 levels has low prognostic value in patients with advanced-stage, high-grade serous ovarian cancer who are treated with NACT followed by IDS. However, the preoperative level of the HE4 biomarker may be useful in identifying patients at higher risk for suboptimal cytoreductive surgery or who may require more extensive surgery. Further prospective studies are warranted to explore the prognostic utility of eventual combinations of clinical, radiological, and biological parameters, notably by using artificial intelligence-based models.

Multidisciplinary Surgical Approach to Increase Survival for Advanced Ovarian Cancer in a Tertiary Gynaecological Oncology Centre

PURPOSE

The purpose of this paper is to report on changes in overall survival, progression-free survival, and complete cytoreduction rates in the 5-year period after the implementation of a multidisciplinary surgical team (MDT).

METHODS

Two cohorts were used. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients from January 2017 to September 2021.

RESULTS

This study included 146 patients in cohort A (2006-2015) and 174 patients in cohort B (2017-2021) with FIGO stage III/IV ovarian cancer. Median follow-up in cohort A was 60 months and 48 months in cohort B. The rate of primary cytoreductive surgery increased from 38% (55/146) in cohort A to 46.5% (81/174) in cohort B. Complete macroscopic resection increased from 58.9% (86/146) in cohort A to 78.7% (137/174) in cohort B (p < 0.001). At 3 years, 75% (109/144) patients had disease progression in cohort A compared with 48.8% (85/174) in cohort B (log-rank, p < 0.001). Also at 3 years, 64.5% (93/144) of patients had died in cohort A compared with 24% (42/174) of cohort B (log-rank, p < 0.001). Cox multivariate analysis demonstrated that MDT input, residual disease, and age were independent predictors of overall (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.203-0.437, p < 0.001) and progression-free survival (HR 0.31, 95% CI 0.21-0.43, p < 0.001). Major morbidity remained stable throughout both study periods (2006-2021).

CONCLUSIONS

Our data demonstrate that the implementation of multidisciplinary-team, intraoperative approach allowed for a change in surgical philosophy and has resulted in a significant improvement in overall survival, progression-free survival, and complete resection rates.

Correlation between progression-free survival and overall survival in patients with ovarian cancer after cytoreductive surgery: a systematic literature review

OBJECTIVES

This analysis aimed to better define the relationship between progression-free survival and overall survival in adult patients with ovarian cancer (including fallopian tube or primary peritoneal cancer) following primary cytoreductive surgery or interval cytoreductive surgery.

METHODS

A systematic literature review was carried out across the Medline, Embase, and Cochrane Central databases on 7 July 2020 (date limits 1 January 2011 to 7 July 2020) to identify studies with the following eligibility criteria: clinical trials/observational studies including >200 patients with ovarian cancer aged ≥18 years, evaluating overall survival/progression-free survival following cytoreductive surgery by residual disease status in the United States, Europe, Japan, or China. Weighted linear regression models were used to assess any correlation between median progression-free survival and overall survival, and between logHR for progression-free survival and logHR for overall survival. Risk of bias was assessed for all included studies.

RESULTS

Of the 50 studies reported, 43 were observational studies (41 retrospective and two prospective cohort studies), and seven were reporting for randomized clinical trials-of which four were retrospective data analyses. For analyses of the relationship between overall survival and progression-free survival, 21 studies were eligible. The weighted linear regression model showed a strong positive association between the two survival endpoints. Goodness-of-fit analysis measured the adjusted R2 as 0.84 (p<0.001); a positive association was also observed between logHRs for overall survival and progression-free survival in the included studies.

CONCLUSIONS

Median progression-free survival was predictive of median overall survival. This correlation between progression-free survival and overall survival after primary treatment for ovarian cancer highlights the validity of progression-free survival as a primary endpoint. Observational studies contributed most data, with limited information on disease stage and histology.

Optimal First-Line Medico-Surgical Strategy in Ovarian Cancers: Are We There Yet?

In spite of tremendous advances in advanced ovarian cancer management through the past decade, notably owing to surgical expertise and novel combination molecules (including bevacizumab and PARP inhibitors), the optimal initial sequential strategy remains a major concern. Indeed, following seminal clinical trials, primary cytoreductive surgery (PCS) followed by adjuvant systemic therapy and interval cytoreductive surgery (ICS) following neoadjuvant chemotherapy (NACT) have been positioned as validated alternatives with distinct pros and cons, although a definite response is still unassessed. In clinical practice, decisions between PCS and ICS rely on multilayer parameters: the tumor itself, the patient, and the health structure. In this state-of-the-art review, we will discuss the current evidence based on clinical trials and real-world data and highlight the remaining questions, including the fittest positioning of PCS vs. ICS and the optimal number of NACT cycles; subsequently, we will discuss current axes of research such as dedicated clinical trials and more global perspectives. These ongoing strategies and perspectives could contribute to improving the patient journey through personalized medicine.

Adipose tissue area is a predictive biomarker for the efficacy of pegylated liposomal doxorubicin in platinum-refractory/resistant ovarian cancer

BACKGROUND

Pegylated liposomal doxorubicin (PLD), an anthracycline agent, is widely used as a treatment option for platinum-refractory/resistant epithelial ovarian cancer (EOC). Although only a subset of patients with platinum-refractory/resistant EOC derive benefit from PLD, predictive biomarkers for patients who will respond to the drug have not yet been established. Here, we evaluated the relationship between adipose tissue status and PLD efficacy in patients with platinum-refractory/resistant EOC.

METHODS

Patients with platinum-refractory/resistant EOC who were treated with single-agent PLD were included in this retrospective cohort study. Adipose tissue areas including visceral adipose tissue area (VATA), subcutaneous adipose tissue area (SATA), and visceral to subcutaneous adipose tissue area ratio (VSR) were calculated prior to the initiation of PLD using computed tomography images. The associations of adipose tissue areas with objective response rate (ORR) and patient survival were evaluated.

RESULTS

Forty-four patients with platinum-refractory/resistant EOC who received single-agent PLD were included. Subjects were categorized into high and low groups according to the median VATA, SATA, and VSR values, and body mass index (BMI). The ORR of PLD was significantly lower in the VSR-high group than in the VSR-low group (p = 0.0089). Patients in the high VSR group showed significantly shorter progression-free survival (PFS) compared with patients in the low VSR group (median, 4.0 vs. 8.5 months; p = 0.020). In the multivariable analysis, high VSR was a significant prognostic factor for shorter PFS (hazard ratio, 2.07; 95% confidence interval, 1.05-4.19; p = 0.035). VATA, SATA, and BMI showed no significant association with ORR and survival of patients who received PLD.

CONCLUSIONS

High VSR is associated with lower ORR and shorter PFS in patients with platinum-refractory/resistant EOC who received single-agent PLD. VSR is a robust predictive biomarker for the efficacy of PLD.

Impact of pattern of recurrence on post-relapse survival according to surgical timing in patients with advanced ovarian cancer

OBJECTIVE

Our study aimed to evaluate the association between timing of cytoreductive surgery and pattern of presentation of the first recurrence in patients with advanced ovarian cancer. We also aimed to assess the impact of the pattern of recurrence on post-relapse overall survival according to surgical timing.

METHODS

This retrospective multicenter study evaluated patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC-IV ovarian cancer. Patients had undergone either primary debulking surgery, early interval debulking surgery after 3-4 cycles of neoadjuvant chemotherapy, or delayed debulking surgery after 6 cycles, with minimal or no residual disease, between January 2008 and December 2015. Survival analyses were conducted using the Log-rank test and the Cox model. Cumulative incidences of the different patterns of recurrence were estimated using a competing risks methodology.

RESULTS

A total of 549 patients were included: 175 (31.9%) patients had primary, 224 (40.8%) early interval, and 150 (27.3%) delayed debulking surgery. The cumulative incidence of peritoneal recurrences at 2 years was higher with increasing neoadjuvant cycles (24.4%, 30.9% and 39.2%; p=0.019). For pleural or pulmonary recurrences, it was higher after early interval surgery (9.9%, 13.0% and 4.1%; p=0.022). Median post-relapse overall survival was 33.5 months (95% confidence interval (CI) (24.3 to 44.2)), 26.8 months (95% CI (22.8 to 32.6)), and 24.5 months (95% CI (18.6 to 29.4)) for primary, early interval, and delayed debulking surgery groups, respectively (p=0.025). The pattern of recurrence in a lymph node (hazard ratio (HR) 0.42, 95% CI (0.27 to 0.64)), delayed surgery (HR 1.53, 95% CI (1.11 to 2.13)) and time to first recurrence (HR 0.95, 95% CI (0.93 to 0.96)) were associated with post-relapse overall survival. For primary and early interval surgery, lymph node recurrences were associated with significantly longer post-relapse overall survival.

CONCLUSIONS

The pattern of first recurrence was associated with timing of surgery, with peritoneal recurrences being more frequent with the increasing number of cycles of neoadjuvant chemotherapy. Lymph node recurrences were associated with better prognosis, having higher post-relapse overall survival. This improved prognosis of lymphatic recurrences was not observed in patients who underwent delayed surgery.

Cost-Effectiveness Analysis of Olaparib in Combination with Bevacizumab Compared with Bevacizumab Monotherapy for the First-Line Maintenance Treatment of Homologous Recombination Deficiency-Positive Advanced Ovarian Cancer

BACKGROUND

In the PAOLA-1 trial, olaparib plus bevacizumab demonstrated significant clinical benefit following partial or complete response to platinum-based chemotherapy in homologous recombination deficiency (HRD)-positive ovarian cancer. Our study evaluated the cost effectiveness of olaparib plus bevacizumab compared with bevacizumab alone as a maintenance treatment for women in this population.

METHODS

Our model was a cohort-level partitioned survival model with a lifetime horizon from a US healthcare system perspective. Its four health states were progression-free, post first progression, post second progression, and death, modeled using time to first progression (PFS1), second progression (PFS2), and overall survival (OS) from PAOLA-1. We modeled PFS1 through mixture survival modeling, and PFS2 and OS by fitting standard parametric models. Time-on-treatment was sourced directly from PAOLA-1, with treatment capped at 24 months for olaparib and 15 months for bevacizumab. Costs included drug acquisition and administration, adverse events, disease management, biomarker testing, and subsequent treatments. Deterministic and probabilistic sensitivity analyses tested the results.

RESULTS

Compared with bevacizumab alone, olaparib plus bevacizumab increased quality-adjusted life-years (QALYs; +2.89) and life-years (LYs; +3.43) at an incremental cost of $164,209, leading to an incremental cost-effectiveness ratio of $56,863 per QALY. Olaparib plus bevacizumab had a 97.0% probability of being cost effective compared with bevacizumab alone at a willingness-to-pay threshold of $100,000 per QALY.

CONCLUSION

The addition of olaparib to bevacizumab led to clinically significant increases in progression-free survival, resulting in substantial predicted LYs and QALYs gained, while being cost effective in the maintenance treatment of advanced ovarian cancer with HRD in the US.

Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction

Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials-CHORUS, JCOG0602, and SCORPION-have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.

The targeted SMAC mimetic SW IV-134 augments platinum-based chemotherapy in pre-clinical models of ovarian cancer

Background

Ovarian cancer is initially responsive to frontline chemotherapy. Unfortunately, it often recurs and becomes resistant to available therapies and the survival rate for advanced and recurrent ovarian cancer is unacceptably low. We thus hypothesized that it would be possible to achieve more durable treatment responses by combining cisplatin chemotherapy with SW IV-134, a cancer-targeted peptide mimetic and inducer of cell death. SW IV-134 is a recently developed small molecule conjugate linking a sigma-2 ligand with a peptide analog (mimetic) of the intrinsic death pathway activator SMAC (second-mitochondria activator of caspases). The sigma-2 receptor is overexpressed in ovarian cancer and the sigma-2 ligand portion of the conjugate facilitates cancer selectivity. The effector portion of the conjugate is expected to synergize with cisplatin chemotherapy and the cancer selectivity is expected to reduce putative off-target toxicities.

Methods

Ovarian cancer cell lines were treated with cisplatin alone, SW IV-134 alone and a combination of the two drugs. Treatment efficacy was determined using luminescent cell viability assays. Caspase-3/7, − 8 and − 9 activities were measured as complementary indicators of death pathway activation. Syngeneic mouse models and patient-derived xenograft (PDX) models of human ovarian cancer were studied for response to SW IV-134 and cisplatin monotherapy as well as combination therapy. Efficacy of the therapy was measured by tumor growth rate and survival as the primary readouts. Potential drug related toxicities were assessed at necropsy.

Results

The combination treatment was consistently superior in multiple cell lines when compared to the single agents in vitro. The expected mechanism of tumor cell death, such as caspase activation, was confirmed using luminescent and flow cytometry-based assay systems. Combination therapy proved to be superior in both syngeneic and PDX-based murine models of ovarian cancer. Most notably, combination therapy resulted in a complete resolution of established tumors in all study animals in a patient-derived xenograft model of ovarian cancer.

Conclusions

The addition of SW IV-134 in combination with cisplatin chemotherapy represents a promising treatment option that warrants further pre-clinical development and evaluation as a therapy for women with advanced ovarian cancer.

Factors associated with response to neoadjuvant chemotherapy in advanced stage ovarian cancer

OBJECTIVES

To evaluate the factors associated with response to neoadjuvant chemotherapy (NACT) and the ability to undergo interval tumor reductive surgery (iTRS) in patients with advanced ovarian cancer.

METHODS

We performed a retrospective review from April 2013 to March 2019 of patients with advanced stage ovarian cancer triaged to NACT based on our standard triage algorithm. Clinicopathologic and treatment data were analyzed for factors associated with response to NACT, outcomes at iTRS, and their impact on progression-free survival (PFS).

RESULTS

562 patients met inclusion criteria and triaged to NACT following laparoscopy (n = 132) or without laparoscopy (n = 430). 413 patients underwent iTRS (74%). Factors that correlated with a patient reaching iTRS included increasing age (p < 0.001), higher Charlson comorbidity index (p < 0.001), ECOG status 2 or 3 (<0.001), and laparoscopic assessment (<0.001). Patients with CA-125 ≤ 35 U/mL at iTRS had higher rates of complete gross resection (88% vs. 65%, p < 0.001) and improved PFS (16.8 vs. 12.7 months, p < 0.001). Patients receiving dose-dense paclitaxel (76% vs. 60%, p = 0.004) and CA-125 ≤ 35 U/mL at iTRS (85% vs. 66%, p < 0.001) had higher rates of complete radiographic response. On multivariate analysis, germline BRCA 1/2 mutation (p = 0.001), iTRS vs. no surgery (R0, p < 0.001; ≤1 cm, p < 0.001; >1 cm, p < 0.001), dose-dense chemotherapy (p = 0.01), and CA-125 ≤ 35 U/mL at iTRS (p = 0.001) were independent significant factors affecting PFS.

CONCLUSIONS

Normalization of CA-125 at the time of iTRS following NACT may serve as a surrogate marker for prognosis in this high-risk population. Our NACT cohort experienced improved response rates and PFS with dose-dense therapy compared to conventional dosing.

Total parietal peritonectomy performed during interval cytoreductive surgery for advanced epithelial serous ovarian cancer results in a low incidence of platinum resistant recurrence- results of a prospective multi-centre study

BACKGROUND

The reported incidence of platinum resistant recurrence (PRR) (recurrence within 6 months of the last dose of platinum therapy) after interval debulking/cytoreductive surgery (CRS) is high compared to that after primary CRS. The goal was to study PRR following a total parietal peritonectomy (TPP), that addresses occult disease more completely.

METHODS

This is a prospective multi-center study (CTRI/2018/08/015350). A TPP was performed during interval CRS following a fixed surgical protocol. Patients with a follow-up of 6 months(M) or more were included in this analysis. The incidence and patterns of PRR and factors affecting recurrence were analyzed.

RESULTS

From July 2018 to October 2019, 70 patients with serous carcinoma were included. The median surgical PCI was 15 [range 5-37]. A CC-0 resection was obtained in 55 (78.5%); CC-1 in 10 (14.2%). Occult residual disease was seen in 40%. At a median follow-up of 13 months, 17 (24.2%) had developed recurrence/progression. PRR was seen in 5 (7.1%) patients. The sites of progression (>1 in 2 patients) were pleura (n = 1), visceral peritoneum (n = 2), retroperitoneal nodes (n = 2), mediastinal nodes (n = 1) and small bowel mesentery (n = 2). Overall, though the most common site of recurrence was the visceral peritoneum (N = 9), seven (>40%) patients did not develop recurrence in the visceral peritoneum. Patients with high PCI and grade 3-4 complications had a higher probability of developing recurrence.

CONCLUSIONS

TPP performed during interval CRS resulted in a very low incidence of PRR. These findings need confirmation in a larger series. The benefit of TPP over conventional surgery should be evaluated in a randomized trial.

Highly expressed STAT1 contributes to the suppression of stemness properties in human paclitaxel-resistant ovarian cancer cells

Signal transducer and activator of transcription-1 (STAT1) is an important factor in various cellular processes. The cancer stem cell (CSC) is considered as a tumor-initiating cell that drives the inner hierarchy in many cancers including epithelial ovarian cancer (EOC). Here, we explored for the first time the regulation of STAT1 on stemness properties in chemoresistant EOC cells. The paclitaxel (PTX)-resistant EOC cell line (OV3R-PTX) was derived from PTX-sensitive OVCAR-3 cells treated by the PTX regimen. A single cell clone OV3R-PTX-B4 was selected by fluorescence-activated cell sorting. PTX-resistant cells grew slowly in conventional 2D and 3D cultures, but tumor xenograft with PTX-resistant cells grew fast in nude mice. Interestingly, OV3R-PTX-B4 cells shared the characteristics of CSCs and stemness properties were found to be increased in the non-adherent spheroid culture system. The PTX-resistant cells had a high expression of CSC-related markers and low expression of STAT1 that had a high methylation level of CpG in its promoter region. Overexpressed STAT1 suppressed stemness properties, cell proliferation, and colony formation and favored the overall survival of patients with EOC. In summary, these data indicate a regulatory mechanism of STAT1 underlying drug resistance and provide a potential therapeutic application for EOC patients with PTX resistance.

Efficacy and toxicity of prolonged pegylated liposomal doxorubicin use in women with recurrent epithelial ovarian cancer

OBJECTIVE

To evaluate the efficacy and toxicity of extended duration pegylated liposomal doxorubicin (PLD) in women with recurrent epithelial ovarian carcinoma (rEOC).

METHODS

Women with rEOC who received >7 cycles of PLD were retrospectively identified. Response was determined by RECIST 1.1. Progression free survival (PFS) and overall survival (OS) were calculated from PLD initiation. Toxicity was assessed by CTCAE v5.0. Kaplan Meier estimates and Cox proportional hazards were used to evaluate differences in time to recurrence or survival.

RESULTS

69 patients with rEOC received a median of 11.0 cycles (range, 7-115) at a median cumulative dose of 400 mg/m² (range, 210-4600 mg/m²); 29.0% (n = 20) had platinum sensitive and 71.0% (n = 49) had platinum resistant disease. Of the observed grade ¾ toxicities (31.9%; n = 22), dermatologic were most frequent (n = 13; 18.8%). 41 women (59.4%) experienced clinical benefit; complete response in 17.4% (n = 12), partial response in 13.0% (n = 9) and stable disease in 29.0% (n = 20). Median PFS for all patients was 13.0 months (95% CI, 10.7, 15.2); there were no significant differences between platinum sensitive versus resistant disease (15.9 months vs. 12.3 months; HR 1.15, 95% CI, 0.66, 2.00; p = .61). With extended duration PLD, median OS was 40.2 months (95% CI 30.0, 49.0); no significant differences were noted for platinum sensitive versus resistant disease (44.7 months vs. 33.3 months; HR 1.85, 95% CI, 0.91, 3.78; p = .07). Four cases (5.8%) of oral squamous cell carcinoma occurred during treatment.

CONCLUSIONS

Among women with both platinum sensitive and resistant rEOC who received >7 cycles of PLD, approximately one-half experienced sustained clinical benefit with acceptable toxicity. PLD may be considered for extended usage and maintenance in initially responding women with rEOC at least stable disease.

Pathologic chemotherapy response score in epithelial ovarian cancer: Surgical, genetic, and survival considerations

OBJECTIVE

A pathologic chemotherapy response score (CRS) is used to grade ovarian cancer response to neoadjuvant chemotherapy (NACT). We evaluated the prognostic significance of the CRS in a single institution cohort.

METHODS

A retrospective review of all consecutive epithelial ovarian cancer patients undergoing interval debulking surgery (IDS) after NACT from 2016 to 2017 were included. Clinical, pathologic, surgical, outcomes, and genetic data were abstracted from medical records. CRS was assigned by pathology based on a section of omentum as follows: 1 = minimal response, 2 = moderate response, and 3 = near complete response.

RESULTS

Among the 50 subjects, 14 (28%) were classified as CRS1, 29 (58%) as CRS2, and 7 (14%) as CRS3. The majority of patients were diagnosed with high grade serous histology (94%). Most women in this cohort underwent either an optimal or complete cytoreduction to no gross residual disease (96%). Women in the CRS2 group were most likely to have a pathogenic variant (51.7%) while those in the CRS1 were least likely (7.1%). Most women recurred regardless of CRS. CRS was not associated with progression-free survival (log-rank p = 0.82) or overall survival (log-rank p = 0.30).

CONCLUSIONS

Though previous data support the use of CRS as a prognostic indicator, we failed to show a correlation between CRS and survival in our continuous single institution cohort. The high rate of optimal debulking across all CRS groups in this study may mitigate the prognostic significance of the scoring system. Nevertheless, tumors that respond poorly to traditional chemotherapy should remain of avid interest for potential novel therapies.

Does the method of primary treatment affect the pattern of first recurrence in high-grade serous ovarian cancer?

PURPOSE

To determine if the primary treatment approach (primary debulking surgery (PDS) versus neoadjuvant chemotherapy and interval debulking surgery (NACT-IDS)) influences the pattern of first recurrence in patients with completely cytoreduced advanced high-grade serous ovarian carcinoma (HGSOC).

MATERIALS AND METHODS

This retrospective study included 178 patients with newly diagnosed stage IIIC-IV HGSOC, complete gross resection during PDS (n = 124) or IDS (n = 54) from January 2008-March 2013, and baseline and first recurrence contrast-enhanced computed tomography scans. Clinical characteristics and number of disease sites at baseline were analyzed for associations with time to recurrence. In 135 patients who experienced recurrence, the overlap in disease locations between baseline and recurrence and the number of new disease locations at recurrence were analyzed according to the primary treatment approach.

RESULTS

At univariate and multivariate analyses, NACT-IDS was associated with more overlapping locations between baseline and first recurrence (p ≤ 0.003) and fewer recurrences in new anatomic locations (p ≤ 0.043) compared with PDS. The same results were found in a subgroup that received intra-peritoneal adjuvant chemotherapy after either treatment approach. At univariate analysis, patient age, primary treatment approach, adjuvant chemotherapy route, and number of disease locations at baseline were associated with time to recurrence (p ≤ 0.009). At multivariate analysis, older patient age, NACT-IDS, and greater disease locations at baseline remained significant (p ≤ 0.018).

CONCLUSION

The distribution of disease at the time of first recurrence varied with the choice of primary treatment. Compared to patients treated with PDS, patients who underwent NACT-IDS experienced recurrence more often in the same locations as the original disease.

Primary debulking surgery vs. interval debulking surgery for advanced ovarian cancer: review of the literature and meta-analysis

INTRODUCTION

Epithelial ovarian cancer (EOC) is the seventh most common cancer among women in the world and the leading cause of death from gynecological malignancies. The standard treatment for advanced EOC consists of optimal primary debulking surgery (PDS) associated with an adjuvant chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) have been proposed in the management of advanced EOC to increase the rate of complete citoreductive surgery and to reduce morbidity and mortality. This systematic review and meta-analysis is conducted to compare the oncologic and postoperative outcomes of NACT and IDS with PDS followed by chemotherapy in patients with ovarian cancer.

EVIDENCE ACQUISITION

We conducted a search on the electronic databases PubMed/Medline, Cochrane and Scopus. All randomized controlled trials, cohort and case-control studies comparing PDS and IDS in ovarian cancer published in English until 28 February 2019 were considered eligible.

EVIDENCE SYNTHESIS

Twenty studies were included in the systematic review. As regards the meta-analysis, only studies that allowed the data we needed to be extracted were included: five were included for the evaluation of overall survival (OS) and PFS and 9 for the evaluation of major postoperative complications and days of hospital stay.

CONCLUSIONS

From the meta-analysis of the current available literature, none of the two investigated procedures has proven to be superior in terms of OS and PFS in the treatment of advanced ovarian cancer. However surgical complexity and postoperative complications are reduced in the IDS group.

Retrospective analysis of the efficacy of adjuvant CIK cell therapy in epithelial ovarian cancer patients who received postoperative chemotherapy

Cytokine-induced killer (CIK) cells are demonstrated to possess potent cytolytic effect against ovarian cancer cells in vitro and in vivo. However, the clinical efficacy of maintenance therapy of CIK cells in patients with epithelial ovarian cancer (EOC) after first-line treatment remains unclear. This retrospective study included 646 cases of postoperative EOC patients, 72 of which received chemotherapy and sequential immunotherapy (CIT group), and 574 of which received only chemotherapy (Control group). Patients in the CIT group received at least four cycles of CIK cell (range 8.0 × 10⁹ – 1.3 × 10¹⁰ cells) transfusion, with the interval of each cycle being 2 weeks. Survival analysis showed a significantly higher overall survival (OS) rate in the CIT group compared with the control group, as well as a favorable progression-free survival (PFS). Univariate and multivariate analyses indicated that adjuvant CIT was an independent prognostic factor for the OS of patients with EOC. Furthermore, subgroup analyses showed that adjuvant CIT significantly improved the OS of patients older than 45 years, with CA125 ≤ 1000, or with moderate or poorly differentiated tumors, and prolonged the PFS of patients with residual disease > 1 cm. Additionally, Kaplan-Meier analyses revealed that a higher fraction of CD3⁺CD8⁺/CD3⁺CD56⁺ phenotypes or lower percentage of CD3⁺CD4⁺/CD3⁻CD56⁺ phenotypes in the infused CIK cells significantly associated with better survival of patients with EOC. Furthermore, across all processes of CIK cell immunotherapy in the CIT group, 12.5% (9/72) of patients developed self-limiting light fevers and shivering at grade 1 or 2. No immunotherapy-related serious reactions were recorded. These data indicate that adjuvant CIT with CIK cells is an effective therapeutic approach to prolonging the survival of EOC patients.

Combined Immunotherapy (OK-432, IL-2) With Chemotherapy Decrease the Recurrence Rate in Advanced Ovarian Cancer

OBJECTIVE

In advanced ovarian cancer, traditional therapy included debulking surgery and postoperative chemotherapy. We proposed immunochemotherapy (IMCT) combined with picibanil (OK-432), interleukin-2 (IL-2), and traditional platinum- and taxol-based chemotherapy as a better treatment option for advanced ovarian cancer.

METHODS

We retrospectively reviewed the medical records of 51 patients with advanced ovarian cancer between 2007 and 2015 at Chang Gung Memorial Hospital Linkou Medical Center, including 26 patients who were treated with OK-432, IL-2, and platinum- and taxol-based chemotherapy (IMCT group) after debulking surgery; another 25 were treated with traditional platinum- and taxol-based chemotherapy (traditional chemotherapy group) after debulking surgery. We analyzed the difference in age, follow-up period, recurrence rate, and diagnosis-to-recurrence period between the 2 groups. We also analyzed the difference in complete blood cell counts, differentiating counts, and cancer antigen 125 (CA-125) at 1 month after treatment.

RESULTS

The recurrence rate between the IMCT and traditional chemotherapy groups showed a significant difference (53.8% vs 88%; P = .0128). The diagnosis-to-recurrence duration was longer in the IMCT than in the traditional chemotherapy groups (33.21 vs 25.63 months), although no statistical significance was found ( P = .4668). In laboratory analysis at 1 month after treatment, the white blood cell, absolute neutrophil, and absolute lymphocyte counts (ALCs) were significantly higher in the IMCT group. On the other hand, CA-125 was significantly lower, and ALC was significantly higher in the nonrecurrence group.

CONCLUSIONS

Combined IMCT and chemotherapy have lower recurrence rate compared to traditional chemotherapy after debulking surgery for the treatment of advanced ovarian cancer.

The Impact of Number of Cycles of Neoadjuvant Chemotherapy on Survival of Patients Undergoing Interval Debulking Surgery for Stage IIIC–IV Unresectable Ovarian Cancer: Results From a Multi-Institutional Study

Objectives

Neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) may be a valuable treatment option in advanced ovarian cancer when primary cytoreduction is not feasible. However, a consensus on the ideal number of NACT cycles is still lacking. In the present investigation, we aimed to evaluate how number of cycles of NACT influenced patients' outcomes.

Methods

Data of consecutive patients undergoing NACT and IDS were retrospectively reviewed in 4 Italian centers, and survival outcomes were evaluated.

Results

Overall, 193 patients were included. Cycles of NACT were 3, 4, and at least 5 in 77 (40%), 74 (38%), and 43 (22%) patients, respectively. Patients undergoing 3 cycles experienced a similar disease-free survival (hazard ratio [HR], 1.12; 95% confidence interval [CI], 0.89–1.65; P = 0.20) but an improved overall survival (HR, 1.64; 95% CI, 1.05–2.4; P = 0.02) in comparison to patients receiving at least 4 cycles. Five-year overall survival was 46% and 31% for patients having 3 and at least 4 cycles. Ten-year overall survival was 26% and 18% for patients having 3 and at least 4 cycles (HR, 1.70; 95% CI, 1.13–2.55; P = 0.009). Using multivariate analysis, we observed that only Eastern Cooperative Oncology Group performance status correlated with overall survival (HR, 1.76; 95% CI, 1.2–2.49; P = 0.001). In addition, a trend toward worse overall survival was observed for patients with residual disease at IDS (HR, 1.29; 95% CI, 0.98–1.70; P = 0.06) and patients receiving at least 4 cycles (HR, 1.76; 95% CI, 0.95–3.22; P = 0.06).

Conclusion

Our data underline the potential implication of number of cycles of NACT before IDS. Further prospective studies are warranted to assess this correlation.

Neoadjuvant chemotherapy versus primary debulking surgery in advanced epithelial ovarian cancer: A meta-analysis of peri-operative outcome

Objective

To assess whether neoadjuvant chemotherapy (NACT) is superior to primary debulking surgery (PDS) with regard to optimal cytoreduction, peri-operative morbidity, mortality, and quality of life (QOL) in advanced epithelial ovarian cancer (EOC).

Methods

We searched the PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, Registers of Clinical Trials for randomized controlled trials (RCTs) comparing NACT to PDS in women with Federation of International Gynaecologists and Obstetricians stage Ⅲ-Ⅳ EOC. RevMan 5.3 software was utilized for statistical analysis.

Results

Four RCTs involving 1,607 women with advanced EOC were included. Compared with PDS, NACT provided a higher rate of complete cytoreduction (risk ratio [RR], 1.95; 95% confidence interval [CI], 1.33 to 2.87), optimal cytoreduction (RR: 1.61 [95%CI: 1.05 to 2.47]), but there was no significant difference in residual disease 0–1 cm (p = 0.49). NACT was associated with lower peri-operative morbidity with respect to infection (RR: 0.30 [95% CI: 0.16 to 0.56]), gastrointestinal fistula (RR: 0.24 [95% CI: 0.06 to 0.95]), any grade 3 or 4 adverse event (RR: 0.29 [95% CI: 0.11 to 0.78]), and less post-surgical death within 28 days (RR: 0.14 [95% CI: 0.04 to 0.49]). NACT provided better QOL in terms of fatigue (weight mean difference [WMD], -3.28; [95% CI: -3.99 to -2.57]), role functioning (WMD: 5.29 [95% CI: 4.44 to 6.14]), emotional functioning (WMD: 6.19 [95% CI: 5.57 to 6.82]), and cognitive functioning (WMD: 1.02 [95% CI: 0.43 to 1.61]) at 6-month follow-up compared with PDS.

Conclusions

NACT is associated with superior optimal cytoreduction, lower peri-operative morbidity as well as post-surgical mortality, and better QOL compared to initial surgery in patients with advanced EOC. Future research should focus on improving the efficacy of NACT.

Recent Advances in Understanding, Diagnosing, and Treating Ovarian Cancer

Ovarian cancer, a term that encompasses ovarian, fallopian, and peritoneal cancers, is the leading cause of gynecologic cancer mortality. To improve patient outcomes, the field is currently focused on defining the mechanisms of cancer formation and spread, early diagnosis and prevention, and developing novel therapeutic options. This review summarizes recent advances in these areas.