Preoperative Predictive Factors for Complete Cytoreduction and Survival Outcome in Epithelial Ovarian, Tubal, and Peritoneal Cancer After Neoadjuvant Chemotherapy

External validation of Standardized KELIM and platinum-resistant recurrence scores in patients with advanced epithelial ovarian cancer

BACKGROUND

Neoadjuvant chemotherapy followed by interval debulking surgery is currently a common treatment option for advanced epithelial ovarian cancer (EOC). The Standardized CA-125 ELIMination rate constant K (Std KELIM) and the Platinum Resistant Recurrence (PtRR) Score have been proposed as markers of tumor chemosensitivity. The aim of our study was to validate these tools for predicting platinum sensitivity in a real-world population of patients with advanced EOC treated with neoadjuvant chemotherapy.

EXPERIMENTAL DESIGN

All patients with advanced EOC treated with neoadjuvant chemotherapy at the Institut Curie between 2000 and 2015 were included. The Std KELIM was calculated with the CA-125 concentrations during the first 100 days of chemotherapy. The predictive value of Std KELIM and PtRR scores for the risk of subsequent PtRR was assessed using receiver operating characteristic (ROC) curve analysis, logistic regression and calibration curve. Kaplan-Meier survival analysis was performed for the treatment-free interval from platinum (TFIp) therapy and overall survival (OS).

RESULTS

Std KELIM data were available for 149 patients. The AUC was 0.67 for PtRR. A low Std KELIM was significantly associated with PtRR (OR = 0.19 (95% CI [0.06, 0.53], p = 0.002)) according to the univariate analysis. The calibration curve of the PtRR showed a slight but significant underestimation (p = 0.02) of the probability of platinum resistance. Favorable Std KELIM (≥ 1) alone and combined with the completeness of surgery were associated with significantly better survival in terms of TFIp and OS.

CONCLUSIONS

Std KELIM is an early prognostic marker of chemosensitivity in a real-life setting complementary to surgical status. It could help the clinician in the early management of patients by identifying those with a worse prognosis.

Is there a correlation of positive peritoneal washing cytology during interval debulking surgery on the survival outcomes of ovarian cancer patients? A systematic review and meta-analysis of the literature

OBJECTIVE

The aim of the present study was to evaluate the prognostic impact of peritoneal washing cytology (PWC) on progression-free (PFS) and overall survival (OS) of patients undergoing interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT) for ovarian cancer (OC).

METHODS

We systematically searched Medline (1966-2020), Scopus (2004-2020), EMBASE (1980-2020), Cochrane Central Register of Controlled Trials CENTRAL (1999-2020), Clinicaltrials.gov (2008-2020) and Google Scholar (2004-2020). All the studies that investigated the correlation of peritoneal washing cytology with survival outcomes of patients undergoing interval debulking for ovarian cancer, were finally included in the present meta-analysis.

RESULTS

A total of 7 retrospective studies were included, comprising 907 patients, of whom 535 had positive peritoneal washing cytology on interval debulking surgery. The methodological quality of the included studies was assessed as moderate, primarily due to the lack of data referring to the adequacy of the follow-up of patients and secondarily due the lack of comparability of patients. Progression - free survival was significantly better in the negative peritoneal cytology group (HR 2.07, 95% CI 1.73, 2.48 respectively), however, overall survival did not reach a significant difference among the two groups (HR 1.90, 95% CI 0.99, 3,65, p = 0.052).

CONCLUSIONS

Our data support a negative correlation between positive peritoneal washing cytology at interval debulking surgery and the survival of ovarian cancer patients.

Emerging Trends in Neoadjuvant Chemotherapy for Ovarian Cancer

Simple Summary

Epithelial ovarian cancer is one of the most lethal cancers in women and is typically diagnosed at an advanced-stage. Historically, primary tumor reductive surgery was attempted followed by postoperative chemotherapy in most patients diagnosed with advanced ovarian cancer. However, neoadjuvant chemotherapy followed by interval tumor reductive surgery is an alternative approach for patients with advanced-stage ovarian cancer where primary tumor reductive surgery is not feasible. Here, we review proposed models that can assist in selecting patients who would benefit most from neoadjuvant chemotherapy followed by surgery.

Abstract

Epithelial ovarian cancer remains a leading cause of death amongst all gynecologic cancers despite advances in surgical and medical therapy. Historically, patients with ovarian cancer underwent primary tumor reductive surgery followed by postoperative chemotherapy; however, neoadjuvant chemotherapy followed by interval tumor reductive surgery has gradually become an alternative approach for patients with advanced-stage ovarian cancer for whom primary tumor reductive surgery is not feasible. Decision-making about the use of these approaches has not been uniform. Hence, it is essential to identify patients who can benefit most from neoadjuvant chemotherapy followed by interval tumor reductive surgery. Several prospective and retrospective studies have proposed potential models to guide upfront decision-making for patients with advanced ovarian cancer. In this review, we summarize important decision-making models that can improve patient selection for personalized treatment. Models based on clinical factors (clinical parameters, radiology studies and laparoscopy scoring) and molecular markers (circulating and tumor-based) are useful, but laparoscopic staging is among the most informative diagnostic methods for upfront decision-making in patients medically fit for surgery. Further research is needed to explore more reliable models to determine personalized treatment for advanced epithelial ovarian cancer.

Inflammatory signals induce MUC16 expression in ovarian cancer cells via NF-κB activation

Cancer antigen 125 (CA125), encoded by the mucin 16 cell surface associated (MUC16) gene, has been widely used as a biomarker for ovarian cancer (OC) screening. However, it has yet to be elucidated as to why its levels increase with tumor progression as well as with certain other non-malignant conditions. Based on our knowledge of the inflammatory microenvironment (IME) in OC, HEY cells were treated with several inflammation-associated factors as well as their antagonists, and it was observed that inflammation-associated factors upregulated MUC16 gene expression. Considering the role of nuclear factor (NF)-κB in the inflammatory signaling network and our previous research on OC, chromatin immunoprecipitation was performed, and it was observed that activated NF-κB bound to the MUC16 gene promoter and enhanced its expression, thereby elevating secreted CA125 levels. These findings demonstrated that IME and MUC16 gene expression were associated in OC, partly elucidating the role of IME in tumor progression, explaining the elevated serum CA125 levels in some non-malignant conditions, and confirming IME as a potential target for OC therapy.

The Emerging Role of Neutral Argon Plasma (PlasmaJet) in the Treatment of Advanced Stage Ovarian Cancer: A Systematic Review

Objective. To evaluate the contribution of PlasmaJet application in achieving optimal cytoreduction in advanced ovarian cancer. Methods. We systematically searched for articles published up to June 2019 using MEDLINE, Scopus, Google Scholar databases and clinicaltrials.gov along with the references of the articles retrieved in full text. Observational studies and case reports addressing cases of women with peritoneal spread due to advanced stage ovarian cancer who were treated with application of PlasmaJet device were considered eligible for inclusion. Results. Three studies were excluded from further analysis when they were retrieved in full text. Five studies (2 retrospective, 1 prospective, and 2 case reports) that comprised 77 patients with age range from 38 to 85 years were included. Forty-three women underwent interval debulking surgery, 24 patients primary debulking surgery, and 6 had optimal debulking surgery, while in the remaining 4, a secondary debulking surgery was performed. Incidence of intraoperative complications was 32% (8/25), but none of them was due to the application of PlasmaJet. Complete macroscopic resection was achieved in 59 out of 70 (84.3%) women. Postoperatively, 17 out of 72 patients (23.6%) developed complications such as pneumothorax due to diaphragmatic resection, systemic infections, or wound-related complications. No postoperative mortality was recorded. Conclusions. Preliminary data on the use of PlasmaJet for ablation of ovarian cancer implants in the peritoneal cavity showed its safety and presented with promising outcomes in achieving complete cytoreduction.

Preoperative serum levels of HE4 and CA125 predict primary optimal cytoreduction in advanced epithelial ovarian cancer: a preliminary model study

Objective

The aim of this study is to establish a noninvasive preoperative model for predicting primary optimal cytoreduction in advanced epithelial ovarian cancer by HE4 and CA125 combined with clinicopathological parameters.

Methods

Clinical data including preoperative serum HE4 and CA125 level of 83 patients with advanced epithelial ovarian cancer were collected. The sensitivity, specificity, positive predictive value, negative predictive value and overall accuracy of each clinical parameter were calculated. The Predictive Index score model and the logistic model were constructed to predict the primary optimal cytoreduction.

Results

Optimal surgical cytoreduction was achieved in 62.65% (52/83) patients. Cutoff values of preoperative serum HE4 and CA125 were 777.10 pmol/L and 313.60 U/ml. (1) Patients with PIV ≥ 6 may not be able to achieve optimal surgical cytoreduction. The diagnostic accuracy, NPV, PPV and specificity for diagnosing suboptimal cytoreduction were 71, 100, 68, and 100%, respectively. (2) The logistic model was: logit p = 0.12 age − 2.38 preoperative serum CA125 level − 1.86 preoperative serum HE4 level-2.74 histological type-3.37. AUC of the logistic model in the validation group was 0.71(95%CI 0.54–0.88, P = 0.025). Sensitivity and specificity were 1.00 and 0.44, respectively.

Conclusion

Age, preoperative serum CA125 level and preoperative serum HE4 level are important non-invasive predictors of primary optimal surgical cytoreduction in advanced epithelial ovarian cancer. Our PIV and logistic model can be used for assessment before expensive and complex predictive methods including laparoscopy and diagnostic imaging. Further future clinical validation is needed.

Neutrophil-to-lymphocyte ratio as a prognostic factor in advanced stage ovarian carcinoma treated with neoadjuvant chemotherapy

OBJECTIVES

To evaluate the prognostic significance of neutrophil-to-lymphocyte ratio (NLR) upon diagnosis, and its impact on surgical outcome, among patients with advanced stage ovarian carcinoma treated with neoadjuvant chemotherapy (NACT).

METHODS

A retrospective cohort study included all women with stage IIIC and IV ovarian carcinoma receiving NACT in Rabin Medical Center, Petah-Tikva, Israel; January 1, 2005, to June 30, 2017. Demographics and treatment outcome were compared between patients with NLR at diagnosis ≥6.0 and those with NLR <6.0. Primary outcome was optimal debulking (<1 cm largest residual disease). Overall survival was compared between groups using Kaplan-Meier survival analysis.

RESULTS

Of 111 patients, 33 (29.7%) had NLR ≥6.0 at diagnosis, and 78 (70.3%) had NLR <6.0. No difference was found in rates of optimal debulking between the group with NLR ≥6.0 and that with NLR <6.0 (78.9% vs 84.7%, respectively, P=0.555). Using Kaplan-Meier survival analysis, NLR ≥6.0 was associated with significantly worse overall survival (P<0.05). In a multivariate Cox proportional hazard model, elevated NLR was not statistically associated with poor overall survival (P=0.080).

CONCLUSIONS

In advanced stage ovarian carcinoma, NLR ≥6.0 at diagnosis did not predict surgical outcome, however it was a predictive factor for poor overall survival.

Lymphopenia after induction chemotherapy correlates with incomplete surgical resection in patients with advanced ovarian cancer

BACKGROUND

Lymphopenia is associated with poor outcomes in patients with various cancers, but little is known about the prognostic impact of lymphopenia in patients with epithelial ovarian cancer (EOC) after induction chemotherapy (IC). This study investigated the prognostic significance of pre- and post-IC lymphopenia in patients with advanced EOC.

METHODS

We reviewed medical records of 68 patients with stage III/IV ovarian, fallopian tube, or peritoneal cancer treated with IC at our institution between 2009 and 2017. We assessed the associations of pre- and post-IC inflammatory markers, including lymphocyte counts, with several oncological outcomes, such as the implementation of interval debulking surgery (IDS), complete resection, progression-free survival (PFS), and overall survival (OS).

RESULTS

Lymphocyte counts increased significantly post-IC compared with the pre-IC values (P = 0.009). Pre-IC lymphopenia was observed in 27 patients (40%), whereas only 16 patients (24%) displayed lymphopenia post-IC (P = 0.020). Among several inflammatory markers, only post-IC lymphopenia was significantly associated with incomplete resection outcome during IDS (P = 0.012). Moreover, post-IC lymphopenia was significantly associated with poor PFS (log-rank test, P = 0.009), whereas pre-IC lymphopenia was associated with neither PFS nor OS.

CONCLUSIONS

Post-IC lymphopenia may predict incomplete resection during IDS and poor prognosis in patients with advanced EOC.

Prognostic Value of Pathologic Chemotherapy Response Score in Patients With Ovarian Cancer After Neoadjuvant Chemotherapy

OBJECTIVES

The aim of the study was to investigate the correlation of chemotherapy response score (CRS) after neoadjuvant chemotherapy (NACT) to treatment outcomes in ovarian cancer (OC).

METHODS

Chemotherapy response score was retrospectively determined on pathology slides of all patients with epithelial OC that had interval debulking surgery (IDS) between 2009-2014. Chemotherapy response score 1 was given when tumor was present and infiltrated by inflammatory cells, CRS 2 when both tumor and regressive chemotherapy changes were present, and CRS 3 when scant tumor was seen within extensive chemotherapy-induced changes. Patients' characteristics including survival data were collected and compared between CRS groups.

RESULTS

Pathology slides of 132 patients were reviewed. Forty-nine patients had CRS 1, 65 had CRS 2, and 18 had CRS 3. Age, stage, and grade were not different across CRS groups. A higher percent of CRS 1 and 2 patients required more than 3 cycles of NACT, whereas CRS 3 patients had higher rates of no residual disease at completion of IDS. Chemotherapy response score 3 group showed the most significant CA125 decrease after NACT (97% decrease, P = 0.016). Kaplan-Meir survival curves showed a significantly longer progression-free survival but not overall survival for patients with CRS 3 (median progression-free survival = 7.5, 12, and 17 months for CRS 1, 2, and 3, respectively, P = 0.012), and this remained statistically significant in both univariate and multivariate analysis. Interobserver reproducibility for CRS was good (weighed κ = 0.762).

CONCLUSIONS

Patients with CRS 3 have longest progression-free survival and highest CA125 drop after NACT. These parameters have important prognostic value and can be used for clinical decision-making.

A predictive score for optimal cytoreduction at interval debulking surgery in epithelial ovarian cancer: a two- centers experience

Background

Optimal cytoreduction (macroscopic Residual Tumor, RT = 0) is the best survival predictor factor in epithelial ovarian cancer (EOC). It doesn’t exist a consolidated criteria to predict optimal surgical resection at interval debulking surgery (IDS). The aim of this study is to develop a predictive model of complete cytoreduction at IDS.

Methods

We, retrospectively, analyzed 93 out of 432 patients, with advanced EOC, underwent neoadjuvant chemotherapy (NACT) and IDS from January 2010 to December 2016 in two referral cancer centers. The correlation between clinical-pathological variables and residual disease at IDS has been investigated with univariate and multivariate analysis. A predictive score of cytoreduction (PSC) has been created by combining all significant variables. The performance of each single variable and PSC has been reported and the correlation of all significant variables with progression free survival (PFS) has been assessed.

Results

At IDS, 65 patients (69,8%) had complete cytoreduction with no residual disease (R = 0). Three criteria independently predicted R > 0: age ≥ 60 years (p = 0.014), CA-125 before NACT > 550 UI/dl (p = 0.044), and Peritoneal Cancer Index (PCI) > 16 (p < 0.001). A PSC ≥ 3 has been associated with a better accuracy (85,8%), limiting the number of incomplete surgeries to 16,5%. Moreover, a PCI > 16, a PSC ≥ 3 and the presence of R > 0 after IDS were all significantly associated with shorter PFS (p < 0.001, p < 0.001 and p = 0.004 respectively).

Conclusions

Our PSC predicts, in a large number of patients, complete cytoreduction at IDS, limiting the rate of futile extensive surgeries in case of presence of residual tumor (R > 0). The PSC should be prospectively validated in a larger series of EOC patients undergoing NACT-IDS.