Cytoreductive surgery and intraoperative administration of paclitaxel-loaded expansile nanoparticles delay tumor recurrence in ovarian carcinoma

BACKGROUND

Locoregional recurrence significantly impacts survival and quality of life in patients with ovarian carcinoma. We hypothesize that local administration of paclitaxel-loaded expansile nanoparticles (pax-eNP) at the time of cytoreductive surgery decreases local tumor recurrence.

METHODS

In vitro cytotoxicity of pax-eNP was assessed against both the OVCAR-3 human ovarian cancer cell line and tumor cells isolated from a malignant pleural effusion from a patient with multidrug-resistant ovarian cancer. A murine xenogenic model involving surgical cytoreduction of established OVCAR-3 intra-abdominal tumor was used to evaluate in vivo efficacy of intraoperative intraperitoneal (IP) injection of 10 mg/kg of paclitaxel either as pax-eNP or paclitaxel in Cremophor EL/ethanol solution (pax-C/E) versus empty eNP controls. Cytoreductive surgery and intraoperative treatment were performed 4 weeks after established tumor. All animals were sacrificed when empty eNP controls displayed extensive evidence of disease progression.

RESULTS

Labeled-eNP entered tumor cells in vitro within 4 h and specifically accumulated at sites of tumor in vivo. Pax-eNP exhibited dose-dependent cytotoxicity in both OVCAR-3 and patient tumor cells isolated from a malignant pleural effusion and effectively prevented tumor recurrence following debulking (p = 0.003 vs. empty eNP). Furthermore, pax-eNP-treated animals did not develop severe recurrent carcinomatosis compared with 43 % of the pax-C/E-treated cohort, suggesting that single-dose intracavitary pax-eNP is more effective than an equivalent dose of pax-C/E.

CONCLUSIONS

Expansile nanoparticles readily enter human ovarian tumor cells and localize to sites of tumor in vivo with pax-eNP cytotoxicity resulting in superior inhibition of locoregional tumor recurrence following cytoreductive surgery.

Intraperitoneal chemotherapy for epithelial ovarian cancer - single center experience

Majority of intraperitoneal (IP) chemotherapy complications were related to the chemoport. Aim of our study was to find the means of reducing complications of IP chemoport, to increase the benefits of IP chemotherapy. During January 2007 to December 2010, hundred consecutive patients of stage III epithelial ovarian cancer who had optimal cytoreduction underwent chemoport insertion during laparotomy. Initial 20 cases had 14.3F Bard IP chemoport, and later cases had 9.6Fr single lumen venous port inserted intraperitoneally. Entry point into the peritoneum was single, 6 cm lateral to the umbilicus and double purse-string suture taken around the catheter to prevent peri-catheter backflow of ascitic fluid or drug. Modified IP chemotherapy regimen (SWOG-9912 trial) was used. Age of the patient ranged from 34 years to 76 years. In total 600 cycles, 516 cycles (86 %) were completed. Seventy patients (70 %) received all the 6 cycles by IP route. Two in the initial 10 patients had vaginal leak, for whom first 2 cycles were given by IV route and then shifted to IP route. Subsequently all cases had double layer closure of vaginal vault. Nine patients (9 %) had port related complications, in which 8 were transient. Catheter block was seen in 5 cases, of which 4 salvaged by heparin injection lock for 2 h and in subsequent cases IV port access catheter with valve replaced the fenestrated IP catheter. None of the IV catheters had the block. Four cases had backflow of fluid around catheter collecting around the port chamber site. Two patients had severe abdominal pain due to dense adhesions and further cycles were completed by IV route. Cisplatin was replaced with carboplatin in 5 cases with severe toxicity. Longest follow-up is 4 years with median follow up of 1.8 years.70 % are disease free on follow up. Local recurrence rate was 18 and systemic in 8 cases. Mortality rate is 4 %. Complications of IP ports are low when insertion is done meticulously with a dedicated team. With modified IP dose and drug regimen, side effects are less and most patients can complete all the desired cycles.

Current and future directions of clinical trials for ovarian cancer

BACKGROUND

The management of ovarian cancer includes a combination of surgery and chemotherapy. The majority of clinical trials have historically addressed questions pertaining to the selection, dosing, and schedule of chemotherapy agents.

METHODS

In this report, a comprehensive review of the major clinical trials in ovarian cancer is performed. The increasing data and clinical experience in the management of ovarian cancer, as it sets the stage for currently active protocols and future clinical trial design, are emphasized.

RESULTS

Paclitaxel plus carboplatin is the primary intravenous treatment strategy in the front-line setting. Recent data show an improvement in overall survival for intravenous dose-dense treatment. Multiple randomized controlled trials support the use of intraperitoneal treatment. For recurrent disease, a growing number of new agents including targeted therapeutics are now available. Increasingly, surgical approach, biologic targets, and quality of life endpoints are included in clinical trial design.

CONCLUSIONS

Over the last several decades, clinical trials have defined the current therapeutic approach for ovarian cancer. Paclitaxel with a platinum-based agent is currently the preferred front-line therapy, with encouraging data to support either dose-dense or intraperitoneal drug delivery. Future trials will determine the role of biologic agents and vaccine therapies, as well as their impact on quality of life.

Targeted agents in ovarian cancer

Despite recent advances in the treatment of ovarian cancer, a large majority of women with this diagnosis will die from recurrence of their disease. Targeted therapies, in the form of monoclonal antibodies and small molecule tyrosine kinase inhibitors have significantly altered the management of many solid tumors and hematologic malignancies. No such agents have been approved by the US FDA for use in ovarian cancer, although Phase II data suggests excellent single-agent activity of some of these drugs. Antiangiogenic agents in combination with chemotherapy are being evaluated in Phase III clinical trials, both in the adjuvant setting and in recurrent platinum-sensitive disease. Poly-ADP-ribose polymerase inhibitors are promising agents in BRCA1/2-mutated breast and ovarian cancers. Ongoing clinical trials are exploring the anti-tumor effect of poly-ADP-ribose polymerase inhibitors administered as single agents and in combination with chemotherapy. Many other new drugs are in earlier grades of development. In this article, we review the state of the art in targeted therapies for ovarian cancer and identify future directions for their development in the management of this often devastating disease.

Current and Future Directions of Clinical Trials for Ovarian Cancer

Background

The management of ovarian cancer includes a combination of surgery and chemotherapy. The majority of clinical trials have historically addressed questions pertaining to the selection, dosing, and schedule of chemotherapy agents.

Methods

In this report, a comprehensive review of the major clinical trials in ovarian cancer is performed. The increasing data and clinical experience in the management of ovarian cancer, as it sets the stage for currently active protocols and future clinical trial design, are emphasized.

Results

Paclitaxel plus carboplatin is the primary intravenous treatment strategy in the front-line setting. Recent data show an improvement in overall survival for intravenous dose-dense treatment. Multiple randomized controlled trials support the use of intraperitoneal treatment. For recurrent disease, a growing number of new agents including targeted therapeutics are now available. Increasingly, surgical approach, biologic targets, and quality of life endpoints are included in clinical trial design.

Conclusions

Over the last several decades, clinical trials have defined the current therapeutic approach for ovarian cancer. Paclitaxel with a platinum-based agent is currently the preferred front-line therapy, with encouraging data to support either dose-dense or intraperitoneal drug delivery. Future trials will determine the role of biologic agents and vaccine therapies, as well as their impact on quality of life.