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Weigert M, Cui XL, West-Szymanski D, Yu X, Bilecz AJ, Zhang Z, Dhir R, Kehoe M, Zhang W, He C, Lengyel E. 5-Hydroxymethylcytosine signals in serum are a predictor of chemoresistance in high-grade serous ovarian cancer. Gynecol Oncol 2024; 182:82-90. [PMID: 38262243 DOI: 10.1016/j.ygyno.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 12/11/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE The genome-wide profiling of 5-hydroxymethylcytosines (5hmC) on circulating cell-free DNA (cfDNA) has revealed promising biomarkers for various diseases. The purpose of this study was to investigate 5hmC signals in serum cfDNA and identify novel predictive biomarkers for the development of chemoresistance in high-grade serous ovarian cancer (HGSOC). We hypothesized that 5hmC profiles in cfDNA reflect the development of chemoresistance and elucidate pathways that may drive chemoresistance in HGSOC. Moreover, we sought to identify predictors that would better stratify outcomes for women with intermediate-sensitive HGSOC. METHODS Women diagnosed with HGSOC and known platinum sensitivity status were selected for this study. Nano-hmC-Seal was performed on cfDNA isolated from archived serum samples, and differential 5hmC features were identified using DESeq2 to establish a model predictive of chemoresistance. RESULTS A multivariate model consisting of three features (preoperative CA-125, largest residual implant after surgery, 5hmC level of OSGEPL), stratified samples from intermediate sensitive, chemo-naive women diagnosed with HGSOC into chemotherapy-resistant- and sensitive-like strata with a significant difference in overall survival (OS). Independent analysis of The Cancer Genome Atlas data further confirmed that high OSGEPL1 expression is a favorable prognostic factor for HGSOC. CONCLUSIONS We have developed a novel multivariate model based on clinico-pathologic data and a cfDNA-derived 5hmC modified gene, OSGEPL1, that predicted response to platinum-based chemotherapy in intermediate-sensitive HGSOC. Our multivariate model applies to chemo-naïve samples regardless if the patint was treated with adjuvant or neoadjuvant chemotherapy. These results merit further investigation of the predictive capability of our model in larger cohorts.
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Affiliation(s)
- Melanie Weigert
- Department of Obstetrics and Gynecology/Section of Gynecologic Oncology, The University of Chicago, Chicago, IL, USA
| | - Xiao-Long Cui
- Department of Chemistry, Department of Biochemistry and Molecular Biology, Institute for Biophysical Dynamics, The University of Chicago, Chicago, IL, USA
| | - Diana West-Szymanski
- Department of Chemistry, Department of Biochemistry and Molecular Biology, Institute for Biophysical Dynamics, The University of Chicago, Chicago, IL, USA
| | - Xianbin Yu
- Department of Chemistry, Department of Biochemistry and Molecular Biology, Institute for Biophysical Dynamics, The University of Chicago, Chicago, IL, USA
| | | | - Zhou Zhang
- Department of Preventive Medicine and The Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Rohin Dhir
- Department of Obstetrics and Gynecology/Section of Gynecologic Oncology, The University of Chicago, Chicago, IL, USA
| | - Mia Kehoe
- Department of Obstetrics and Gynecology/Section of Gynecologic Oncology, The University of Chicago, Chicago, IL, USA
| | - Wei Zhang
- Department of Preventive Medicine and The Robert H. Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chuan He
- Department of Chemistry, Department of Biochemistry and Molecular Biology, Institute for Biophysical Dynamics, The University of Chicago, Chicago, IL, USA; Howard Hughes Medical Institute, The University of Chicago, Chicago, IL, USA
| | - Ernst Lengyel
- Department of Obstetrics and Gynecology/Section of Gynecologic Oncology, The University of Chicago, Chicago, IL, USA.
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Bryant A, Hiu S, Kunonga PT, Gajjar K, Craig D, Vale L, Winter-Roach BA, Elattar A, Naik R. Impact of residual disease as a prognostic factor for survival in women with advanced epithelial ovarian cancer after primary surgery. Cochrane Database Syst Rev 2022; 9:CD015048. [PMID: 36161421 PMCID: PMC9512080 DOI: 10.1002/14651858.cd015048.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ovarian cancer is the seventh most common cancer among women and a leading cause of death from gynaecological malignancies. Epithelial ovarian cancer is the most common type, accounting for around 90% of all ovarian cancers. This specific type of ovarian cancer starts in the surface layer covering the ovary or lining of the fallopian tube. Surgery is performed either before chemotherapy (upfront or primary debulking surgery (PDS)) or in the middle of a course of treatment with chemotherapy (neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS)), with the aim of removing all visible tumour and achieving no macroscopic residual disease (NMRD). The aim of this review is to investigate the prognostic impact of size of residual disease nodules (RD) in women who received upfront or interval cytoreductive surgery for advanced (stage III and IV) epithelial ovarian cancer (EOC). OBJECTIVES To assess the prognostic impact of residual disease after primary surgery on survival outcomes for advanced (stage III and IV) epithelial ovarian cancer. In separate analyses, primary surgery included both upfront primary debulking surgery (PDS) followed by adjuvant chemotherapy and neoadjuvant chemotherapy followed by interval debulking surgery (IDS). Each residual disease threshold is considered as a separate prognostic factor. SEARCH METHODS We searched CENTRAL (2021, Issue 8), MEDLINE via Ovid (to 30 August 2021) and Embase via Ovid (to 30 August 2021). SELECTION CRITERIA We included survival data from studies of at least 100 women with advanced EOC after primary surgery. Residual disease was assessed as a prognostic factor in multivariate prognostic models. We excluded studies that reported fewer than 100 women, women with concurrent malignancies or studies that only reported unadjusted results. Women were included into two distinct groups: those who received PDS followed by platinum-based chemotherapy and those who received IDS, analysed separately. We included studies that reported all RD thresholds after surgery, but the main thresholds of interest were microscopic RD (labelled NMRD), RD 0.1 cm to 1 cm (small-volume residual disease (SVRD)) and RD > 1 cm (large-volume residual disease (LVRD)). DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. Where possible, we synthesised the data in meta-analysis. To assess the adequacy of adjustment factors used in multivariate Cox models, we used the 'adjustment for other prognostic factors' and 'statistical analysis and reporting' domains of the quality in prognosis studies (QUIPS) tool. We also made judgements about the certainty of the evidence for each outcome in the main comparisons, using GRADE. We examined differences between FIGO stages III and IV for different thresholds of RD after primary surgery. We considered factors such as age, grade, length of follow-up, type and experience of surgeon, and type of surgery in the interpretation of any heterogeneity. We also performed sensitivity analyses that distinguished between studies that included NMRD in RD categories of < 1 cm and those that did not. This was applicable to comparisons involving RD < 1 cm with the exception of RD < 1 cm versus NMRD. We evaluated women undergoing PDS and IDS in separate analyses. MAIN RESULTS We found 46 studies reporting multivariate prognostic analyses, including RD as a prognostic factor, which met our inclusion criteria: 22,376 women who underwent PDS and 3697 who underwent IDS, all with varying levels of RD. While we identified a range of different RD thresholds, we mainly report on comparisons that are the focus of a key area of clinical uncertainty (involving NMRD, SVRD and LVRD). The comparison involving any visible disease (RD > 0 cm) and NMRD was also important. SVRD versus NMRD in a PDS setting In PDS studies, most showed an increased risk of death in all RD groups when those with macroscopic RD (MRD) were compared to NMRD. Women who had SVRD after PDS had more than twice the risk of death compared to women with NMRD (hazard ratio (HR) 2.03, 95% confidence interval (CI) 1.80 to 2.29; I2 = 50%; 17 studies; 9404 participants; moderate-certainty). The analysis of progression-free survival found that women who had SVRD after PDS had nearly twice the risk of death compared to women with NMRD (HR 1.88, 95% CI 1.63 to 2.16; I2 = 63%; 10 studies; 6596 participants; moderate-certainty). LVRD versus SVRD in a PDS setting When we compared LVRD versus SVRD following surgery, the estimates were attenuated compared to NMRD comparisons. All analyses showed an overall survival benefit in women who had RD < 1 cm after surgery (HR 1.22, 95% CI 1.13 to 1.32; I2 = 0%; 5 studies; 6000 participants; moderate-certainty). The results were robust to analyses of progression-free survival. SVRD and LVRD versus NMRD in an IDS setting The one study that defined the categories as NMRD, SVRD and LVRD showed that women who had SVRD and LVRD after IDS had more than twice the risk of death compared to women who had NMRD (HR 2.09, 95% CI 1.20 to 3.66; 310 participants; I2 = 56%, and HR 2.23, 95% CI 1.49 to 3.34; 343 participants; I2 = 35%; very low-certainty, for SVRD versus NMRD and LVRD versus NMRD, respectively). LVRD versus SVRD + NMRD in an IDS setting Meta-analysis found that women who had LVRD had a greater risk of death and disease progression compared to women who had either SVRD or NMRD (HR 1.60, 95% CI 1.21 to 2.11; 6 studies; 1572 participants; I2 = 58% for overall survival and HR 1.76, 95% CI 1.23 to 2.52; 1145 participants; I2 = 60% for progression-free survival; very low-certainty). However, this result is biased as in all but one study it was not possible to distinguish NMRD within the < 1 cm thresholds. Only one study separated NMRD from SVRD; all others included NMRD in the SVRD group, which may create bias when comparing with LVRD, making interpretation challenging. MRD versus NMRD in an IDS setting Women who had any amount of MRD after IDS had more than twice the risk of death compared to women with NMRD (HR 2.11, 95% CI 1.35 to 3.29, I2 = 81%; 906 participants; very low-certainty). AUTHORS' CONCLUSIONS In a PDS setting, there is moderate-certainty evidence that the amount of RD after primary surgery is a prognostic factor for overall and progression-free survival in women with advanced ovarian cancer. We separated our analysis into three distinct categories for the survival outcome including NMRD, SVRD and LVRD. After IDS, there may be only two categories required, although this is based on very low-certainty evidence, as all but one study included NMRD in the SVRD category. The one study that separated NMRD from SVRD showed no improved survival outcome in the SVRD category, compared to LVRD. Further low-certainty evidence also supported restricting to two categories, where women who had any amount of MRD after IDS had a significantly greater risk of death compared to women with NMRD. Therefore, the evidence presented in this review cannot conclude that using three categories applies in an IDS setting (very low-certainty evidence), as was supported for PDS (which has convincing moderate-certainty evidence).
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Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Patience T Kunonga
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ketankumar Gajjar
- Department of Gynaecological Oncology, 1st Floor Maternity Unit, City Hospital Campus, Nottingham, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Brett A Winter-Roach
- The Department of Surgery, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Ahmed Elattar
- City Hospital & Birmingham Treatment Centre, Birmingham, UK
| | - Raj Naik
- Gynaecological Oncology, Northern Gynaecological Oncology Centre, Gateshead, UK
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Thaker PH, Bradley WH, Leath CA, Gunderson Jackson C, Borys N, Anwer K, Musso L, Matsuzaki J, Bshara W, Odunsi K, Alvarez RD. GEN-1 in Combination with Neoadjuvant Chemotherapy for Patients with Advanced Epithelial Ovarian Cancer: A Phase I Dose-escalation Study. Clin Cancer Res 2021; 27:5536-5545. [PMID: 34326131 PMCID: PMC9338778 DOI: 10.1158/1078-0432.ccr-21-0360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 05/25/2021] [Accepted: 07/21/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE GEN-1 (phIL-12-005/PPC), an IL12 plasmid formulated with polyethyleneglycol-polyethyleneimine cholesterol lipopolymer, has preclinical activity when combined with platinum-taxane intravenous chemotherapy and administered intraperitoneally in epithelial ovarian cancer (EOC) models. OVATION I was a multicenter, nonrandomized, open-label phase IB trial to evaluate the safety, preliminary antitumor activity, and immunologic response to GEN-1 in combination with neoadjuvant chemotherapy (NACT) carboplatin-paclitaxel in patients with advanced EOC. PATIENTS AND METHODS A total of 18 patients with newly diagnosed stage IIIC and IV EOC were enrolled. A standard 3+3 dose-escalation design tested four GEN-1 doses (36, 47, 61, 79 mg/m2) to determine the maximum tolerated dose and dose-limiting toxicities (DLTs). GEN-1 was administered in eight weekly intraperitoneal infusions starting at cycle 1 week 2 in combination with three 21-day cycles of NACT carboplatin AUC 6 and weekly paclitaxel 80 mg/m2. RESULTS The most common treatment-emergent adverse events at least possibly related were nausea, fatigue, abdominal pain/cramping, anorexia, diarrhea, and vomiting. Eight patients experience grade 4 neutropenia attributed to NACT. No DLTs occurred. A total of 14 patients were evaluable for response and 12 (85.7%) had radiological response (two complete response and 10 partial response) prior to debulking; nine were R0 at debulking and one patient had complete pathologic response. IL12 and its downstream cytokine, IFNγ, increased in peritoneal washings but not as much in blood. Increased levels of myeloid dendritic cells and T-effector memory cells in peritoneal fluid, plus elevated CD8+ T cells and reduced immunosuppression within the tumor microenvironment were found. A median time to treatment failure of 18.4 months (95% confidence interval, 9.2-24.5) was observed in the intention-to-treat population. CONCLUSIONS Adding GEN-1 to standard NACT is safe, appears active, and has an impact on the tumor microenvironment.
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Affiliation(s)
- Premal H Thaker
- Washington University School of Medicine, St. Louis, Missouri.
| | | | - Charles A Leath
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | | | | | | | - Wiam Bshara
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kunle Odunsi
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Neoadjuvant chemotherapy before surgery versus surgery followed by chemotherapy for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 7:CD005343. [PMID: 34328210 PMCID: PMC8406953 DOI: 10.1002/14651858.cd005343.pub6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require a combination of surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases up to 9 October 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. We extracted data of overall (OS) and progression-free survival (PFS), adverse events, surgically-related mortality and morbidity and quality of life outcomes. We used GRADE methods to determine the certainty of evidence. MAIN RESULTS We identified 2227 titles and abstracts through our searches, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1774 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the four studies where data were available and found little or no difference with regard to overall survival (OS) (Hazard Ratio (HR) 0.96, 95% CI 0.86 to 1.08; participants = 1692; studies = 4; high-certainty evidence) or progression-free survival in four trials where we were able to pool data (Hazard Ratio 0.98, 95% CI 0.88 to 1.08; participants = 1692; studies = 4; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were variably and incompletely reported across studies. There are probably clinically meaningful differences in favour of NACT compared to PDS with regard to overall postoperative serious adverse effects (SAE grade 3+): 6% in NACT group, versus 29% in PDS group, (risk ratio (RR) 0.22, 95% CI 0.13 to 0.38; participants = 435; studies = 2; heterogeneity index (I2) = 0%; moderate-certainty evidence). NACT probably results in a large reduction in the need for stoma formation: 5.9% in NACT group, versus 20.4% in PDS group, (RR 0.29, 95% CI 0.12 to 0.74; participants = 632; studies = 2; I2 = 70%; moderate-certainty evidence), and probably reduces the risk of needing bowel resection at the time of surgery: 13.0% in NACT group versus 26.6% in PDS group (RR 0.49, 95% CI 0.30 to 0.79; participants = 1565; studies = 4; I2 = 79%; moderate-certainty evidence). NACT reduces postoperative mortality: 0.6% in NACT group, versus 3.6% in PDS group, (RR 0.16, 95% CI 0.06 to 0.46; participants = 1623; studies = 5; I2 = 0%; high-certainty evidence). QoL on the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scale produced inconsistent and imprecise results in three studies (MD -0.29, 95% CI -2.77 to 2.20; participants = 524; studies = 3; I2 = 81%; very low-certainty evidence) but the evidence is very uncertain and should be interpreted with caution. AUTHORS' CONCLUSIONS The available high to moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT probably reduces the risk of serious adverse events, especially those around the time of surgery, and reduces the risk of postoperative mortality and the need for stoma formation. These data will inform women and clinicians (involving specialist gynaecological multidisciplinary teams) and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 2:CD005343. [PMID: 33543776 PMCID: PMC8094177 DOI: 10.1002/14651858.cd005343.pub5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; Hazard Ratio (HR) 0.95, 95% CI 0.84 to 1.07; I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 0.97, 95% CI 0.87 to 1.07; I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Obstetrics and Gynaecology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Primary site disease and recurrence location in ovarian cancer patients undergoing primary debulking surgery vs. interval debulking surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 47:1075-1082. [PMID: 32981794 DOI: 10.1016/j.ejso.2020.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/02/2020] [Accepted: 09/15/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The natural history and patterns of ovarian cancer (OC) relapse are still unclear. Recurrent disease can be peritoneal, parenchymal, or nodal. This study aims to analyze the location and pattern of OC recurrence according to the primary site of disease and to the type of surgical approach used. MATERIAL AND METHODS All OC patients underwent primary debulking surgery (PDS) or interval debulking surgery (IDS), with 2014 FIGO stage III-IV, and with platinum-sensitive recurrence were included in the study. Primary disease location and site of recurrences were divided into peritoneal, parenchymal, and nodal, according to the presence of peritoneal carcinomatosis, parenchymal metastasis, and nodal involvement, respectively. RESULTS A total of 355 patients were initially considered; of them, 295 met the inclusion criteria. Two hundred thirty-three patients obtained no macroscopic residual tumor at the end of primary surgical treatment. Primary parenchymal disease relapsed in 84.6% cases at a parenchymal site (p < 0.001), 97.2% of peritoneal diseases relapsed on the peritoneum (p < 0.001), and 100% of nodal diseases had a nodal recurrence (p < 0.001). Stratifying by the surgical approach all these correlations have been confirmed both in the PDS (p < 0.001) and IDS (p < 0.001) groups. CONCLUSION Our study shows that the site of relapse in cases of platinum-sensitive OC recurrence is closely related to the primary location of the disease, regardless of the type of initial treatment. Therefore, more attention during followup should be paid to areas where the initial tumor was present.
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Gac MM, Loaec C, Silve J, Vaucel E, Augereau P, Wernert R, Bourgin C, Aireau X, Lortholary A, Descamps P, Priou F, Deblaye P, Bourgeois H, Delecroix V, Empereur F, Campion L, Classe JM. Quality of advanced ovarian cancer surgery: A French assessment of ESGO quality indicators. Eur J Surg Oncol 2020; 47:360-366. [PMID: 32863097 DOI: 10.1016/j.ejso.2020.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/28/2020] [Accepted: 08/05/2020] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES In 2016, the European Society of Gynecology Oncology (ESGO) published indicators defining the quality of surgical management of advanced ovarian cancer. The objective of the study was to assess the quality of ovarian cancer patient management in regional centers authorized for gynecological cancer, based on the ESGO list of quality indicators. METHODS A multicenter retrospective observational cohort study was conducted from January 1 to June 30, 2016. The following quality indicators 1 "rate of complete surgical resection", 4 "center participating in clinical trials in gynecologic oncology", 5 "treatment planned and reviewed at a multidisciplinary team meeting", 6 "required preoperative workup", 8 "minimum required elements in operative reports" and 9 "minimum required elements in pathology reports" were selected. RESULTS 91 patients were evaluated in 16 centers. The required preoperative workup was incomplete in 25% of cases. Treatment was not planned at a multidisciplinary team meeting for 24%. An evaluation score of peritoneal involvement was included in 40% of the operative reports and the quality of surgical resection was reported in 72%. Primary surgery was most often performed in a peripheral hospital (48%), interval surgery in a private center (37%), and closure surgery in a regional cancer center (43%). No institution respected the six quality indicators evaluated. One regional cancer center respected five items and two private centers did not respect any. CONCLUSION Whilst the ESGO quality indicators provide objective, validated and evaluable support which centers can use to improve quality of care, we observed heterogeneous practices amongst the centers evaluated.
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Affiliation(s)
- Marie-Mélanie Gac
- Department of Surgical Oncology, Institut Cancérologie de L'Ouest, Nantes, Saint Herblain, France
| | - Cécile Loaec
- Department of Surgical Oncology, Institut Cancérologie de L'Ouest, Nantes, Saint Herblain, France.
| | - Johanna Silve
- Onco Pays de La Loire, Plateau des écoles, 50 Route de Saint-Sébastien, 44093, Nantes, France
| | - Edouard Vaucel
- Department of Obstetrics and Gynecology, CHU de Nantes, France
| | - Paule Augereau
- Department of Medical Oncology, Institut de Cancérologie de L'Ouest, Angers, France
| | - Romuald Wernert
- Department of Surgical Oncology, Institut de Cancérologie de L'Ouest, Angers, France
| | - Charlotte Bourgin
- Department of Surgical Oncology, Institut Cancérologie de L'Ouest, Nantes, Saint Herblain, France
| | - Xavier Aireau
- Department of Obstetrics and Gynecology, Centre Hospitalier de Cholet, France
| | - Alain Lortholary
- Confluent Private Hospital, Institut de Cancérologie Catherine de Sienne, Nantes, France
| | | | - Frank Priou
- CHD Vendee-Hopital Les Oudairies, La Roche Sur Yon, France
| | | | - Hugues Bourgeois
- Department of Medical Oncology, Clinique Victor Hugo, Le Mans, France
| | | | - Fabienne Empereur
- Onco Pays de La Loire, Plateau des écoles, 50 Route de Saint-Sébastien, 44093, Nantes, France
| | - Loïc Campion
- Biometrics, Institut de Cancérologie de L'Ouest, Centre René Gauducheau, Saint-Herblain, France; CRCINA, University of Nantes, INSERM UMR1232, CNRS-ERL6001, Nantes, France
| | - Jean-Marc Classe
- Department of Surgical Oncology, Institut Cancérologie de L'Ouest, Nantes, Saint Herblain, France
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Huang CY, Cheng M, Lee NR, Huang HY, Lee WL, Chang WH, Wang PH. Comparing Paclitaxel-Carboplatin with Paclitaxel-Cisplatin as the Front-Line Chemotherapy for Patients with FIGO IIIC Serous-Type Tubo-Ovarian Cancer. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17072213. [PMID: 32224896 PMCID: PMC7177627 DOI: 10.3390/ijerph17072213] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 12/11/2022]
Abstract
The use of weekly chemotherapy for the treatment of patients with advanced-stage serous-type epithelial Tubo-ovarian cancer (ETOC), and primary peritoneal serous carcinoma (PPSC) is acceptable as the front-line postoperative chemotherapy after primary cytoreductive surgery (PCS). The main component of dose-dense chemotherapy is weekly paclitaxel (80 mg/m2), but it would be interesting to know what is the difference between combination of triweekly cisplatin (20 mg/m2) or triweekly carboplatin (carboplatin area under the curve 5-7 mg/mL per min [AUC 5-7]) in the dose-dense paclitaxel regimen. Therefore, we compared the outcomes of women with Gynecology and Obstetrics (FIGO) stage IIIC ETOC and PPSC treated with PCS and a subsequent combination of dose-dense weekly paclitaxel and triweekly cisplatin (paclitaxel–cisplatin) or triweekly carboplatin using AUC 5 (paclitaxel–carboplatin). Between January 2010 and December 2016, 40 women with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC EOC, FTC, or PPSC were enrolled, including 18 treated with paclitaxel–cisplatin and the remaining 22 treated with paclitaxel–carboplatin. There were no statistically significant differences in disease characteristics of patients between two groups. Outcomes in paclitaxel–cisplatin group seemed to be little better than those in paclitaxel–carboplatin (median progression-free survival [PFS] 30 versus 25 months as well as median overall survival [OS] 58.5 versus 55.0 months); however, neither reached a statistically significant difference. In terms of adverse events (AEs), patients in paclitaxel–carboplatin group had more AEs, with a higher risk of neutropenia and grade 3/4 neutropenia, and the need for a longer period to complete the front-line chemotherapy, and the latter was associated with worse outcome for patients. We found that a period between the first-time chemotherapy to the last dose (6 cycles) of chemotherapy >21 weeks was associated with a worse prognosis in patients compared to that ≤21 weeks, with hazard ratio (HR) of 81.24 for PFS and 9.57 for OS. As predicted, suboptimal debulking surgery (>1 cm) also contributed to a worse outcome than optimal debulking surgery (≤1 cm) with HR of 14.38 for PFS and 11.83 for OS. Based on the aforementioned findings, both regimens were feasible and effective, but maximal efforts should be made to achieve optimal debulking surgery and following the on-schedule administration of dose-dense weekly paclitaxel plus triweekly platinum compounds. Randomized trials validating the findings are warranted.
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Affiliation(s)
- Chen-Yu Huang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (C.-Y.H.); (M.C.)
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
| | - Min Cheng
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (C.-Y.H.); (M.C.)
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
| | - Na-Rong Lee
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (C.-Y.H.); (M.C.)
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Hsin-Yi Huang
- Biostatics Task Force, Taipei Veterans General Hospital, Taipei 112, Taiwan;
| | - Wen-Ling Lee
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Medicine, Cheng-Hsin General Hospital, Taipei 112, Taiwan
- Department of Nursing, Oriental Institute of Technology, New Taipei City 220, Taiwan
| | - Wen-Hsun Chang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (C.-Y.H.); (M.C.)
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Nursing, Taipei Veterans General Hospital, Taipei 112, Taiwan
- Correspondence: (W.-H.C.); (P.-H.W.); Tel.: +886-2-2875-7826 (W.-H.C.); +886-2-2875-7566 (P.-H.W.)
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei 112, Taiwan; (C.-Y.H.); (M.C.)
- Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei 112, Taiwan
- Institute of Clinical Medicine, National Yang-Ming University, Taipei 112, Taiwan;
- Department of Medical Research, China Medical University Hospital, Taichung 440, Taiwan
- Female Cancer Foundation, Taipei 104, Taiwan
- Correspondence: (W.-H.C.); (P.-H.W.); Tel.: +886-2-2875-7826 (W.-H.C.); +886-2-2875-7566 (P.-H.W.)
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Impact of neoadjuvant chemotherapy cycles on survival of patients with advanced ovarian cancer: A French national multicenter study (FRANCOGYN). Eur J Obstet Gynecol Reprod Biol 2020; 245:64-72. [DOI: 10.1016/j.ejogrb.2019.12.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/03/2019] [Accepted: 12/04/2019] [Indexed: 12/13/2022]
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Coleridge SL, Bryant A, Lyons TJ, Goodall RJ, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2019; 2019:CD005343. [PMID: 31684686 PMCID: PMC6822157 DOI: 10.1002/14651858.cd005343.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; hazard ratio (HR) 1.06; 95% confidence interval (CI) 0.94 to 1.19, I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 1.02; 95% CI 0.92 to 1.13, I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Taunton and Somerset NHS Foundation TrustObstetrics and GynaecologyMusgrove Park HospitalTauntonUKTA1 5DA
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Thomas J Lyons
- University of BristolSchool of Medical Sciences38 Kings Parade AvenueBristolUKBS8 2RB
| | - Richard J Goodall
- Imperial College LondonDepartment of Surgery and CancerKensingtonLondonUKSW7 2AZ
| | - Sean Kehoe
- University of BirminghamInstitute of Cancer and GenomicsBirminghamUKB15 2TT
| | - Jo Morrison
- Musgrove Park HospitalDepartment of Gynaecological OncologyTaunton and Somerset NHS Foundation TrustTauntonSomersetUKTA1 5DA
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Economic Analysis of Neoadjuvant Chemotherapy Versus Primary Debulking Surgery for Advanced Epithelial Ovarian Cancer Using an Aggressive Surgical Paradigm. Int J Gynecol Cancer 2019; 28:1077-1084. [PMID: 29683880 DOI: 10.1097/igc.0000000000001271] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES Neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced epithelial ovarian cancer (AEOC) remains controversial in the United States. Generalizability of existing trial results has been criticized because of less aggressive debulking procedures than commonly used in the United States. As a result, economic evaluations using input data from these trials may not accurately reflect costs and outcomes associated with more aggressive primary surgery. Using data from an ongoing trial performing aggressive debulking, we investigated the cost-effectiveness and cost-utility of NACT versus PDS for AEOC. METHODS A decision tree model was constructed to estimate differences in short-term outcomes and costs for a hypothetical cohort of 15,000 AEOC patients (US annual incidence of AEOC) treated with NACT versus PDS over a 1-year time horizon from a Medicare payer perspective. Outcomes included costs per cancer-related death averted, life-years and quality-adjusted life-years (QALYs) gained. Base-case probabilities, costs, and utilities were based on the Surgical Complications Related to Primary or Interval Debulking in Ovarian Neoplasms trial. Base-case analyses assumed equivalent survival; threshold analysis estimated the maximum survival difference that would result in NACT being cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds. Probabilistic sensitivity analysis was used to characterize model uncertainty. RESULTS Compared with PDS, NACT was associated with $142 million in cost savings, 1098 fewer cancer-related deaths, and 1355 life-years and 1715 QALYs gained, making it the dominant treatment strategy for all outcomes. In sensitivity analysis, NACT remained dominant in 99.3% of simulations. Neoadjuvant chemotherapy remained cost-effective at $50,000/QALY and $100,000/QALY willingness-to-pay thresholds if survival differences were less than 2.7 and 1.4 months, respectively. CONCLUSIONS In the short term, NACT is cost-saving with improved outcomes. However, if PDS provides a longer-term survival advantage, it may be cost-effective. Research is needed on the role of patient preferences in tradeoffs between survival and quality of life.
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Al Mutairi N, Le T. Does Neoadjuvant Chemotherapy Impact Prognosis in Advanced-Stage Epithelial Ovarian Cancer Optimally Debulked at Surgery? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 41:185-190. [PMID: 30316718 DOI: 10.1016/j.jogc.2018.05.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 05/21/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Neoadjuvant chemotherapy (NAC) has been shown to be noninferior to primary surgery in advanced stage ovarian cancer. We examined the impact of the neoadjuvant approach in patients with optimal residuals (<1 cm). METHODS Retrospective review of optimally debulked stage 3/4 ovarian cancer was performed. Chi-square tests were used to detect significant associations between categorical variables. A Cox regression model was built to predict patients' overall survival, adjusting for age, tumour grade, histology, use of adjuvant intraperitoneal chemotherapy, residual status, and primary treatment modality. RESULTS One hundred one patients were reviewed. Median age was 60.5 (range 39-85). NAC was used in 34 patients. Serous histology was documented in 60 of 101 patients (59%). Microscopic residuals were achieved in 70 patients (69%). There was no significant association between primary treatment modality and microscopic residuals status. With a median follow-up time of 33 months, progression was observed in 53% of patients, with a median progression-free survival of 19.4 months. The use of NAC was an independent adverse prognostic factor (hazard ratio 5.79; 95% CI 2.15-15.55, P = 0.001) for overall survival. Macroscopic residual was an independent adverse prognostic factor (hazard ratio 10.76; 95% CI 2.98-38.89, P < 0.001). The overall Kaplan-Meier median survival estimate was 54.5 months (95% CI 50.64-58.36) in the primary surgery group compared with 41.43 months (95% CI 35.58-47.29) in those given NAC (P = 0.002) CONCLUSION: Primary surgery should be the preferred approach in patients with an initial high likelihood of being optimally cytoreduced.
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Affiliation(s)
- Nashmia Al Mutairi
- Division of Gynecology Oncology, Oncology Department, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Tien Le
- Division of Gynecologic Oncology, University of Ottawa, Ottawa, ON.
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13
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Kim S, Han Y, Kim SI, Kim HS, Kim SJ, Song YS. Tumor evolution and chemoresistance in ovarian cancer. NPJ Precis Oncol 2018; 2:20. [PMID: 30246154 PMCID: PMC6141595 DOI: 10.1038/s41698-018-0063-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 12/30/2022] Open
Abstract
Development of novel strategies to overcome chemoresistance is central goal in ovarian cancer research. Natural history of the cancer development and progression is being reconstructed by genomic datasets to understand the evolutionary pattern and direction. Recent studies suggest that intra-tumor heterogeneity (ITH) is the main cause of treatment failure by chemoresistance in many types of cancers including ovarian cancer. ITH increases the fitness of tumor to adapt to incompatible microenvironment. Understanding ITH in relation to the evolutionary pattern may result in the development of the innovative approach based on individual variability in the genetic, environment, and life style. Thus, we can reach the new big stage conquering the cancer. In this review, we will discuss the recent advances in understanding ovarian cancer biology through the use of next generation sequencing (NGS) and highlight areas of recent progress to improve precision medicine in ovarian cancer.
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Affiliation(s)
- Soochi Kim
- 1Seoul National University Hospital Biomedical Research Institute, Seoul, 03080 Republic of Korea.,2Cancer Research Institute, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea
| | - Youngjin Han
- 2Cancer Research Institute, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea.,3WCU Biomodulation, Department of Agricultural Biotechnology, Seoul National University, Seoul, 03080 Republic of Korea
| | - Se Ik Kim
- 4Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea
| | - Hee-Seung Kim
- 4Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea
| | - Seong Jin Kim
- 5Precision Medicine Research Center, Advanced Institutes of Convergence Technology, Seoul National University, Suwon, Gyeonggi-do 16229 Republic of Korea.,6Department of transdisciplinary Studies, Graduate School of Convergence Science and Technology, Seoul National University, Suwon, Gyeonggi-do 16229 Republic of Korea
| | - Yong Sang Song
- 2Cancer Research Institute, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea.,3WCU Biomodulation, Department of Agricultural Biotechnology, Seoul National University, Seoul, 03080 Republic of Korea.,4Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea.,7Interdisciplinary Program in Cancer Biology, Seoul National University College of Medicine, Seoul, 03080 Republic of Korea
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14
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Cole AL, Austin AE, Hickson RP, Dixon MS, Barber EL. Review of methodological challenges in comparing the effectiveness of neoadjuvant chemotherapy versus primary debulking surgery for advanced ovarian cancer in the United States. Cancer Epidemiol 2018; 55:8-16. [PMID: 29758492 PMCID: PMC6054914 DOI: 10.1016/j.canep.2018.05.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 12/20/2022]
Abstract
Randomized trials outside the U.S. have found non-inferior survival for neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced ovarian cancer (AOC). However, these trials reported lower overall survival and lower rates of optimal debulking than U.S. studies, leading to questions about generalizability to U.S. practice, where aggressive debulking is more common. Consequently, comparative effectiveness in the U.S. remains controversial. We reviewed U.S. comparative effectiveness studies of NACT versus PDS for AOC. Here we describe methodological challenges, compare results to trials outside the U.S., and make suggestions for future research. We identified U.S. studies published in 2010 or later that evaluated the comparative effectiveness of NACT versus PDS on survival in AOC through a PubMed search. Two independent reviewers abstracted data from eligible articles. Nine of 230 articles were eligible for review. Methodological challenges included unmeasured confounders, heterogeneous treatment effects, treatment variations over time, and inconsistent measurement of treatment and survival. Whereas some limitations were unavoidable, several limitations noted across studies were avoidable, including conditioning on mediating factors and immortal time introduced by measuring survival beginning from diagnosis. Without trials in the U.S., non-randomized studies are an important source of evidence for the ideal treatment for AOC. However, several methodological challenges exist when assessing the comparative effectiveness of NACT versus PDS in a non-randomized setting. Future observational studies must ensure that treatment is consistent throughout the study period and that treatment groups are comparable. Rapidly-evolving oncology data networks may allow for identification of treatment intent and other important confounders.
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Affiliation(s)
- Ashley L Cole
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, 27599, USA.
| | - Anna E Austin
- Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Ryan P Hickson
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Matthew S Dixon
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, 27599, USA
| | - Emma L Barber
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL, 60611 USA
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Zhang J, Liu N, Zhang A, Bao X. Potential risk factors associated with prognosis of neoadjuvant chemotherapy followed by interval debulking surgery in stage IIIc-IV high-grade serous ovarian carcinoma patients. J Obstet Gynaecol Res 2018; 44:1808-1816. [PMID: 30019801 DOI: 10.1111/jog.13710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Accepted: 05/25/2018] [Indexed: 01/17/2023]
Abstract
AIM No consensus has been achieved on the prognostic factors for patients with advanced stage epithelial ovarian cancer who underwent neoadjuvant chemotherapy (NAC) followed by interval debulking surgery (IDS). This study aimed to investigate the prognostic factors for the patients diagnosed as International Federation of Gynecology and Obstetrics stage IIIc-IV high-grade serous ovarian cancer (HG-SOC). METHODS A total of 200 patients histologically diagnosed as IIIc-IV stage HG-SOC were retrospectively analyzed. All patients underwent platinum-NAC followed by IDS treatment between January 2003 and December 2013. The potential predictive factors (including preoperative ascites volume, cancer antigen 125 [CA-125] and CA-125 decreasing kinetics, NAC and adjuvant chemotherapy cycle number as well as tumor characteristics) for optimal cytoreduction by IDS and for progression free survival (PFS) and overall survival (OS) were assessed. RESULTS Optimal cytoreduction by IDS was achieved in 78% of HG-SOC patients who underwent NAC. The median number of NAC cycle was 3 (range 1-8). No ascites regression (P < 0.01, odds ratio [OR] = 2.28, 95% confidence interval [CI]: 1.41-3.69), and worse CA-125 decreasing kinetics (P < 0.01, OR = 2.01, 95% CI: 1.37-2.93) were independent predictive factors for suboptimal cytoreduction by IDS. Multivariate regression analysis revealed that PFS and OS were independently associated with preoperative ascites (P < 0.01, hazard ratio [HR] = 2.13, 95% CI: 1.38-3.28 and P < 0.01, HR = 2.33, 95% CI: 1.27-4.26, respectively) and CA-125 decreasing kinetics (P = 0.01, HR = 1.10, 95% CI: 1.02-1.18 and P < 0.01, HR = 1.22, 95% CI: 1.08-1.37, respectively). PFS of patients who underwent more than four NAC cycles was shorter than those of patients who received four or less number of NAC cycles; however, no difference was observed for OS. CONCLUSION Ascites regression and CA-125 decreasing kinetics were independently associated with the optimal cytoreduction rate and survival of patients diagnosed with advanced stage HG-SOC and treated with NAC/IDS.
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Affiliation(s)
- Jie Zhang
- Department of Gynecology, Weifang Yidu Central Hospital, Weifang, China
| | - Ning Liu
- Department of Gynecology, Weifang Yidu Central Hospital, Weifang, China
| | - Aihong Zhang
- Department of Gynecology, Weifang Yidu Central Hospital, Weifang, China
| | - Xiangxiang Bao
- Department of Gynecology, Weifang People's Hospital, Weifang, China
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Preoperative Predictive Factors for Complete Cytoreduction and Survival Outcome in Epithelial Ovarian, Tubal, and Peritoneal Cancer After Neoadjuvant Chemotherapy. Int J Gynecol Cancer 2018; 27:420-429. [PMID: 28187098 DOI: 10.1097/igc.0000000000000924] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE The study aims to identify preoperative predictors of complete cytoreduction and early recurrence and death in epithelial ovarian, tubal, and peritoneal cancer after neoadjuvant chemotherapy (NACT). METHODS We performed a retrospective analysis of 85 patients who underwent 3 cycles of NACT. Patients were divided into 2 groups according to residual tumor at interval debulking surgery (IDS), and clinicopathologic, surgical, and follow-up data were compared. RESULTS Cancer antigen 125 (CA-125) levels before the IDS after completion of NACT were higher in the residual tumor group (42.0 vs 116.6 U/mL, P = 0.006). The drop rate of CA-125 after NACT was higher in the no residual tumor group (96.8% vs 89.9%, P = 0.001). Patients with residual tumor showed lower disease-free and overall survival outcomes than patients with no residual tumor. In univariate analysis, CA-125 of 100 U/mL or less before IDS and a drop rate after NACT greater than 80% were preoperative predictive factors for complete cytoreduction. In multivariate analysis, a drop rate of CA-125 after NACT greater than 80% was an independent preoperative predictive factor for complete cytoreduction (P = 0.002). Progressive disease on follow-up image during NACT was an independent preoperative predictive factor for early recurrence and death (P < 0.001, both). CONCLUSIONS A significant drop of CA-125 after NACT and progressive disease on follow-up image are independent preoperative predictors for complete cytoreduction and early recurrence and death.
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Melamed A, Fink G, Wright AA, Keating NL, Gockley AA, Del Carmen MG, Schorge JO, Rauh-Hain JA. Effect of adoption of neoadjuvant chemotherapy for advanced ovarian cancer on all cause mortality: quasi-experimental study. BMJ 2018; 360:j5463. [PMID: 29298771 PMCID: PMC5751831 DOI: 10.1136/bmj.j5463] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVE To estimate the causal effect of increased use of neoadjuvant chemotherapy (NACT) on all cause mortality in advanced epithelial ovarian cancer. DESIGN Quasi-experimental fuzzy regression discontinuity design and cross sectional analysis. SETTING Cancer programs throughout the United States accredited by the Commission on Cancer. PARTICIPANTS 6034 women with a diagnosis of stage 3C or 4 epithelial ovarian cancer from regions that rapidly adopted use of NACT from 2011 to 2012 (27% increase in the New England and east south central regions) or remained unchanged (control regions, south Atlantic, west north central, and east north central regions). MAIN OUTCOME MEASURE All cause mortality within three years of diagnosis. Kaplan-Meier curves and proportional hazard models were estimated to compare mortality differences between rapidly adopting regions and controls. RESULTS 1156 women were treated for advanced epithelial ovarian cancer during 2011 and 2012 in the two rapidly adopting regions and 4878 women in the three control regions. In the rapidly adopting regions, patients treated in 2012 compared with 2011 had a mortality hazard ratio of 0.81 (95% confidence interval 0.71 to 0.94) after adjusting for mortality time trends, whereas no difference was observed in control regions (1.02, 0.93 to 1.12). Compared with control regions, larger declines in 90 day surgical mortality (7.0% to 4.0% v 5.0% to 4.3%, P=0.01) and in the proportion of women not receiving surgery and chemotherapy (20.0% to 17.4% v 19.0 to 19.5%, P=0.04) were observed in rapidly adopting regions. Cross sectional analysis confirmed that treatment in regions with greater use of NACT was associated was lower mortality (P=0.001). CONCLUSIONS Adoption of NACT for advanced epithelial ovarian cancer in New England and east south central regions led to a sizable reduction in mortality within three years after diagnosis.
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Affiliation(s)
- Alexander Melamed
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Günther Fink
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Alexi A Wright
- Division of Population Sciences, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Nancy L Keating
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA
| | - Allison A Gockley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA, USA
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - J Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, Division of Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Scalici JM, Arapovic S, Saks E, Atkins KA, Petroni G, Duska LR, Slack-Davis JK. Mesothelium expression of vascular cell adhesion molecule-1 (VCAM-1) is associated with an unfavorable prognosis in epithelial ovarian cancer (EOC). Cancer 2017; 123:977-984. [PMID: 28263384 PMCID: PMC5341143 DOI: 10.1002/cncr.30415] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 09/06/2016] [Accepted: 10/04/2016] [Indexed: 01/04/2023]
Abstract
BACKGROUND Mesothelium vascular cell adhesion molecule-1 (VCAM-1) expression in the metastatic epithelial ovarian cancer (EOC) microenvironment is induced by tumor and mediates tumor cell invasion. VCAM-1 imaging suggests expression during treatment is an indicator of platinum resistance. Here, we assess the potential prognostic significance of mesothelium VCAM-1 expression and prospectively evaluate whether soluble VCAM-1 (sVCAM-1) is a surrogate for mesothelium expression. METHODS A retrospective review of EOC patients was performed to evaluate outcomes with mesothelium VCAM-1 expression determined by immunohistochemistry of peritoneum or omentum specimens. A prospective cohort of EOC patients was identified and followed through primary treatment. Serum for sVCAM-1 evaluation, which was performed via enzyme-linked immunosorbent assay, was collected before surgery or neoadjuvant chemotherapy and at each treatment cycle. Peritoneal specimens were obtained during debulking to assess mesothelial VCAM-1 expression. RESULTS A retrospective review identified 54 advanced-stage EOC patients. Patients expressing mesothelium VCAM-1 had shortened overall survival (44 vs 79 months, P = 0.035) and progression-free survival (18 vs 67 months, P = 0.010); the median time to platinum resistance was 36 months for VCAM-1-expressing patients and not yet determined for the VCAM-1-negative group. In our prospective observational cohort, 18 EOC patients completed primary treatment; 3 were negative for mesothelium VCAM-1 expression, and sVCAM-1 did not vary between groups. CONCLUSIONS Mesothelium VCAM-1 expression is negatively associated with progression-free and overall survival in EOC. This is especially compelling in light of previous data suggesting that persistent VCAM-1 expression during treatment is an indicator of platinum resistance. Our pilot study had insufficient cases to determine whether sVCAM-1 would substitute for mesothelium expression. Cancer 2017;123:977-84. © 2016 American Cancer Society.
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Affiliation(s)
- Jennifer M. Scalici
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, USA
| | - Sanja Arapovic
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, USA
| | - Erin Saks
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, USA
| | - Kristen A. Atkins
- Department of Pathology, University of Virginia, Charlottesville, VA, USA
- Cancer Center, University of Virginia, Charlottesville, VA, USA
| | - Gina Petroni
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
- Cancer Center, University of Virginia, Charlottesville, VA, USA
| | - Linda R. Duska
- Department of Obstetrics and Gynecology, University of Virginia, Charlottesville, VA, USA
- Cancer Center, University of Virginia, Charlottesville, VA, USA
| | - Jill K. Slack-Davis
- Department of Microbiology, Immunology and Cancer Biology, University of Virginia, Charlottesville, VA, USA
- Cancer Center, University of Virginia, Charlottesville, VA, USA
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Stewart JM, Tone AA, Jiang H, Bernardini MQ, Ferguson S, Laframboise S, Murphy KJ, Rosen B, May T. The optimal time for surgery in women with serous ovarian cancer. Can J Surg 2017; 59:223-32. [PMID: 27240134 DOI: 10.1503/cjs.014315] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Advanced high-grade serous ovarian carcinoma (HGSC) is commonly treated with surgery and chemotherapy. We investigated the survival of patients treated with primary or interval surgery at different times following neoadjuvant chemotherapy. Their survival was compared with that of patients treated with primary cytoreductive surgery and adjuvant chemotherapy. METHODS Patients with stage III or IV HGSC were included in this retrospective cohort study. Clinical data were obtained from patient records. Patients were divided into 2 groups based on treatment with neoadjuvant chemotherapy and interval cytoreductive surgery (NAC) or with primary cytoreductive surgery and adjuvant chemotherapy (PCS). Study groups were stratified by several clinical variables. RESULTS We included 334 patients in our study: 156 in the NAC and 178 in the PCS groups. Survival of patients in the NAC group was independent of when they underwent interval cytoreductive surgery following initiation of neoadjuvant chemotherapy (p < 0.001). Optimal surgical cytoreduction had no impact on overall survival in the NAC group (p < 0.001). Optimal cytoreduction (p < 0.001) and platinum sensitivity (p < 0.001) were independent predictors of improved survival in the PCS but not in the NAC group. Patients in the NAC group had significantly worse overall survival than those in the PCS group (31.6 v. 61.3 mo, p < 0.001). CONCLUSION Women with advanced HGSC who underwent PCS had better survival than those who underwent interval NAC, regardless of the number of cycles of neoadjuvant therapy. Optimal cytoreduction did not provide a survival advantage in the NAC group.
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Affiliation(s)
- Jocelyn M Stewart
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Alicia A Tone
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Haiyan Jiang
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Marcus Q Bernardini
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Sarah Ferguson
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Stephane Laframboise
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - K Joan Murphy
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Barry Rosen
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
| | - Taymaa May
- From the Division of Gynecologic Oncology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ont. (Stewart, Tone, Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); the Department of Obstetrics and Gynecology, Faculty of Medicine, University of Toronto, Toronto, Ont. (Bernardini, Ferguson, Laframboise, Murphy, Rosen, May); and the Department of Biostatistics, University of Toronto, Toronto, Ont. (Jiang)
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Xu X, Deng F, Lv M, Chen X. The number of cycles of neoadjuvant chemotherapy is associated with prognosis of stage IIIc-IV high-grade serous ovarian cancer. Arch Gynecol Obstet 2016; 295:451-458. [PMID: 27913927 DOI: 10.1007/s00404-016-4256-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 11/25/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE No consensus exists on the number of chemotherapy cycles to be administered before and after interval debulking surgery (IDS) in patients with advanced stage epithelial ovarian cancer. The present study aims to explore the optimal number of cycles of neoadjuvant chemotherapy (NAC) and post-operation chemotherapy to treat the International Federation of Gynecology and Obstetrics stage IIIc-IV high-grade serous ovarian cancer (HG-SOC). MATERIALS AND METHODS A total of 129 IIIc-IV stage HG-SOC cases were retrospectively analyzed. Cases were comprised of patients who underwent NAC followed by IDS and who achieved clinical complete response (CCR) at the end of primary therapy. Patients were recruited from the Jiangsu Institute of Cancer Research between 1993 and 2013. Optimal IDS-associated factors were explored with logistic regression. The association between progression-free survival (PFS), overall survival (OS) duration, and covariates was assessed by Cox proportional hazards model and log-rank test. RESULTS The median number of NAC cycle was 3 (range 1-8). CA-125 decreasing kinetics (p = 0.01) was independently associated with optimal IDS. CA-125 decreasing kinetics, optimal IDS, and NAC cycles was independently associated with OS (p < 0.01, p < 0.01, p = 0.03, respectively) and PFS (p < 0.01, p < 0.01, p = 0.04, respectively). The PFS of patients who underwent ≥5 NAC cycles was shorter than those of patients who underwent <5 NAC cycles (12.3 versus 17.2 months). The PFS and OS of patients who underwent <5 cycles of adjuvant chemotherapy post-IDS were shorter than those of patients who underwent ≥5 cycles (14.2 and 20.3 versus 21.2 and 28.8 months). CONCLUSION NAC cycles, CA-125 decreasing kinetics, and optimal debulking are independently associated with the prognosis of patients with advanced stage HG-SOC who underwent NAC/IDS and achieved CCR. The number of administered NAC cycles should not exceed 4.
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Affiliation(s)
- Xia Xu
- Department of Chemotherapy, Jiangsu Cancer Hospital, 42# Baiziting Street, Nanjing, 210009, Jiangsu, People's Republic of China
| | - Fei Deng
- Department of Gynecologic Oncology, Jiangsu Cancer Hospital, 42# Baiziting Street, Nanjing, 210009, Jiangsu, People's Republic of China
| | - Mengmeng Lv
- Department of Gynecologic Oncology, Jiangsu Cancer Hospital, 42# Baiziting Street, Nanjing, 210009, Jiangsu, People's Republic of China
| | - Xiaoxiang Chen
- Department of Gynecologic Oncology, Jiangsu Cancer Hospital, 42# Baiziting Street, Nanjing, 210009, Jiangsu, People's Republic of China.
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Xu X, Deng F, Lv M, Ren B, Guo W, Chen X. Ascites regression following neoadjuvant chemotherapy in prediction of treatment outcome among stage IIIc to IV high-grade serous ovarian cancer. J Ovarian Res 2016; 9:85. [PMID: 27912779 PMCID: PMC5134071 DOI: 10.1186/s13048-016-0294-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/29/2016] [Indexed: 02/22/2023] Open
Abstract
Background No consensus exists on the outcome-related factors of interval debulking surgery (IDS) in patients with advanced high-grade serous ovarian cancer (HG-SOC) who underwent neoadjuvant chemotherapy (NAC). This study aimed to explore the optimal timing for IDS and the prognosis-associated factors of International Federation of Gynecology and Obstetrics stage IIIc to IV HG-SOC patients. Methods A total of 160 IIIc to IV stage HG-SOC patients were retrospectively analyzed. Patients with large volume ascites underwent NAC and subsequent IDS from the Jiangsu Institute of Cancer Research between 1993 and 2013. The outcome of IDS-associated factors was explored by logistic regression. To predict IDS outcome, the potential values of serum CA-125 levels and CA-125 decreasing kinetics were determined by the receiver operating characteristic curve. The associations between survival durations and covariates were assessed by Cox proportional hazards model and log-rank test. Results Optimal IDS was achieved in 80.6% of HG-SOC patients who underwent NAC. Multivariate analyses revealed that ascites regression (p = 0.01), serum CA-125 level (p = 0.02), and CA-125 decreasing kinetics (p = 0.01) were independent optimal IDS predictors. CA-125 decreasing kinetics, IDS outcome, and ascites volume were independently associated with overall survival (OS) (p = 0.04, p < 0.01, p = 0.03, respectively) and progression-free survival (PFS) (p < 0.01, p < 0.01, p = 0.02, respectively). Patients who exhibited disappearance of ascites (<500 ml) had longer PFS (19.7 months vs.14.9 months) and OS (32.1 months vs. 26.0 months) than patients who exhibited residual ascites (≥500 ml). Subsets with higher CA-125 decreasing kinetics (≥2.2) had longer PFS (21.4 months vs.13.1 months) and OS (29.6 months vs.26.8 months) than counterparts (kinetics < 2.2). Conclusions Ascites regression and CA-125 decreasing kinetics were independently associated with surgical outcome and prognosis in advanced HG-SOC patients who underwent NAC.
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Affiliation(s)
- Xia Xu
- Department of Chemotherapy, Jiangsu Cancer Hospital, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Fei Deng
- Department of Gynecologic Oncology, Jiangsu Cancer Hospital, 42# Baiziting street, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Mengmeng Lv
- Department of Gynecologic Oncology, Jiangsu Cancer Hospital, 42# Baiziting street, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Binhui Ren
- Department of Thoracic Oncology, Jiangsu Cancer Hospital, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Wenwen Guo
- The Second Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, 210009, People's Republic of China
| | - Xiaoxiang Chen
- Department of Gynecologic Oncology, Jiangsu Cancer Hospital, 42# Baiziting street, Nanjing, Jiangsu, 210009, People's Republic of China.
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Zeng LJ, Xiang CL, Gong YZ, Kuang Y, Lu FF, Yi SY, Zhang Y, Liao M. Neoadjuvant chemotherapy for Patients with advanced epithelial ovarian cancer: A Meta-Analysis. Sci Rep 2016; 6:35914. [PMID: 27804983 PMCID: PMC5090201 DOI: 10.1038/srep35914] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 09/30/2016] [Indexed: 12/15/2022] Open
Abstract
The value of neoadjuvant chemotherapy (NAC) has not yet been fully defined. We aimed to systematically evaluate the influence of neoadjuvant chemotherapy (NAC) on survival and complete cytoreduction after debulking surgery in advanced epithelial ovarian cancer (AEOC) patients. We searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials for the randomized controlled trials (RCTs) comparing NAC and primary debulking surgery (PDS) in AEOC patients. The last search date is February 25, 2016. Cochrane systematic evaluation was used to evaluate bias risk of included studies. RevMan 5.3 software was used for statistical analysis. A total of 4 RCTs involving 1922 patients were included. Compared with PDS, NAC may contribute to the completeness of debulking removal [no residual disease (RR: 2.37; 95%CI: 1.94–2.91; P<0.00001), residual disease ≤1 cm (RR: 1.28; 95%CI: 1.04–1.57; P = 0.02), optimal cytoreduction rate (RR: 1.76; 95%CI: 1.57–1.98; P<0.00001)], but there were no significant differences in both groups with regard to overall survival (HR: 0.94; 95%Cl: 0.81–1.08; P = 0.38) and progression-free survival (HR: 0.89; 95%Cl: 0.77–1.03; P = 0.12). This meta-analysis indicates that the higher rate of optimal debulking made NAC more favorable as a treatment option for AEOC patients with non-inferior survival compared with PDS.
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Affiliation(s)
- Long-Jia Zeng
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Chun-Lin Xiang
- The First Clinical Medical College of Guangxi Medical University, Nanning, Guangxi, China
| | - Yi-Zhen Gong
- Department of Evidence-based Medicine, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Yan Kuang
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Fang-Fang Lu
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Su-Yi Yi
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Yue Zhang
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
| | - Meng Liao
- Department of Gynaecology and Obstetrics, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, P. R. China
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Akladios C, Baldauf JJ, Marchal F, Hummel M, Rebstock LE, Kurtz JE, Petit T, Afors K, Mathelin C, Lecointre L, Schrot-Sanyan S. Does the Number of Neoadjuvant Chemotherapy Cycles before Interval Debulking Surgery Influence Survival in Advanced Ovarian Cancer? Oncology 2016; 91:331-340. [PMID: 27784027 DOI: 10.1159/000449203] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 08/15/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed. METHODS This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity. RESULTS Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups. CONCLUSIONS The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.
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Affiliation(s)
- Cherif Akladios
- Département de Gynécologie Obstétrique, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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24
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Martinez A, Ngo C, Leblanc E, Gouy S, Luyckx M, Darai E, Classe JM, Guyon F, Pomel C, Ferron G, Filleron T, Querleu D. Surgical Complexity Impact on Survival After Complete Cytoreductive Surgery for Advanced Ovarian Cancer. Ann Surg Oncol 2016; 23:2515-21. [DOI: 10.1245/s10434-015-5069-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Indexed: 01/07/2023]
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Petrillo M, Zannoni GF, Beltrame L, Martinelli E, DiFeo A, Paracchini L, Craparotta I, Mannarino L, Vizzielli G, Scambia G, D'Incalci M, Romualdi C, Marchini S. Identification of high-grade serous ovarian cancer miRNA species associated with survival and drug response in patients receiving neoadjuvant chemotherapy: a retrospective longitudinal analysis using matched tumor biopsies. Ann Oncol 2016; 27:625-34. [PMID: 26782955 DOI: 10.1093/annonc/mdw007] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 01/07/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Neoadjuvant chemotherapy (NACT) has been recognized as a reliable therapeutic strategy in patients with unresectable advanced epithelial ovarian cancer (EOC). The molecular events leading to platinum (Pt) response in NACT settings have hitherto not been explored. In the present work, longitudinal changes of miRNA expression profile were investigated to identify miRNA families with prognostic role in high-grade serous EOC patients who received the NACT regimen. PATIENTS AND METHODS One hundred sixty-four matched tumor biopsies taken at initial laparoscopic evaluation and at interval-debulking surgery (IDS) after four courses of Pt-based therapy were selected from 82 stage IIIC-IV high-grade serous-EOC patients that were judged unsuitable for complete primary debulking and subjected the NACT protocol. miRNA profiling by microarray, real-time PCR and immuno-histochemical staining for Smad2 phosphorylation (P-Smad2) were used for data analysis. RESULTS Analysis revealed that 369 miRNAs were differentially expressed in matched biopsies (referred to as DEMs). DEMs were not scattered across the genome, but clustered into families: miR-199, let-7, miR-30, miR-181 and miR-29. Multivariate analysis showed that miR-199a-3p, miR-199a-5p, miR-181a-5p and let-7g-5p associated with overall and progression-free survival (P < 0.05); miR-199a-3p, miR-199a-5p and miR-181a-5p associated with residual tumor volume and Pt-free interval (P < 0.05). Immuno-histochemical staining confirmed an enrichment of P-Smad2, a marker of transforming growth factor-β activation, in tumors from patients with shorter PFS and OS, and with high levels of expression of miR-181a-5p (P < 0.05). Kaplan-Meier curves plotting concomitant expression of P-Smad2 and miR-181a-5p show significant differences in PFS and OS compared with those depicting the expression of each biomarker alone (P < 0.001). CONCLUSIONS This study describes several miRNA families with a prognostic role in the NACT setting. It also confirms that concomitant analysis of P-Smad2 and miR-181a-5p in surgical samples may be capable of identifying those ovarian cancer patients with poor outcome and little chance of response to Pt-based NACT.
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Affiliation(s)
- M Petrillo
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology
| | - G F Zannoni
- Department of Human Pathology, Catholic University of the Sacred Heart, Rome
| | - L Beltrame
- Department of Oncology, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - E Martinelli
- Department of Human Pathology, Catholic University of the Sacred Heart, Rome
| | - A DiFeo
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - L Paracchini
- Department of Oncology, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - I Craparotta
- Department of Oncology, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - L Mannarino
- Department of Oncology, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - G Vizzielli
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology
| | - G Scambia
- Department of Obstetrics and Gynaecology, Division of Gynaecologic Oncology
| | - M D'Incalci
- Department of Oncology, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
| | - C Romualdi
- Department of Biology, University of Padova, Padova, Italy
| | - S Marchini
- Department of Oncology, IRCCS Istituto di Ricerche Farmacologiche 'Mario Negri', Milan, Italy
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Minig L, Zorrero C, Iserte PP, Poveda A. Selecting the best strategy of treatment in newly diagnosed advanced-stage ovarian cancer patients. World J Methodol 2015; 5:196-202. [PMID: 26713279 PMCID: PMC4686416 DOI: 10.5662/wjm.v5.i4.196] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 08/27/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Although it is assumed that the combination of chemotherapy and radical surgery should be indicated in all newly diagnosed advanced-stage ovarian cancer patients, one of the main raised questions is how to select the best strategy of initial treatment in this group of patients, neoadjuvant chemotherapy followed by interval debulking surgery or primary debulking surgery followed by adjuvant chemotherapy. The selection criteria to offer one strategy over the other as well as a stepwise patient selection for initial treatment are described. Selecting the best strategy of treatment in newly diagnosed advanced stage ovarian cancer patients is a multifactorial and multidisciplinary decision. Several factors should be taken into consideration: (1) the disease factor, related to the extension and localization of the disease as well as tumor biology; (2) the patient factor, associated with patient age, poor performance status, and co-morbidities; and (3) institutional infrastructure factor, related to the lack of prolonged operative time, an appropriate surgical armamentarium, as well as well-equipped intensive care units with well-trained personnel.
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FDG-PET/CT to predict optimal primary cytoreductive surgery in patients with advanced ovarian cancer: preliminary results. TUMORI JOURNAL 2015; 102:103-7. [PMID: 26350201 DOI: 10.5301/tj.5000396] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2015] [Indexed: 11/20/2022]
Abstract
AIMS AND BACKGROUND Primary cytoreductive surgery (CRS) has a significant impact on prognosis in epithelial ovarian cancer (EOC). Patient selection is important to recognize factors limiting optimal CRS and to avoid unnecessary aggressive surgical procedures. We evaluated the contribution of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) in the presurgical identification of disease sites that may preclude EOC cytoreducibility. METHODS Patients with suspected EOC underwent 18F-FDG-PET/CT within 20 days before debulking surgery. The PET/CT results were compared with surgical findings and postsurgery histopathology in order to assess the diagnostic value. RESULTS Between August 2013 and January 2014, 29 patients were evaluated. The histopathology showed 23 EOC and 6 benign tumors. The FDG-PET/CT was positive (maximum standardized uptake value [SUVmax] 11.3 ± 5.4) in 21/23 (91%) patients with EOC and provided 2 false-negatives (1 mucinous and 1 clear cell carcinoma; SUVmax ≤2.8). The FDG-PET/CT was true-negative (SUVmax 2.2 ± 1.6) in 4 out of 6 patients (67%). False-positive FDG-PET results were obtained in 2 cellular fibromas (SUVmax 4.8 and 5.6). The sensitivity, specificity, and accuracy of PET/CT to characterize ovarian masses were 91%, 67%, and 86%, respectively. Among the 21 FDG-PET/CT-positive EOC, we detected factors limiting optimal CRS in 6 cases (29%): 4 hepatic hilum infiltration and 2 root mesentery involvement, confirmed at surgical exploration. The FDG-PET did not find limiting factors in the remaining 15 patients (71%) in whom optimal CRS was obtained. CONCLUSIONS Fluorodeoxyglucose-PET/CT shows high sensitivity but suboptimal specificity in the characterization of ovarian masses. However, PET/CT may play a role in noninvasively selecting patients with EOC who can benefit from primary CRS.
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Della Pepa C, Tonini G, Pisano C, Di Napoli M, Cecere SC, Tambaro R, Facchini G, Pignata S. Ovarian cancer standard of care: are there real alternatives? CHINESE JOURNAL OF CANCER 2015; 34:17-27. [PMID: 25556615 PMCID: PMC4302086 DOI: 10.5732/cjc.014.10274] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ovarian cancer remains a major issue for gynecological oncologists, and most patients are diagnosed when the disease is already advanced with a poor chance of survival. Debulking surgery followed by platinum-taxane chemotherapy is the current standard of care, but based on several different strategies currently under evaluation, some encouraging data have been published in the last 4 to 5 years. This review provides a state-of-the-art overview of the available alternatives to conventional treatment and the most promising new combinations. For example, neoadjuvant chemotherapy does not seem to be inferior to primary debulking. Despite its outcome improvements, intraperitoneal chemotherapy struggles for acceptance due to the heavy toxicity. Dose-dense chemotherapy, after showing an impressive efficacy in Asian populations, has not produced equal results in a European cohort, and the results of alternative platinum doublets are not superior to those of carboplatin and paclitaxel. In this setting, adherence to a maintenance therapy after first-line treatment and multiple (primarily antiangiogenic) agents appears to be effective. Although many questions, including the duration of maintenance treatment and the use of bevacizumab beyond progression, remain unanswered, new biologic agents, such as poly(ADP-ribose) polymerase (PARP) inhibitors, nintedanib, and mitogen-activated protein/extracellular signal-regulated kinase (MEK) inhibitors, have emerged as potential therapeutic options in the very near future. Based on the multiplicity of available strategies, the histological and molecular features of the tumor, in addition to patient's clinical condition and disease state, continue to gain importance in guiding treatment choices.
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Affiliation(s)
- Chiara Della Pepa
- Department of Medical Oncology, Campus Bio-Medico University of Rome, Via Alvaro Del Portillo, 200, Rome 00128, Italy.
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Patankar S, Burke WM, Hou JY, Tergas AI, Huang Y, Ananth CV, Neugut AI, Hershman DL, Wright JD. Risk stratification and outcomes of women undergoing surgery for ovarian cancer. Gynecol Oncol 2015; 138:62-9. [PMID: 25976399 DOI: 10.1016/j.ygyno.2015.04.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 04/29/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Cytoreduction for ovarian cancer is associated with substantial morbidity. We examined the outcome of patients undergoing surgery for ovarian cancer to determine if there are sub-groups of patients who may benefit from alternative treatments. METHODS The National Surgical Quality Improvement Program database was used to identify women who underwent surgery for ovarian cancer from 2005-2012. Multivariable logistic regression models were used to examine the effect of age, race, functional status, ASA class, preoperative albumin and performance of extended cytoreductive procedures on morbidity, mortality and resource utilization. RESULTS A total of 2870 women were identified. The perioperative complication rate increased from 9.5% in women <50years, to 13.4% in those age 60-69years, and 14.6% in women ≥70years (P<0.0001). Similarly, complications rose from 7.3% in those who did not require any extended procedures to 12.9% after 1 procedure, 28.4% for those who had 2, and 30.0% in women who underwent ≥3 extended procedures (P<0.0001). In a series of multivariable models, the number of extended cytoreductive procedures performed and preoperative albumin were the factors most consistently associated with morbidity. Using a series of model fit statistics, compared to chance alone, the ability to predict any complication increased by 27.4% when procedure score was analyzed, 22.0% with preoperative albumin, 11% with age, and 4% with functional status. CONCLUSIONS While preoperative clinical and demographic factors may help predict the risk of adverse outcomes for women undergoing surgery for ovarian cancer, performance of extended cytoreductive procedures is the strongest risk factor for complications.
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Affiliation(s)
- Sonali Patankar
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA
| | - William M Burke
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Ana I Tergas
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Yongmei Huang
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA
| | - Cande V Ananth
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA
| | - Alfred I Neugut
- Department of Medicine, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Dawn L Hershman
- Department of Medicine, Columbia University College of Physicians and Surgeons, USA; Department of Epidemiology, Mailman School of Public Health, Columbia University, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, USA; Herbert Irving Comprehensive Cancer Center, Columbia University College of Physicians and Surgeons, USA; New York Presbyterian Hospital, USA.
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Comparative effectiveness research in gynecologic oncology. Cancer Treat Res 2015; 164:237-59. [PMID: 25677027 PMCID: PMC4484275 DOI: 10.1007/978-3-319-12553-4_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The field of gynecologic oncology is faced with a number of challenges including how to incorporate new drugs and procedures into practice, how to balance therapeutic efficacy and toxicity of treatment, how to individualize therapy to particular patients or groups of patients, and how to contain the rapidly rising costs associated with oncologic care. In this chapter we examine three common and highly debated clinical scenarios in gynecologic oncology: the initial management of ovarian cancer, the role of lymphadenectomy in the treatment of endometrial cancer, and the choice of adjuvant therapy for ovarian cancer.
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Leung AWY, Kalra J, Santos ND, Bally MB, Anglesio MS. Harnessing the potential of lipid-based nanomedicines for type-specific ovarian cancer treatments. Nanomedicine (Lond) 2014; 9:501-22. [PMID: 24746193 DOI: 10.2217/nnm.13.220] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Epithelial ovarian cancers are a group of at least five histologically and clinically distinct diseases, yet at this time patients with these different diseases are all treated with the same platinum and taxane-based chemotherapeutic regimen. With increased knowledge of histotype-specific differences that correlate with treatment responses and resistance, novel treatment strategies will be developed for each distinct disease. Type-specific or resistance-driven molecularly targeted agents will provide some specificity over traditional chemotherapies and it is argued here that nanoscaled drug delivery systems, in particular lipid-based formulations, have the potential to improve the delivery and specificity of pathway-specific drugs and broad-spectrum cytotoxic chemotherapeutics. An overview of the current understanding of ovarian cancers and the evolving clinical management of these diseases is provided. This overview is needed as it provides the context for understanding the current role of drug delivery systems in the treatment of ovarian cancer and the need to design formulations for treatment of clinically distinct forms of ovarian cancer.
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Affiliation(s)
- Ada W Y Leung
- Experimental Therapeutics, British Columbia Cancer Agency Cancer Research Centre, Vancouver, BC, Canada
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Shim SH, Lee SJ, Kim SO, Kim SN, Kim DY, Lee JJ, Kim JH, Kim YM, Kim YT, Nam JH. Nomogram for predicting incomplete cytoreduction in advanced ovarian cancer patients. Gynecol Oncol 2014; 136:30-6. [PMID: 25448457 DOI: 10.1016/j.ygyno.2014.11.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 10/31/2014] [Accepted: 11/02/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Accurately predicting cytoreducibility in advanced-ovarian cancer is needed to establish preoperative plans, consider neoadjuvant chemotherapy, and improve clinical trial protocols. We aimed to develop a positron-emission tomography/computed tomography-based nomogram for predicting incomplete cytoreduction in advanced-ovarian cancer patients. METHODS Between 2006 and 2012, 343 consecutive advanced-ovarian cancer patients underwent positron-emission tomography/computed tomography before primary cytoreduction: 240 and 103 patients were assigned to the model development or validation cohort, respectively. After reviewing the detailed surgical documentation, incomplete cytoreduction was defined as a remaining gross residual tumor. We evaluated each individual surgeon's surgical aggressiveness index (number of high-complex surgeries/total number of surgeries). Possible predictors, including surgical aggressiveness index and positron-emission tomography/computed tomography features, were analyzed using logistic regression modeling. A nomogram based on this model was developed and externally validated. RESULTS Complete cytoreduction was achieved in 120 patients (35%). Surgical aggressiveness index and five positron-emission tomography/computed tomography features were independent predictors of incomplete cytoreduction. Our nomogram predicted incomplete cytoreduction by incorporating these variables and demonstrated good predictive accuracy (concordance index = 0.881; 95% CI = 0.838-0.923). The predictive accuracy of our validation cohort was also good (concordance index = 0.881; 95% CI = 0.790-0.932) and the predicted probability was close to the actual observed outcome. Our model demonstrated good performance across surgeons with varying degrees of surgical aggressiveness. CONCLUSION We have developed and validated a nomogram for predicting incomplete cytoreduction in advanced-ovarian cancer patients which may help stratify patients for clinical trials, establish meticulous preoperative plans, and determine if neoadjuvant chemotherapy is warranted.
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Affiliation(s)
- Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seon-Ok Kim
- Department of Clinical Epidemiology and Biostatistics, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Soo-Nyung Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Dae-Yeon Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea.
| | - Jong Jin Lee
- Department of Nuclear Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jong-Hyeok Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Yong-Man Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Young-Tak Kim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Joo-Hyun Nam
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea
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Sato S, Itamochi H. Neoadjuvant chemotherapy in advanced ovarian cancer: latest results and place in therapy. Ther Adv Med Oncol 2014; 6:293-304. [PMID: 25364394 PMCID: PMC4206650 DOI: 10.1177/1758834014544891] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Approximately 70% of women with epithelial ovarian cancer (EOC) are diagnosed with advanced stage disease, which is associated with high morbidity and mortality. The standard approach to treating patients with advanced EOC remains primary debulking surgery (PDS) followed by chemotherapy. EOC is one of the most sensitive of all solid tumors to cytotoxic drugs, with over 80% of women showing a response to standard chemotherapy combined with taxane and platinum. Furthermore, residual disease is a major prognostic factor for survival. On the basis of the clinical features, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) is considered to be an alternative treatment option to standard treatment in patients unable to undergo complete resection during PDS. Noninferiority of NACT-IDS to PDS has been demonstrated in some randomized controlled trials and meta-analyses. NACT would also lead to improved quality of life (QOL) of patients, however there are still problems to be solved in the treatment strategy. The uncertainty of perioperative visual assessment of tumor dissemination after NACT has been reported. In addition, several papers have shown the possibility that NACT induces platinum resistance. Furthermore, a notable risk associated with NACT is that patients with significant side effects and refractory disease will lose the opportunity for debulking surgery. Appropriate selection of the patient cohort for NACT is an important issue. Bevacizumab (Bev) is active in patients with advanced EOC. However, the use of Bev is not recommended in the neoadjuvant setting. Bev has a specific adverse event profile that needs to be considered, especially for surgical management, such as gastrointestinal perforation, hemorrhage, and thromboembolic events. NACT could be an alternative treatment option in patients with stage III or IV EOC. However, further studies are needed to clarify the precise role of NACT in the management of advanced EOC.
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Affiliation(s)
- Seiya Sato
- Department of Obstetrics and Gynecology, Tottori University School of Medicine, Yonago-City, Tottori, Japan
| | - Hiroaki Itamochi
- Department of Obstetrics and Gynecology, Tottori University School of Medicine, 36-1 Nishicho, Yonago-City 683-8504, Tottori, Japan
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Cappellesso R, Tinazzi A, Giurici T, Simonato F, Guzzardo V, Ventura L, Crescenzi M, Chiarelli S, Fassina A. Programmed cell death 4 and microRNA 21 inverse expression is maintained in cells and exosomes from ovarian serous carcinoma effusions. Cancer Cytopathol 2014; 122:685-93. [PMID: 24888238 DOI: 10.1002/cncy.21442] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 04/30/2014] [Accepted: 05/05/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ovarian serous carcinoma (OSC) is a fatal gynecologic malignancy usually presenting with bilateral localization and malignant peritoneal effusion. Programmed cell death 4 (PDCD4) is a tumor suppressor gene whose expression is directly controlled by microRNA-21 (miR-21). Exosomes are small cell-derived vesicles that participate in intercellular communication, delivering their cargo of molecules to specific cells. Exosomes are involved in several physiological and pathological processes including oncogenesis, immunomodulation, angiogenesis, and metastasis. The current study analyzed the expression of PDCD4 and miR-21 in resected OSC specimens and in cells and exosomes from OSC peritoneal effusions. METHODS PDCD4 was immunohistochemically examined in 14 normal ovaries, 14 serous cystadenoma (CA), and 14 OSC cases. Quantitative reverse transcriptase-polymerase chain reaction analysis of PDCD4 and miR-21 expression was performed in CA and OSC cases and in cells and exosomes obtained from 10 OSC and 10 nonneoplastic peritoneal effusions. miR-21 was also evaluated by in situ hybridization. RESULTS Immunohistochemistry demonstrated a gradual PDCD4 loss from normal ovaries to CA and OSC specimens. Quantitative reverse transcriptase-polymerase chain reaction displayed higher PDCD4 messenger RNA levels in CA specimens compared with OSC cases and highlighted miR-21 overexpression in OSC specimens. In situ hybridization detected miR-21 only in OSC cells. This PDCD4 and miR-21 inverse expression was also noted in cells and exosomes from OSC peritoneal effusions compared with nonneoplastic effusions. CONCLUSIONS PDCD4 and miR-21 are involved in OSC oncogenesis. The transfer of miR-21 by exosomes could promote oncogenic transformation in target cells distant from the primary tumor without direct colonization by cancer cells and could be used as a diagnostic tool.
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Affiliation(s)
- Rocco Cappellesso
- Surgical Pathology and Cytopathology Unit, Department of Medicine, University of Padua, Padua, Italy
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Lu Y, Yang J, Cao D, Huang H, Wu M, You Y, Chen J, Lang J, Shen K. Role of neoadjuvant chemotherapy in the management of advanced ovarian yolk sac tumor. Gynecol Oncol 2014; 134:78-83. [PMID: 24582864 DOI: 10.1016/j.ygyno.2014.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Revised: 02/17/2014] [Accepted: 02/20/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The aim of the study was to identify the role of neoadjuvant chemotherapy (NACT) in the treatment of the patients with advanced stage ovarian yolk sac tumor (OYST). METHODS The comparative study was based on 53 cases with advanced stage OYST registered at Peking Union Medical College Hospital from 1995 to 2010. Twenty one cases were treated with NACT followed by interval debulking surgery (IDS). Thirty two cases were treated with primary debulking surgery (PDS). Data on patient characteristics, treatment and survival were analyzed and compared between two groups to assess the outcome of NACT. RESULTS After NACT, the overall status of the patients was improved significantly. Patients in NACT had better optimal cytoreduction rate and less peri-operative morbidities. Seven patients (13.2%) suffered from relapse. There was a significantly better PFS for patients with ovarian tumor size >20cm in the NACT than those underwent PDS. Residual disease >2cm was the independent risk factor of relapse. CONCLUSIONS NACT is the better treatment option for some patients with advanced stage OYST, especially for those with unresectable tumors and poor general condition.
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Affiliation(s)
- Yan Lu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Jiaxin Yang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Dongyan Cao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Huifang Huang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Ming Wu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Yan You
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Jie Chen
- Department of Pathology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Pathology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Jinhe Lang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China
| | - Keng Shen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, People's Republic of China and Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Peking Union Medical College, People's Republic of China.
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TP53 K351N mutation-associated platinum resistance after neoadjuvant chemotherapy in patients with advanced ovarian cancer. Gynecol Oncol 2014; 132:752-7. [PMID: 24463159 DOI: 10.1016/j.ygyno.2014.01.028] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Revised: 01/04/2014] [Accepted: 01/16/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE TP53 K351N mutation is associated with acquired cisplatin resistance in ovarian cancer cells following exposure to cisplatin. We investigated the effect of TP53 K351N mutation on outcome in patients with epithelial ovarian cancer (EOC) who received platinum-based chemotherapy. METHODS We assessed TP53 K351N mutations by allele specific real-time PCR (AS-PCR) and DNA sequencing in tumor samples of 153 patients with stage IIIC/IV EOC. Clinicopathologic and follow-up data were collected by a retrospective chart review. RESULTS TP53 K351N mutations were detected in 8 (11.27%) of 71 patients who underwent neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) but not in 82 patients who underwent primary debulking surgery (PDS) (P<0.01). In patients with relapse within 6 months, the relapse rate was 14 (19.72%) of 71 patients for NACT-IDS compared to 15 (18.29%) of 82 patients for PDS (P=0.49), and TP53 K351N mutation was observed in 8 of NACT-IDS 14 patients (57.14% P<0.01). In the patients retreated at first recurrence within 6 months, 7 with TP53 K351N mutation of 14 NACT-IDS patients exhibited progression of disease, compared to 2 of PDS 15 patients (50.00% vs. 13.33%, P=0.04). The median disease-free survival (DFS) for NACT-IDS was 13.0 months compared to 15.0 months for PDS (P=0.02). In multivariate analysis, TP53 K351N mutation is an independent factor for shorter DFS in the patients who underwent NACT-IDS (HR=19.05; P=0.01). CONCLUSIONS TP53 K351N mutation may be associated with induction of platinum resistance after NACT in advanced EOC.
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Clinical trials of neoadjuvant chemotherapy for ovarian cancer: what do we gain after an EORTC trial and after two additional ongoing trials are completed? Curr Oncol Rep 2013; 15:197-200. [PMID: 23504482 DOI: 10.1007/s11912-013-0313-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of neoadjuvant chemotherapy is to reduce the tumor volume or spread of the disease before the main treatment, and it could possibly make the main procedures easier or less invasive. Although the standard therapeutic strategy for advanced ovarian cancer is a maximum primary debulking surgery followed by chemotherapy, a European Organisation for Research and Treatment of Cancer (EORTC) prospective randomized trial demonstrated that neoadjuvant chemotherapy followed by interval debulking surgery was not inferior to the standard procedure. This study raised a number of controversies, particularly regarding the quality of debulking surgery. To solve the questions, we need to wait for the results of two additional ongoing randomized trials. However, the results of those two trials must be carefully assessed, because the quality of debulking surgery would significantly affect survival, and may make the interpretation of the trial results more confusing and difficult.
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Muraji M, Sudo T, Iwasaki SI, Ueno S, Wakahashi S, Yamaguchi S, Fujiwara K, Nishimura R. Histopathology predicts clinical outcome in advanced epithelial ovarian cancer patients treated with neoadjuvant chemotherapy and debulking surgery. Gynecol Oncol 2013; 131:531-4. [DOI: 10.1016/j.ygyno.2013.09.030] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Revised: 09/18/2013] [Accepted: 09/28/2013] [Indexed: 11/28/2022]
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van Meurs HS, Tajik P, Hof MH, Vergote I, Kenter GG, Mol BWJ, Buist MR, Bossuyt PM. Which patients benefit most from primary surgery or neoadjuvant chemotherapy in stage IIIC or IV ovarian cancer? An exploratory analysis of the European Organisation for Research and Treatment of Cancer 55971 randomised trial. Eur J Cancer 2013; 49:3191-201. [DOI: 10.1016/j.ejca.2013.06.013] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2013] [Revised: 06/11/2013] [Accepted: 06/13/2013] [Indexed: 10/26/2022]
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Coleman RL, Monk BJ, Sood AK, Herzog TJ. Latest research and treatment of advanced-stage epithelial ovarian cancer. Nat Rev Clin Oncol 2013; 10:211-24. [PMID: 23381004 PMCID: PMC3786558 DOI: 10.1038/nrclinonc.2013.5] [Citation(s) in RCA: 400] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The natural history of ovarian cancer continues to be characterized by late-stage presentation, metastatic bulky disease burden and stagnant mortality statistics, despite prolific drug development. Robust clinical investigation, particularly with modifications to primary treatment surgical goals and adjuvant therapy are increasing median progression-free survival and overall survival, although the cure rates have been affected only modestly. Maintenance therapy holds promise, but studies have yet to identify an agent and/or strategy that can affect survival. Recurrent disease is largely an incurable state; however, current intervention with selected surgery, combination and targeted therapy and investigational protocols are impacting progression-free survival. Ovarian cancer is a diverse and genomically complex disease, which commands global attention. Rational investigation must balance the high rate of discovery with lagging clinical investigation and limited patient resources. Nevertheless, growth in our armamentarium offers unprecedented opportunities for patients suffering with this disease. This Review presents and reviews the contemporary management of the disease spectrum termed epithelial 'ovarian' cancer and describes the direction and early results of clinical investigation.
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Affiliation(s)
- Robert L Coleman
- Department of Gynecologic Oncology & Reproductive Medicine, University of Texas, MD Anderson Cancer Center, 1155 Herman Pressler Drive, Houston, TX 77030, USA. rcoleman@ mdanderson.org
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Positron emission tomography/computed tomography predictors of overall survival in stage IIIC/IV ovarian cancer. Int J Gynecol Cancer 2013; 22:1163-9. [PMID: 22810969 DOI: 10.1097/igc.0b013e3182606ecb] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To evaluate the role of 2-deoxy-2-(F)fluoro-D-glucose (FDG) positron emission tomography/computed tomography (PET/CT) for selecting patients with extensive ovarian cancer (OC) for neoadjuvant chemotherapy by evaluating predictors of overall survival in patients with stage IIIC/IV OC. MATERIALS AND METHODS From September 1, 2004, to November 20, 2011, 514 consecutive patients with a pelvic tumor underwent preoperative PET/CT; 179 patients had stage IIIC/IV OC. Patients' characteristics were collected from 153 patients with stage IIIC/IV OC who underwent primary surgery. In 152 patients with stage IIIC/IV OC, clinical predictors and PET/CT predictors of survival were evaluated. RESULTS Median age was 64 years (range, 38-88 years); 87% (113) of the 153 patients had a performance status of less than 2; 55% (84) of the 153 patients had PET/CT stage III, and 45% (69) of the 153 patients had PET/CT stage IV. Using univariate analysis, incomplete debulking (P = 0.0001), pleural exudates (P = 0.001), postmenopausal state (P = 0.01), WHO performance status greater than 2 (P = 0.01), PET/CT stage IV (P = 0.01), and large bowel mesentery implants (P = 0.02) were statistically significant prognostic variables. Using multivariate Cox regression analysis, incomplete debulking was the only statistically significant independent prognostic variable (P = 0.0001). Median overall survival was significantly longer in the 53 patients with no residual tumor than in the 99 patients with residual tumor (33.3 vs 25.5 months; P = 0.0001) CONCLUSION Suggested PET/CT criteria for referral of patients with advanced OC to neoadjuvant chemotherapy are PET/CT stage IV, pleural exudates, and PET-positive large bowel mesentery implants. Evaluation of selection criteria for neoadjuvant chemotherapy should be promoted in prospective clinical trials, with survival as the primary end point.
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Abstract
Despite the high response rate to first-line treatment of advanced ovarian cancer, the vast majority of patients relapse. Maximal debulking surgery and chemotherapy with a platinum doublet have remained the standard of care for many years and new approaches are imperative. Recent clinical trials have given grounds for hope. Neoadjuvant chemotherapy, intraperitoneal delivery, and dose-dense strategies have all shown promising results, as has the targeting of angiogenesis. A greater understanding of the molecular landscape of ovarian cancer is helping to identify new treatment options. In this review, we will highlight the key trials and recent progress in these areas.
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Affiliation(s)
- Z Kemp
- Department of Oncology, University College London Hospitals
| | - JA Ledermann
- Department of Oncology, University College London Hospitals
- University College London Cancer Institute, University College London, London, United Kingdom
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Tsubamoto H, Itani Y, Ito K, Kanazawa R, Toyoda S, Takeuchi S. Phase II study of interval debulking surgery followed by intraperitoneal chemotherapy for advanced ovarian cancer: a Kansai Clinical Oncology Group study (KCOG9812). Gynecol Oncol 2012; 128:22-27. [PMID: 23063999 DOI: 10.1016/j.ygyno.2012.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 10/01/2012] [Accepted: 10/03/2012] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Intraperitoneal chemotherapy (IP) is known to be effective after optimal primary debulking surgery (PDS) for ovarian cancer (OC). Here, we conducted a phase II study to investigate its effectiveness after interval debulking surgery (IDS). METHODS Thirty-seven patients with FIGO stage IIIB-IV and suboptimal (≥1cm diameter) residual disease after PDS were enrolled. Carboplatin (AUC 4 IV, Day 1) and cisplatin (50mg/m(2) IV, Day 3) were given q21d for 3cycles. After IDS, paclitaxel (175mg/m(2) IV Day 1 or 60mg/m(2) IV Days 1, 8, and 15, since 2000) and cisplatin (75mg/m(2) IP Day 2) were given q21d for 4cycles. The primary endpoint was progression-free survival (PFS), and secondary endpoints were overall survival (OS) and adverse events (CTCAE ver. 2.0). Clinical manifestations at first recurrence and subsequent treatment were also surveyed. RESULTS Of the 37 patients, high-grade, serous adenocarcinoma was found in 33. Stages IIIB, IIIC, and IV were found in 2, 24, and 11 patients, respectively. After IDS, 23 patients had no macroscopic residual tumor. No patients had permanent enterostomy, febrile neutropenia, or platelet transfusion. The treatment protocol was completed in 22 patients, and discontinued in 5 due to IP catheter-related complications. Median PFS and OS were 22 and 57months, respectively. Among the 28 patients with recurrence, 10 had no intraperitoneal disease at first recurrence. Among the 8 patients who underwent surgical cytoreduction, 6 had no residual tumor, while 2 had a <1-cm-diameter residual tumor. CONCLUSION IP after IDS for patients with initially suboptimally debulked OC was effective.
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Vergote I, du Bois A, Amant F, Heitz F, Leunen K, Harter P. Neoadjuvant chemotherapy in advanced ovarian cancer: On what do we agree and disagree? Gynecol Oncol 2012; 128:6-11. [PMID: 23006973 DOI: 10.1016/j.ygyno.2012.09.013] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Revised: 09/04/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022]
Affiliation(s)
- Ignace Vergote
- University Hospital Leuven, Leuven Cancer Institute, Division of Gynecological Oncology, Department of Obstetrics and Gynecology, Leuven, Belgium European Union.
| | - Andreas du Bois
- Kliniken Essen Mitte, Department of Gynecology & Gynecologic Oncology, Essen, Germany
| | - Frederic Amant
- University Hospital Leuven, Leuven Cancer Institute, Division of Gynecological Oncology, Department of Obstetrics and Gynecology, Leuven, Belgium European Union
| | - Florian Heitz
- Kliniken Essen Mitte, Department of Gynecology & Gynecologic Oncology, Essen, Germany
| | - Karin Leunen
- University Hospital Leuven, Leuven Cancer Institute, Division of Gynecological Oncology, Department of Obstetrics and Gynecology, Leuven, Belgium European Union
| | - Philipp Harter
- Kliniken Essen Mitte, Department of Gynecology & Gynecologic Oncology, Essen, Germany
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Raja F, Chopra N, Ledermann J. Optimal first-line treatment in ovarian cancer. Ann Oncol 2012; 23 Suppl 10:x118-27. [DOI: 10.1093/annonc/mds315] [Citation(s) in RCA: 94] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Morrison J, Haldar K, Kehoe S, Lawrie TA. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2012; 2012:CD005343. [PMID: 22895947 PMCID: PMC4050358 DOI: 10.1002/14651858.cd005343.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment is to perform surgery first and then give chemotherapy. However, it is not yet clear whether there are any advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before cytoreductive surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows maximal cytoreductive surgery. SEARCH METHODS For the original review we searched, the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2006), MEDLINE (Silver Platter, from 1966 to 1 Sept 2006), EMBASE via Ovid (from 1980 to 1 Sept 2006), CANCERLIT (from 1966 to 1 Sept 2006), PDQ (search for open and closed trials) and MetaRegister (most current search Sept 2006). For this update randomised controlled trials (RCTs) were identified by searching the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 3, 2011) and the Cochrane Gynaecological Cancer Specialised Register (2011), MEDLINE (August week 1, 2011), EMBASE (to week 31, 2011), PDQ (search for open and closed trials) and MetaRegister (August 2011). SELECTION CRITERIA RCTs of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Data were extracted by two review authors independently, and the quality of included trials was assessed by two review authors independently. MAIN RESULTS One high-quality RCT met the inclusion criteria. This multicentre trial randomised 718 women with stage IIIc/IV ovarian cancer to NACT followed by interval debulking surgery (IDS) or primary debulking surgery (PDS) followed by chemotherapy. There were no significant differences between the study groups with regard to overall survival (OS) (670 women; HR 0.98; 95% CI 0.82 to 1.18) or progression-free survival (PFS) (670 women; HR 1.01; 95% CI 0.86 to 1.17).Significant differences occurred between the NACT and PDS groups with regard to some surgically related serious adverse effects (SAE grade 3/4) including haemorrhage (12 in NACT group vs 23 in PDS group; RR 0.50; 95% CI 0.25 to 0.99), venous thromboembolism (none in NACT group vs eight in PDS group; RR 0.06; 95% CI 0 to 0.98) and infection (five in NACT group vs 25 in PDS group; RR 0.19; 95% CI 0.07 to 0.50). Quality of life (QoL) was reported to be similar for the NACT and PDS groups.Three ongoing RCTs were also identified. AUTHORS' CONCLUSIONS We consider the use of NACT in women with stage IIIc/IV ovarian cancer to be a reasonable alternative to PDS, particularly in bulky disease. With regard to selecting who will benefit from NACT, treatment should be tailored to the patient and should take into account resectability, age, histology, stage and performance status. These results cannot be generalised to women with stage IIIa and IIIb ovarian cancer; in these women, PDS is the standard. We await the results of three ongoing trials, which may change these conclusions.
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Affiliation(s)
- Jo Morrison
- Department of Obstetrics and Gynaecology, Musgrove Park Hospital, Taunton, UK.
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Kuhn W. Clinical trials in elderly ovarian cancer patients - does it make sense? ONKOLOGIE 2012; 35:73-74. [PMID: 22414968 DOI: 10.1159/000336980] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Vergote I, Leunen K, Amant F. Primary surgery or neoadjuvant chemotherapy in ovarian cancer: What is the value of comparing apples with oranges? Gynecol Oncol 2012; 124:1-2. [DOI: 10.1016/j.ygyno.2011.11.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2011] [Indexed: 10/14/2022]
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Fujiwara K, Katsumata N, Onda T. Dose-dense chemotherapy and neoadjuvant chemotherapy for ovarian cancer. Am Soc Clin Oncol Educ Book 2012:349-54. [PMID: 24451762 DOI: 10.14694/edbook_am.2012.32.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Two of the innovative chemotherapeutic approaches to ovarian cancer treatment, dose-dense chemotherapy and neoadjuvant chemotherapy, will be discussed herein. The primary concept of dose-dense chemotherapy is to administer the same cumulative dose of chemotherapy over a shorter period. Increased dose density is achieved by reducing the interval between each dose of chemotherapy. The Japanese Gynecologic Oncology Group (JGOG) first demonstrated the survival advantage of dose-dense weekly administration of paclitaxel in 2009. However, there are unanswered questions, such as the question of dose-dense carboplatin versus less dose-intensive regimens. Clear cell or mucinous carcinomas seem to need other strategies, such as targeted agents. The aim of neoadjuvant chemotherapy is to reduce tumor volume or spread before main treatment. This could then make the main procedures easier or less invasive, just like breast-conserving surgery after neoadjuvant chemotherapy. In advanced ovarian cancer, standard procedure is maximum primary debulking surgery followed by chemotherapy. Recently, a prospective randomized trial demonstrated that neoadjuvant chemotherapy followed by interval debulking surgery was not inferior to the standard procedure. However, there are several questions that remain unanswered, such as the suitable number of chemotherapy cycles before interval debulking surgery. Some of those questions regarding dose-dense chemotherapy or neoadjuvant chemotherapy may be resolved by ongoing or future prospective trials.
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Affiliation(s)
- Keiichi Fujiwara
- From the Department of Gynecologic Oncology, Saitama Medical School International Medical Center, Saitama, Japan; Department of Medical Oncology, Nippon Medical School, Musashikosugi Hospital, Kawasaki-City, Japan; Department of Gynecology, Kitasato University School of Medicine, Sagamihara-City, Kanagawa, Japan
| | - Noriyuki Katsumata
- From the Department of Gynecologic Oncology, Saitama Medical School International Medical Center, Saitama, Japan; Department of Medical Oncology, Nippon Medical School, Musashikosugi Hospital, Kawasaki-City, Japan; Department of Gynecology, Kitasato University School of Medicine, Sagamihara-City, Kanagawa, Japan
| | - Takashi Onda
- From the Department of Gynecologic Oncology, Saitama Medical School International Medical Center, Saitama, Japan; Department of Medical Oncology, Nippon Medical School, Musashikosugi Hospital, Kawasaki-City, Japan; Department of Gynecology, Kitasato University School of Medicine, Sagamihara-City, Kanagawa, Japan
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