Consensus statements and treatment algorithm to guide clinicians in the selection of maintenance therapy for patients with newly diagnosed, advanced ovarian carcinoma: Results of a Delphi study

INTRODUCTION

Standard treatment of newly diagnosed, advanced ovarian carcinoma (OC) consists of cytoreductive surgery followed by platinum-based chemotherapy with or without bevacizumab. Maintenance therapy with PARP inhibitors and olaparib-bevacizumab has recently shown to significantly improve progression-free survival in the first-line setting. Some practical aspects of maintenance therapy, however, are still poorly defined.

AIM OF THE STUDY

To provide guidance to clinicians in the selection of maintenance therapy for newly diagnosed, advanced ovarian carcinoma.

METHODS

A board of six gynecologic oncologists with expertise in the treatment of OC in Italy convened to address issues related to the new options for maintenance treatment. Based on scientific evidences, the board produced practice-oriented statements. Consensus was reached via a modified Delphi study that involved a panel of 22 experts from across Italy.

RESULTS

Twenty-seven evidence- and consensus-based statements are presented, covering the following areas of interest: use of biomarkers (BRCA mutations and presence of homologous recombination deficiency); timing and outcomes of surgery; selection of patients eligible for bevacizumab; definition of response to treatment; toxicity and contraindications; evidence of synergy of bevacizumab plus PARP inhibitor. Two treatment algorithms are also included, for selecting maintenance therapy based on timing and outcomes of surgery, response to platinum-based chemotherapy and biomarker status. A score for the assessment of response to chemotherapy is proposed, but its validation is ongoing.

CONCLUSIONS

We provide here consensus statements and treatment algorithms to guide clinicians in the selection of appropriate and personalized maintenance therapy in the first-line setting of advanced OC management.

An Acid Response IR780-Based Targeted Nanoparticle for Intraoperative Near-Infrared Fluorescence Imaging of Ovarian Cancer

INTRODUCTION

Complete resection of all visible disease (R0 resection) is critical for the treatment of ovarian cancer patients, and accurate real-time guidance provided by intraoperative near-infrared (NIR) fluorescence images is beneficial for achieving complete resection of all visible disease.

METHODS

Based on the optical properties of IR780 and the characteristics of the acidic tumor microenvironment, we develop a new smart nanoparticle (eg, FA-IR780&PFOB-SNPs) by using the pH response nano framework (FA-PEG-PLGA-PEOz) and adjusting the amount of IR780. The FA-IR780&PFOB-SNPs was characterized for morphology, microstructure, particle size, pH-response, drug-loading efficiency and biological safety. The ultraclear fluorescence Navigation Endoscopy System was applied to evaluate the tumor recognition of FA-IR780&PFOB-SNPs in vivo.

RESULTS

The structure of FA-IR780&PFOB-SNPs was stable in a neutral environment, and the near-infrared (NIR) fluorescence was turned off, while the structure of FA-IR780&PFOB-SNPs was degraded in the acidic tumour microenvironment, and the NIR fluorescence was turned on. Through the ovarian subcutaneous xenograft tumour and ovarian intraperitoneal xenograft tumour models, it was confirmed that FA-IR780&PFOB-SNPs could clearly display the boundaries of abdominal micron-sized tumours through near-infrared fluorescence imaging, with a TBR greater than 5.

CONCLUSION

The FA-IR780&PFOB-SNPs have the potential to provide to ovarian cancer intraoperative near infrared fluorescence navigation during precision tumour resection to achieve R0 and improve the prognosis of ovarian cancer patients.

Impact of no residual disease on postoperative computed tomography on survival in patients with optimally debulked advanced high-grade serous ovarian cancer during upfront surgery

OBJECTIVE

We sought to investigate the impact of size of residual tumors as determined by postoperative computed tomography (CT) on survival of patients with advanced, high-grade serous ovarian carcinoma (HGSC) who achieved residual disease less than 1 cm after primary debulking surgery (PDS).

METHODS

We collected data of patients with stage III HGSC who had residual tumor less than 1 cm after PDS between 2013 and 2018. Surgeon-assessed residual disease during surgery was defined as sR0 (no gross residual) or sR1 (gross residual <1 cm), and radiologist-assessed residual disease on postoperative CT was defined as rR0 (no evidence of disease) or rRany (existing residual disease). All patients were classified into the following groups: sR0/rR0, sR1/rR0, sR0/rRany, and sR1/rRany.

RESULTS

A total of 436 patients was placed into the sR0/rR0 (n = 187, 42.9%), sR1/rR0 (n = 59, 13.5%), sR0/rRany (n = 79, 18.1%), or sR1/rRany group (n = 111, 25.5%). Discrepancies between surgical and radiological assessments were recorded for 176 patients (40.4%) including 38 cases of sR1/rRany group with discordant residual tumor location indicated between two methods. During multivariate analysis, patients with ascites on preoperative CT, sR0/rRany group inclusion, and sR1/rRany group inclusion showed unfavorable progression-free and overall survival.

CONCLUSIONS

The incorporation of surgical and radiological evaluations for determining the size of residual tumors was more accurate than surgical evaluation only for predicting survival among patients with advanced ovarian cancer who underwent PDS to residual disease less than 1 cm.

Ovarian cancer staging: What the surgeon needs to know

Ovarian cancer (OC) is the leading cause of gynecological cancer death, and most cases are diagnosed at advanced stages due to a nonspecific and insidious clinical presentation. Radiologists play a critical role in the decision of which patients are candidates for primary debulking surgery and who may benefit from neoadjuvant chemotherapy. This pictorial review summarizes the dissemination patterns of OC, main imaging findings of metastatic disease, and which findings may alter the treatment plan or predict suboptimal tumor resection.

A Molecularly Targeted Intraoperative Near-Infrared Fluorescence Imaging Agent for High-Grade Serous Ovarian Cancer

Ovarian cancer is the fifth leading cause of cancer deaths among women, accounting for more deaths than any other cancer of the female reproductive system. The foundation of its management consists of cytoreductive surgery (CRS) followed by systemic chemotherapy, with the completeness of surgical resection consistently identified as one of the most important prognostic factors for the disease. The goal of our investigation is the development of a near-infrared fluorescence (NIRF) imaging agent for the intraoperative imaging of high-grade serous ovarian cancer (HGSOC). As surgeons are currently limited to the visual and manual assessment of tumor tissue during CRS, this technology could facilitate more complete resections as well as serve important functions at other points in the surgical management of the disease. Elevated levels of cancer antigen 125 (CA125) have proven a useful biomarker of HGSOC, and the CA125-targeting antibody B43.13 has shown potential as a platform for immunoPET imaging in murine models of ovarian cancer. Herein, we report the development of a NIRF imaging agent based on B43.13: ^ssB43.13-IR800. We site-specifically modified the heavy chain glycans of B43.13 with the near-infrared dye IRDye 800CW using a chemoenzymatic approach developed in our laboratories. SDS-PAGE analysis confirmed the specificity of the conjugation reaction, and flow cytometry, immunostaining, and fluorescence microscopy verified the specific binding of ^ssB43.13-IR800 to CA125-expressing OVCAR3 human ovarian cancer cells. NIRF imaging studies demonstrated that ^ssB43.13-IR800 can be used to image CA125-expressing HGSOC tumors in subcutaneous, orthotopic, and patient-derived xenograft mouse models. Finally, ex vivo analyses confirmed that ^ssB43.13-IR800 can bind and identify CA125-expressing cells in primary tumor and metastatic lymph node samples from human patients with HGSOC.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Outcome according to residual disease (surgeon's report vs pre-chemotherapy imaging) in patients with bevacizumab-treated ovarian cancer: Analysis of the ROSiA study

BACKGROUND AND OBJECTIVES

The single-arm ROSiA study evaluated frontline bevacizumab for advanced ovarian cancer. We explored how discordant surgically and radiologically assessed postoperative residual disease affects outcomes.

METHODS

After debulking surgery, 1021 patients received 4 to 8 cycles of carboplatin-paclitaxel plus bevacizumab until progression or up to 24 months. The primary endpoint was safety; progression-free survival (PFS) was a secondary endpoint. We performed post hoc exploratory PFS analyses in four subgroups: surgeon-reported no visible residuum (NVR) without target lesions; surgeon-reported NVR with target lesions; macroscopic (≤1 cm) residuum; and >1 cm residuum.

RESULTS

Surgical and radiological assessments were concordant in 94% of patients; 61 patients (6%; 21% of those with surgeon-reported NVR) had NVR with target lesions. Median PFS was numerically longest in patients with concordant surgically/radiologically assessed NVR (35.5 months), intermediate for surgeon-reported NVR with target lesions (31.8 months), and shortest for visible residuum (27.9 and 20.2 months for visible residuum ≤1 and >1 cm, respectively). One-year and 2-year PFS rates showed the same pattern.

CONCLUSIONS

These analyses suggest that prognosis is potentially worse in patients with radiologically detected target lesions despite surgeon-reported NVR compared with concordant NVR by both assessment methods. Postsurgical imaging may add valuable prognostic information.

Perioperative change in CA125 is an independent prognostic factor for improved clinical outcome in advanced ovarian cancer

OBJECTIVE

Despite being the most important prognostic factor for prolonged overall survival in epithelial ovarian cancer (EOC), the measurement of residual disease is hampered by its subjective character. Additional assessment tools are needed to establish the success of cytoreductive surgery in order to predict patients' prognosis more accurately. The aim of this study is to evaluate the independent prognostic value of perioperative CA125 change in advanced stage EOC patients.

STUDY DESIGN

We identified all patients who underwent primary cytoreductive surgery for advanced stage (FIGO IIB-IV) EOC between 2008 and 2015, from the Netherlands Cancer Registry. The relative perioperative change in CA125 was categorized into four groups; increase, <50% decline, 50-79% decline and ≥80% decline. Overall survival (OS) was analyzed using Kaplan-Meier survival curves and multivariable cox regression models.

RESULTS

We included 1232 eligible patients with known pre- and postoperative CA125 serum levels. Patients with a decline of ≥80% in CA125 levels experienced improved OS compared to those with a decline of <50% (univariable Hazard Ratio (HR) 0.45, 95%CI 0.36-0.57). The prognostic effect of perioperative CA125 change was independent of patient- and treatment characteristics, such as the extent of residual disease after cytoreductive surgery (multivariable HR_≥80% 0.52(0.41-0.66)).

CONCLUSIONS

This study shows that the perioperative change in CA125 is an independent prognostic factor for overall survival after primary surgery for EOC patients. This pleads for the use of a combined model, consisting of perioperative CA125 change and the outcome of residual disease, in order to predict the prognosis of EOC patients more accurately.

Optimization of surgical treatment of advanced ovarian cancer: a Spanish expert perspective

BACKGROUND

Optimal upfront treatment of patients with advanced ovarian cancer is complex and requires the adequate function of a multidisciplinary team. Specific standard of quality of care needs to be taken into consideration.

METHODS

A literature search in PubMed was performed using the following criteria: ("ovarian neoplasms"[MeSH Terms] OR ("ovarian"[All Fields] AND "neoplasms"[All Fields]) OR "ovarian neoplasms"[All Fields] OR ("ovarian"[All Fields] AND "cancer"[All Fields]) OR "ovarian cancer"[All Fields])"[Date - Publication]: "2018/01/14"[Date - Publication]).

RESULTS

This article describes how to optimize the surgical management of advanced ovarian cancer, to achieve the best results in terms of survival and quality of life. For this purpose, this document will cover aspects related to pre-, intra- and postoperative care of newly diagnosed advanced ovarian cancer patients.

CONCLUSION

Optimizing upfront treatment of patients with advanced ovarian cancer is complex and requires a structured quality management program including the wise judgment of a multidisciplinary team. Surgeries performed by gynecologic oncologists with formal training in cytoreductive techniques at referral centers are crucial factors to obtain better clinical and oncological outcomes. However, other factors such as the patient's clinical status, the hospital infrastructure and equipment, as well as the tumor biology of each individual patient should also be taken into account before deciding on an initial therapeutic strategy for advanced-stage ovarian cancer to offer patients the best quality of care.

Fluorescent Nanoparticles for the Guided Surgery of Ovarian Peritoneal Carcinomatosis

Complete surgical resection is the ideal cure for ovarian peritoneal carcinomatosis, but remains challenging. Fluorescent guided surgery can be a promising approach for precise cytoreduction when appropriate fluorophore is used. In the presence paper, we review already developed near- and short-wave infrared fluorescent nanoparticles, which are currently under investigation for peritoneal carcinomatosis fluorescence imaging. We also highlight the main ways to improve the safety of nanoparticles, for fulfilling prerequisites of clinical application.

Predictive significance of preoperative CT findings for suboptimal cytoreduction in advanced ovarian cancer: a meta-analysis

Background

Computed tomography (CT) has been extensively used in predicting suboptimal cytoreduction (SCR) in advanced ovarian cancer (OC). However, disagreements remain in literatures on the predictive value of CT findings for SCR. This meta-analysis was designed to determine the ability of eight preoperative CT findings to predict SCR in advanced OC.

Materials and methods

A comprehensive literature search was conducted for eligible studies to identify the association between the eight preoperative CT findings and SCR in advanced OC. The predictive performances of preoperative CT findings were expressed in terms of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) with pooled proportion.

Results

A total of 10 studies and 1,614 patients were included in this meta-analysis. Large volume ascites had the highest sensitivity (64%, CI 56–71%), with a PLR of 1.3 (CI 1.1–1.5) and an NLR of 0.73 (0.59–0.90), while lymph node involvement had the highest specificity (89%, CI 79–94%). The highest DOR of 3 (CI 2–4) was achieved in peritoneal involvement and large bowel mesentery involvement. The other CT findings had poorer predictive performance.

Conclusion

Preoperative CT findings have a poor discriminative capacity to predict SCR in advanced OC. Preoperative CT predictors should be used with caution amid clinical decision-making.

Perioperative changes in serum CA125 levels: a prognostic factor for disease-specific survival in patients with ovarian cancer

Objective

In patients with advanced stage epithelial ovarian cancer (EOC) the volume of residual tumor after debulking is known as prognostic factor for survival. We wanted to examine the relationship between postoperative decline in serum CA125 and residual disease after cytoreductive surgery and evaluate perioperative changes in serum CA125 levels as predictor for disease-specific survival.

Methods

A retrospective study was conducted of patients with FIGO stage IIb-IV EOC treated with cytoreductive surgery, followed by chemotherapy between 1996 and 2010 in three hospitals in the Southeastern region of the Netherlands. Data were analyzed with the use of multilevel linear regression and Cox-proportional hazard regression models.

Results

A postoperative decline in serum CA125 level of ≥80% was associated with complete primary cytoreduction (p=0.035). Univariate analyses showed favorable associations with survival for both the degree of decline in serum CA125 and residual tumor after primary cytoreduction. In multivariate analyses the decline in serum CA125 but not the outcome of surgery remained significantly associated with better survival (HR_50%–79%=0.52 [95% CI: 0.28–0.96] and HR_≥80%=0.26 [95% CI: 0.13–0.54] vs. the serum CA125 decline of <50% [p<0.001]).

Conclusion

The current study, although hampered by possible biases, suggests that the perioperative decline in serum CA125 is an early biomarker that predicts disease-specific survival in patients who underwent primary cytoreductive surgery for advanced stage EOC. If confirmed prospectively, the perioperative change in serum CA125 could be a better marker for residual tumor volume after primary cytoreductive surgery (and therewith disease-specific survival) than the surgeons’ estimation of residual tumor volume.

Incorporation of postoperative CT data into clinical models to predict 5-year overall and recurrence free survival after primary cytoreductive surgery for advanced ovarian cancer

PURPOSE

The use of multivariable clinical models to assess postoperative prognosis in ovarian cancer increased. All published models incorporate surgical debulking. However, postoperative CT can detect residual disease (CT-RD) in 40% of optimally resected patients. The aim of our study was to investigate the added value of incorporating CT-RD evaluation into clinical models for assessment of overall survival (OS) and progression free survival (PFS) in patients after primary cytoreductive surgery (PCS).

METHODS

212 women with PCS for advanced ovarian cancer between 01/1997 and 12/2011, and a contrast enhanced abdominal CT 1-7 weeks after surgery were included in this IRB approved retrospective study. Two radiologists blinded to clinical data, evaluated all CT for the presence of CT-RD, and Cohen's kappa assessed agreement. Cox proportional hazards regression with stepwise selection was used to develop OS and PFS models, with CT-RD incorporated afterwards. Model fit was assessed with bootstrapped Concordance Probability Estimates (CPE), accounting for over-fitting bias by correcting the initial estimate after repeated subsampling.

RESULTS

Readers agreed on the majority of cases (179/212, k=0.68). For OS and PFS, CT-RD was significant after adjusting for clinical factors with a CPE 0.663 (p=0.0264) and 0.649 (p=0.0008). CT-RD was detected in 37% of patients assessed as optimally debulked (RD<1cm) and increased the risk of death (HR: 1.58, 95% CI: 1.06-2.37%).

CONCLUSION

CT-RD is a significant predictor after adjusting for clinical factors for both OS and PFS. Incorporating CT-RD into the clinical model improved the prediction of OS and PFS in patients after PCS for advanced ovarian cancer.