Comparison of survival outcomes after recurrence detected by cancer antigen 125 elevation versus imaging study in epithelial ovarian cancer

Pharmacotherapeutic treatment options for recurrent epithelial ovarian cancer

INTRODUCTION

Almost 80% of epithelial ovarian cancer present in advanced stage at diagnosis and despite excellent response to surgery and chemotherapy, more than 70% cancers recur. Subsequent therapies become decreasingly effective in controlling the disease, with each successful therapy being effective for a shorter duration. As a result, there is a need for novel therapeutic strategies to effectively treat recurrence.

AREAS COVERED

In this extensive literature review of high-quality articles, we have focused on surveillance strategy to detect recurrence early, classification of recurrence based on timeline, role of surgery, chemotherapy, and targeted agents such as anti-angiogenetic drugs, PARP inhibitors, and immune checkpoint inhibitors in platinum-sensitive and platinum-resistant disease, respectively.

EXPERT OPINION

Recurrent ovarian cancers (ROC) are represented by a heterogenous group of patient population in terms of platinum-free interval (PFI), histology, molecular characteristics and immune recognition. In today's era of precision medicine, chemotherapy should be combined with appropriate targeted agent in a multipronged approach to prolong survival and provide better quality of life outcomes by minimizing side effects.

Current update on malignant epithelial ovarian tumors

Epithelial ovarian cancer (EOC) represents the most frequently occurring gynecological malignancy, accounting for more than 70% of ovarian cancer deaths. Preoperative imaging plays an important role in assessing the extent of disease and guides the next step in surgical decision-making and operative planning. In this article, we will review the multimodality imaging features of various subtypes of EOC. We will also discuss the role of imaging in the staging, management, and surveillance of EOC.

Nanoparticle delivery systems to combat drug resistance in ovarian cancer

Due to the lack of early symptoms and difficulty of accurate diagnosis, ovarian cancer is the most lethal gynecological cancer faced by women. First-line therapy includes a combination of tumor resection surgery and chemotherapy regimen. However, treatment becomes more complex upon recurrence due to development of drug resistance. Drug resistance has been linked to many mechanisms, including efflux transporters, apoptosis dysregulation, autophagy, cancer stem cells, epigenetics, and the epithelial-mesenchymal transition. Thus, developing and choosing effective therapies is exceptionally complex. There is a need for increased specificity and efficacy in therapies for drug-resistant ovarian cancer, and research in targeted nanoparticle delivery systems aims to fulfill this challenge. Although recent research has focused on targeted nanoparticle-based therapies, few of these therapies have been clinically translated. In this review, non-viral nanoparticle delivery systems developed to overcome drug-resistance in ovarian cancer were analyzed, including their structural components, surface modifications, and drug-resistance targeted mechanisms.

The Average Time Gap Between CA-125 Tumor Marker Elevation and Confirmation of Recurrence in Epithelial Ovarian Cancer Patients at Princess Noorah Oncology Center, Jeddah, Saudi Arabia

The monitoring of the tumor marker cancer antigen 125 (CA-125) is commonly used as a part of epithelial ovarian cancer monitoring for recurrence. This study seeks to calculate the average time between CA-125 elevation above 35 IU/mL and evidence of recurrence through any currently accepted modality (positive clinical findings, biopsy, imaging, or PET [positron emission tomography] findings) in a patient population in Jeddah, Saudi Arabia.

We studied patients who were diagnosed between January 2006 and December 2016, underwent successful primary therapy, and were then followed up at Princess Noorah Oncology Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia. We adopted a cross-sectional chart review study design. We used inclusive (consecutive) sampling.

A total of 13 patients were included, of whom 76.9% (10 patients) developed CA-125 elevations above 35 IU/mL prior to the confirmation of recurrence. If all 13 patients are included in the mean average calculation, the mean average time elapsed between CA-125 elevation and confirmation of recurrence was 161.5 days (standard deviation ± 230.6). If only the 10 patients who did exhibit a CA-125 elevation above 35 IU/mL were included, the mean average was 210 days (standard deviation ± 244.2).

Rapid development and use of patient-specific ctDNA biomarkers to avoid a "rash decision" in an ovarian cancer patient

Epithelial ovarian cancer (OvCa) is the most lethal female reproductive tract malignancy. A major clinical hurdle in patient management and treatment is that when using current surveillance technologies 80% of patients will be clinically diagnosed as having had a complete clinical response to primary therapy. In fact, the majority of women nonetheless develop disease recurrence within 18 mo. Thus, without more accurate surveillance protocols, the diagnostic question regarding OvCa recurrence remains framed as "when" rather than "if." With this background, we describe the case of a 61-yr-old female who presented with a 3-mo history of unexplained whole-body rash, which unexpectedly led to a diagnosis of and her treatment for OvCa. The rash resolved immediately following debulking surgery. Nearly 1 yr later, however, the rash reappeared, prompting the prospect of tumor recurrence and requirement for additional chemotherapy. To investigate this possibility, we undertook a genomics-based tumor surveillance approach using a targeted 56-gene NGS panel and biobanked tumor samples to develop personalized ctDNA biomarkers. Although tumor-specific TP53 and PTEN mutations were detectable in all originally collected tumor samples, pelvic washes, and blood samples, they were not detectable in any biosample collected beyond the first month of treatment. No additional chemotherapy was given. The rash spontaneously resolved. Now, 2 yr beyond the patient's original surgery, and in the face of continued negative ctDNA findings, the patient remains with no evidence of disease. As this single case report suggests, we believe for the first time that ctDNA can provide an additional layer of information to avoid overtreatment.

[Follow-up of patients treated for an epithelial ovarian cancer, place of hormone replacement therapy and of contraception: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

OBJECTIVES

To define follow-up modalities after an epithelial ovarian, tubal or primitive peritoneal cancer. To define possibilities of hormone replacement therapy (HRT) and contraceptive use after treatment.

METHODS

Systematic review of the literature in French and English langage conducted on Pubmed/Medline and the Cochrane Library.

RESULTS

After the treatment of an epithelial ovarian, tubal or primitive peritoneal cancer, symptoms evaluation for follow-up is recommended at 3 months, 6 months, 12 months, 18 months, 24 months, and then yearly (Grade B). Only patients with an initial complete surgery (CC0, without any macroscopic signs of disease), and with a good general condition (ECOG 0) should be followed with paraclinic tests, with a serum HE4 or CA125 concentration measurement, from 6 months after the end of treatments (GradeC). Systematic follow-up with CT of the chest, abdomen, and pelvis is not recommended (GradeC). Imaging test is recommended in case of an increased serum concentration of HE4 or CA125 (Grade B). An HRT should be proposed to women younger than 45 after a non-conservative treatment for a high grade serous (GradeC) or for a mucinous (GradeC) ovarian, tubal or primitive peritoneal adenocarcinoma. HRT is not contra-indicated in women older than 45 presenting a climacteric syndrome after the treatment of a high grade serous (Grade B) or of a mucinous (GradeC) ovarian, tubal or primitive peritoneal adenocarcinoma.

Recurrence of Ewing sarcoma: Is detection by imaging follow-up protocol associated with survival advantage?

BACKGROUND

The Cooperative Ewing Sarcoma Study and the Late Effects Surveillance System of the Society for Paediatric Oncology and Haematology recommend a structured follow-up imaging protocol (FUIP) for patients with Ewing sarcoma (EwS) with decreasing frequency of imaging over the first 5 years. The present study aims to assess the effectiveness of the FUIP for EwS patients regarding survival after relapse.

PATIENTS AND METHODS

A retrospective multicenter analysis on 160 eligible patients with EwS recurrence was performed. Potential survival differences following recurrence diagnosis between patients with protocol-detected and symptomatic relapse were investigated using the Kaplan-Meier method. Additional subgroup analyses were performed on the relapse type. Overall survival (OS) was calculated from diagnosis of relapse to last follow-up or death.

RESULTS

In the multicenter analysis, recurrence was detected by FUIP in 77 of 160 patients (48%) and due to symptoms in 83 patients (52%). Regarding the entire study population, OS was significantly superior in patients with protocol-detected relapse compared to patients with symptomatic relapse (median, 2.4 vs. 1.2 years; P < 0.001). In the subgroup analyses, patients whose lung recurrences were detected by the FUIP experienced longer survival after recurrence than those whose recurrences were detected symptomatically (P = 0.023). In the 83 symptomatic patients, pain was the most prevalent symptom of relapse (72%).

CONCLUSION

FUIP may benefit survival in EwS relapse, especially in lung recurrence. Pain was the leading symptom of relapse.

Assessment of Circulating Tumor Cells as a Predictive Biomarker of Histology in Women With Suspected Ovarian Cancer

Background

The clinical assessment of circulating tumor cells (CTCs) as a blood-based biomarker is FDA-approved for use in breast, colorectal, and prostate cancers. The objective of this prospective clinical study was to determine whether pretreatment CTCs are a useful diagnostic biomarker in women with complex pelvic masses.

Methods

Whole blood was collected from 49 women with newly diagnosed pelvic masses. The presence of CTCs was compared between women with and without ovarian cancer histopathologic diagnosis after surgery using a Chi-squared test.

Results

CTCs were absent in those with benign disease (0/14), present in 17% (5/29) of patients with a histologic diagnosis of ovarian carcinoma, and present in 80% (4/5) of patients with ovarian metastases from other cancers (P = 0.001). All 5 women with ovarian cancer who had CTCs present presented stage III or IV of the disease (P = 0.13).

Conclusions

CTCs were more prevalent in patients with metastases to the ovary than in primary ovarian carcinomas.

GDF15 predict platinum response during first-line chemotherapy and can act as a complementary diagnostic serum biomarker with CA125 in epithelial ovarian cancer

BACKGROUND

Growth differentiation factor 15 (GDF15) has attracted much interest as a novel biomarker for epithelial ovarian carcinoma (EOC). Research focus has been directed at GDF15 as a diagnostic detection, while the prognostic determination of GDF15 in EOC patients remains to be clearly elucidated. The present study aimed to investigate GDF15 level relative to clinicopathological characters, chemoresponse, and clinical outcome of EOC patients.

METHODS

Serum from 122 patients with primary diagnosed EOC were analyzed for GDF15 and serum cancer antigen 125 (CA125). All cases were treated with debulking surgery and first-line chemotherapy, and samples were obtained just before debulking surgical treatment and first-line chemotherapy. Subsequently, clinical characteristics, responses to chemotherapy and progression-free survival (PFS) were recorded.

RESULTS

Increasing levels of serum GDF15 was significantly associated with FIGO stage and lymphonodus metastasis. GDF15 and CA125 detection are complementary in the diagnosis of EOC and can be simultaneously profiled. The chemo-resistant EOC patients (median, 1225.0 pg/mL) showed significantly higher GDF15 than chemo-sensitive patients (median, 824.2 pg/mL; P = 0.013). Highly expressed GDF15 was an independent negative prognostic indicator in the PFS (P = 0.026) of the 122 EOC cases in the multivariate analysis. Additionally, patients with high level of serum CA125 significantly associated with suboptimal (P = 0.043) debulking surgery.

CONCLUSIONS

Our results provide valuable evidence that GDF15 is related with first-line chemo-resistance, with highly expressed GDF15 being a strong and an independent indicator of shorter PFS in EOC patients.