High-dose melphalan-based chemotherapy and autologous stem cell transplantation after second look laparotomy in patients with chemosensitive advanced ovarian carcinoma: long-term results

Are there candidates for high-dose chemotherapy in ovarian carcinoma?

Background

Prognosis of advanced ovarian carcinomas (AOC) remains poor with a 5-year survival of 30%. Benefit from high-dose chemotherapy (HDC) in this disease has not been demonstrated to date.

Methods

To evaluate the value of HDC as consolidation treatment after surgery and platinum/taxane-based therapy, we designed a monocentric retrospective comparative study. We used a subset approach to identify parameters associated with HDC efficacy.

Results

One hundred and three AOC patients treated with conventional chemotherapy alone (CCA) were compared to 60 patients receiving HDC plus hematopoietic stem cell support. After a median follow-up of 47.5 months there was no overall survival (OS) advantage for the HDC group in the whole population (p=0.29). Nevertheless, HDC was associated to a better outcome in young patients (≤50 years), both in term of progression-free survival (p=0.02, log-rank test) and OS (p=0.05, log-rank test). Median OS was 54.6 and 36 months in the HDC and CCA groups, respectively.

Conclusions

Although randomized trials failed to demonstrate any benefit for HDC in AOC patients, this study suggests that young patients may derive a substantial advantage from receiving it after the standard treatment. Further prospective studies are warranted to confirm this gain and to search for the biological processes associated with this improvement.

High-dose melphalan and autologous stem cell transplantation as consolidation treatment in patients with chemosensitive ovarian cancer: results of a single-institution randomized trial

The role of high-dose chemotherapy (HDCT) in epithelial ovarian cancer (EOC) remains controversial. This study was initiated to compare the efficacy and tolerability of HDCT as a consolidation approach in women with chemosensitive advanced EOC (FIGO stages IIC-IV). Patients who had achieved their first clinical complete remission after six cycles of conventional paclitaxel and carboplatin combination chemotherapy were randomly assigned to receive or not high-dose melphalan. The primary objective was to compare time to disease progression (TTP). A total of 80 patients were enrolled onto the trial. Patients who were randomized to receive HDCT were initially treated with cyclophosphamide 4 g/m(2) for PBPC mobilization. HDCT consisted of melphalan 200 mg/m(2). Of the 37 patients who were allocated to HDCT, 11 (29.7%) did not receive melphalan either due to patient refusal (n=5) or due to failure of PBPC mobilization (n=6). In an intent-to-treat analysis, there were no significant differences between the two arms in TTP (P=0.059) as well as in overall survival (OS) (P=0.38).

Phase I/II trial of multicycle high-dose chemotherapy with peripheral blood stem cell support for treatment of advanced ovarian cancer

Ovarian cancer is chemosensitive, but most patients with advanced disease die from tumor progression. As 25% of the patients can be cured by chemotherapy, it is reasonable to evaluate high-dose chemotherapy (HDCT). Forty-eight patients with untreated ovarian cancer were entered in a multicenter phase I/II trial of multicycle HDCT. Median age was 46 (19-59 years); International Federation of Gynecology and Obstetrics-stage was III in 79% and IV in 21%; 31% had residual disease >1 cm after surgery. Two courses of induction/mobilization therapy with cyclophosphamide (250 mg/m2) and paclitaxel (250 mg/m2) were used to collect peripheral blood stem cells. HDCT consisted of two courses of carboplatin (area under curve (AUC) 18-22) and paclitaxel followed by one course of carboplatin and melphalan (140 mg/m2) with or without etoposide (1600 mg/m2). Main toxicity was gastrointestinal. Limiting carboplatin to AUC 20 and eliminating etoposide resulted in manageable toxicity (69% without grade 3/4 toxicity). One patient died from treatment-related pneumonitis. At 8 years median follow-up, median progression-free-survival (PFS) and overall survival (OS) is 13.3 and 37.0 months. Five-years PFS and OS is 18 and 33%. Multicycle HDCT is feasible in a multicenter setting. A European phase III trial based on this regimen is evaluating the efficacy of HDCT.

A randomised phase III study comparing high-dose chemotherapy to conventionally dosed chemotherapy for stage III ovarian cancer: the Finnish Ovarian Cancer (FINOVA) study

Women with stage III ovarian cancer and with < or = 2 cm residual tumour were randomly assigned to receive either conventionally dosed chemotherapy (group A) or HDCT (group B). Patients allocated to group A received 6 cycles of paclitaxel (T) 135 mg/m2 and cisplatin (P) 75 mg/m2 every 3 weeks, and those allocated to HDCT received 3 TP cycles followed by peripheral blood stem cell mobilisation with cyclophosphamide (C) 3000 mg/m2 and T 175 mg/m2, and subsequently HDCT with carboplatin 1500 mg/m2, C 120 mg/kg, and mitoxantrone 75 mg/m2. The trial was closed early after 42 patients were entered due to slow accrual. The median follow-up time of patients who were alive was 81 months. The median progression-free survival time was 15.9 and 16.6 months (hazard ratio, HR 0.83; 95% CI 0.41-1.69, P = 0.61) and the median overall survival time was 43.7 and 64.3 months (HR, 0.74; 95% CI 0.34-1.61, P = 0.44) in groups A and B, respectively. Although one patient died of HDCT-related toxicity, the regimen was otherwise relatively well tolerated. We conclude that the HDCT regimen used was feasible, but did not result in significantly improved survival in this prematurely closed trial. A clinically important survival benefit cannot be excluded due to the small sample size.

Identification of prognostic factors after positive second-look surgery in epithelial ovarian carcinoma

OBJECTIVE

The objective of this study was to identify independent prognostic factors for survival in patients with epithelial ovarian cancer who had persistent disease identified at second-look surgery.

METHODS

We performed a retrospective chart review of all patients with epithelial ovarian cancer who had positive findings at second-look surgery between June 1991 and June 2002. All patients achieved a complete clinical remission after a prescribed course of primary therapy. Survival was determined from the time of second-look surgery until last follow-up or death.

RESULTS

The study included a total of 262 patients, with a median age of 54 years (range, 22-80). Of the 262 patients, 166 (63%) had died of disease. Records of initial (salvage) treatment after the positive second-look surgery were available for 243 patients. Therapies included the following: intraperitoneal (IP) cisplatin, 71 (29%); IP cisplatin combined with a second drug, 53 (22%); IP therapy other than cisplatin, 29 (12%); intravenous (IV) chemotherapy, 50 (21%); IP and IV therapy, 35 (14%); and oral chemotherapy, 5 (2%). Of the 13 potential prognostic factors analyzed, only 2 factors emerged that, when combined, were significant--residual disease after primary surgery and size of persistent disease found at second-look surgery. Patients with <or=1 cm residual disease after primary surgery and microscopic disease at second-look surgery had significantly improved survival.

CONCLUSION

In our analysis, the only prognostic factor for survival in patients with positive second-look procedures was a combination of residual disease after primary surgery and size of persistent disease identified at second-look surgery. No individual chemotherapy treatment imparted a survival advantage. Novel that therapeutic approaches are needed in this setting.

Post-operative sequential high-dose chemotherapy with haematopoietic stem cell support as front-line treatment in advanced ovarian cancer: a phase II multicentre study

In spite of multimodal management including aggressive surgery and chemotherapy, the prognosis of advanced ovarian cancer (AOC) remains poor. Multicycle high-dose chemotherapy (HDC) with haematopoietic stem cell (HSC) support has been shown to be a promising procedure in various cancers including AOC. We conducted a phase II multicentre study to evaluate feasibility, toxicity and efficacy of post-operative front-line sequential HDC with HSC support in AOC. Thirty four patients with stage IIIC/IV received a post-operative sequential combination of high-dose cyclophosphamide/epirubicin (D1, D21) with HSC harvesting, high-dose carboplatin (D42, D98) followed by HSC infusion, and dose-dense paclitaxel (D63, D77, D119, D133). Rh-G-CSF (filgrastim) was administered following all cycles. Primary endpoint was pathological complete response rate (pCR). Thirty patients received at least 7 of the scheduled 8 cycles. Haematological toxicity was significant but manageable. Grade 3/4 extra-haematopoietic toxicities were relatively uncommon and reversible. No toxicity-related death was observed. The observed pCR was 37% and did not reach the initial endpoint. Post-operative front-line sequential HDC in AOC is feasible and safe in a multicentre setting. The observed pCR does not support a clear advantage over conventional treatment. This approach remains an experimental strategy to further optimise and validate.

High-dose chemotherapy with autologous haemopoietic support for advanced ovarian cancer in first complete remission: retrospective analysis from the Solid Tumour Registry of the European Group for Blood and Marrow Transplantation (EBMT)

The majority of advanced ovarian cancer patients achieve an objective response following chemotherapy; however, only 20-30% are in remission after 5 years. Intraperitoneal or high-dose chemotherapy (HDC) may prolong disease-free and overall survival (OS) in patients with platinum-sensitive, small volume disease. To better define the subsets of patients who might benefit from HDC, we performed a retrospective analysis on 91 patients in 1st complete remission (CR) treated from 21 centres of the EBMT group. At a median follow-up of 48 months, median time-to-progression (TTP) and OS were 21.2 and 44.4 months, respectively. Tumour grade, stage, residual disease, disease status before HDC, type and year of transplant, source of haemopoietic progenitors and use of haemopoietic growth factors (HGF) after transplant were analysed for TTP and OS. The only significant parameter was the use of HGF: median OS for patients receiving or not receiving HGF was 46.2 vs 17.8 months, respectively (P: 0.035); this difference was maintained after multivariate analysis (P: 0.02). Our analysis does not identify any subgroup of patients in 1st CR who can benefit from HDC; however, median survival of patient with no residual disease has not been reached. The role of HGF after HDC deserves further investigation.

Timing isn't everything: an analysis of when to start salvage chemotherapy in ovarian cancer

OBJECTIVE

Results from GOG 178 showed a prolongation of progression-free survival (PFS) with the immediate use of chemotherapy (CT) following a complete clinical response (CR) in patients with stage III-IV ovarian cancer. We wanted to evaluate our strategy of reserving second line (2nd line) chemotherapy to the time of clinical recurrence by determining PFS intervals following first, second, and third line agents and to compare these finding to results of GOG 178.

METHODS

We conducted a retrospective parallel study to GOG 178 using identical criteria for PFS definitions. Patients (pts) with stage III-IV cancer achieving a CR following surgery and five to eight cycles of platinum-based CT were identified. Patients not obtaining a CR and those with a CR who underwent second look surgery were excluded. Rather than immediately beginning consolidation CT after CR, second line agents were started at recurrence and were followed by a third line when pts progressed. Clinical-pathologic characteristics were abstracted, and time intervals including time to recurrence, time to use of second line CT, time to use of third line (3rd line) CT, and survival were recorded. Time intervals were studied by Kaplan-Meier method.

RESULTS

Of 217 reviewed pts (1991-2001), 59 eligible pts were identified. Forty-nine patients had stage III disease and ten had stage IV. At completion of surgery, 44 were optimally debulked. With a median follow-up of 51 months, the median PFS (from CR) of all patients was 20 months. At 5 years, 36% of pts remain disease-free, and 66% of pts are alive. Twenty-three pts have not received second line agents, and thirty-six have received them. For all pts, the median time from CR to start of second line chemotherapy was 21 months, and the median time to start of third line agents was 43 months. Recurrences occurred after 6 months from completion of first line (1st line) therapy in 87% of cases and after 12 months in 50%.

CONCLUSIONS

Nearly 70% of pts achieving a CR after primary therapy eventually recurred. Most recurrences occurred greater than 6 months from completion of primary chemotherapy, and the use of second line agents at the time of recurrence was effective. In this study, the median time from CR to start of third line agent at 43 months compares favorably with the median PFS of 28 months following 12 months of Taxol reported in GOG 178 and challenges the concept of consolidation chemotherapy in ovarian cancer. A randomized trial to evaluate when to institute second line agents should be performed.

Stem-cell transplantation for the treatment of advanced solid tumors

Over the past two decades, high-dose chemotherapy (HDC) with autologous stem-cell transplantation (ASCT) has been explored for a variety of solid tumors in adults, particularly breast cancer, ovarian cancer and non-seminomatous germ-cell tumors. The results of prospective phase II studies seemed superior in many cases to the outcome expected with standard-dose chemotherapy (SDC). The value of HDC for adult solid tumors remains, in most instances, a controversial issue, currently under the scrutiny of randomized phase III trial evaluation. ASCT pursuing an immune graft-versus-tumor effect has been evaluated in recent years for patients with advanced and refractory solid malignancies. This article reviews the results of the main phase II and III studies of HDC with ASCT, as well as the preliminary experience using allogeneic transplantation for solid tumors.

Consolidation treatment of advanced (FIGO stage III) ovarian carcinoma in complete surgical remission after induction chemotherapy: a randomized, controlled, clinical trial comparing whole abdominal radiotherapy, chemotherapy, and no further treatment

In a prospective randomized trial, consolidation treatment with radiotherapy or chemotherapy was compared with no treatment in a series of 172 patients with epithelial ovarian carcinoma, FIGO stage III, with complete surgical remission after primary cytoreductive surgery and induction chemotherapy. In the subgroup with complete surgical and pathologic remission, progression-free survival was significantly (P = 0.032) better in the radiotherapy group (56% at 5 years) than in the chemotherapy group (36% at 5 years) and the untreated control group (35% at 5 years). Overall survival was also most favorable in the radiotherapy group (69% at 5 years). The number of recurrences was lowest in the radiotherapy group. In the subgroup with microscopic residual carcinoma there were no significant differences in survival between the radiotherapy and the chemotherapy-treated patients. Early and late radiation reactions were recorded. Treatment-related side effects were seen most frequently in the radiotherapy group. Late intestinal radiation reactions of a severe type were recorded in 10%.

Evidence for a graft-versus-tumor effect in refractory ovarian cancer

PURPOSE

A 31-year-old woman suffered a 4th relapse of epithelial ovarian cancer refractory to several cytotoxic drugs including platinum, paclitaxel, and topotecan.

METHODS

Sequential high-dose chemotherapy with autografting (three courses) led to a minor response of short duration. In order to induce a graft-versus-tumor effect, allogeneic hematopoietic stem cell transplantation (HSCT) from an HLA-identical sibling donor, after dose-reduced conditioning, was performed in January 2001.

RESULTS

On day +51 the patient developed acute grade II graft-versus-host disease of the skin and gastrointestinal tract, which was successfully treated by prednisolone. Six months after allogeneic HSCT a complete disappearance of the tumor could be seen. Unfortunately, 14 months later a 5th relapse was diagnosed.

CONCLUSIONS

This case demonstrates, on the one hand, that allogeneic HSCT is able to induce complete remissions (CR) in chemoresistant ovarian cancer. On the other hand, despite achievement of CR after allografting, the chance of cure remains limited for these patients.

Intensive sequential dose dense chemotherapy with stem cell support as first-line treatment in advanced ovarian carcinoma: a phase II study

From August 1995 to December 1997, 15 patients with stage III-IV ovarian cancer were treated with outpatient intensive chemotherapy with G-CSF and stem cell support. The first cycle consisted of cyclophophamide IV 6 g/m(2); second, third, fourth and fifth paclitaxel 250 mg/m(2) and the sixth and seventh carboplatin AUC 18. CD34(+) cells were collected after the first cycle and reinfused after completion of cycles 6 and 7. Fourteen patients had stage IIIc and one patient had stage IV disease with liver metastases. All patients underwent laparotomy to maximize tumor debulking. This was optimal in eight patients and suboptimal in seven patients. Second-look surgery was performed in 14 patients. All patients had macroscopic complete responses and 10 patients had complete histologic response. Median follow-up was 48 months (range, 20 to 62). Twelve patients had further progression at a median of 27 months (range, 9 to 42) and nine are alive, three without evidence of disease progression. This pilot study shows that dose-dense chemotherapy with paclitaxel and carboplatin is associated with low toxicity and may improve the outcome of patients with poor prognosis ovarian cancer.

Patient preferences regarding side effects of chemotherapy for ovarian cancer: do they change over time?

OBJECTIVE

The goals of this study were to: (1) systematically evaluate patient preferences regarding side effects of high-dose chemotherapy with stem cell support for treatment of advanced ovarian cancer; and (2) assess whether patients' preferences changed over time.

METHODS

Forty patients with stage III or IV disease were enrolled in this study. Patients' preferences regarding 12 health states (side effects) were assessed using visual analogue scale (VAS) and time trade-off (TTO) methods during mobilization chemotherapy (T(1)) and 6-7 weeks later after high-dose chemotherapy and stem cell transplant (T(2)). Each assessment involved a 45-min interview conducted at the patient's bedside.

RESULTS

The three most preferred health states were no evidence of disease (NED), a chemotherapy with few or no side effects, and alopecia, while the least preferred health states were chemotherapy with multiple severe side effects, hepatotoxicity, and nausea and vomiting. These results were observed at both T(1) and T(2) using both preference assessment methods. Pancytopenia scores significantly increased from T(1) to T(2) using the VAS method (P < 0.05), but decreased using the TTO method.

CONCLUSIONS

Chemotherapy-experienced women with ovarian cancer have consistent preferences for the best and worst health states associated with the side effects of chemotherapy. Patients are more averse to nausea and vomiting than many other symptoms. Women's perceptions of pancytopenia may be dependent upon the number of prior cycles of chemotherapy and site of care for anemia, thrombocytopenia, and febrile neutropenia.

Second-line and subsequent therapy for ovarian carcinoma

Ovarian carcinoma continues to be the leading cause of death among gynecologic malignancies. Paclitaxel and platinum chemotherapy is still the treatment of choice after primary debulking surgery. Salvage chemotherapy with several single agents has only modest activity and does not prolong survival of patients with relapsed ovarian carcinoma. An intense search has been made for novel approaches to treatment of ovarian cancer, and several new treatments, such as immunotherapy and gene therapy, show promise. Newer combination chemotherapy regimens and molecularly targeted therapy need to be developed. High-dose chemotherapy with autologous stem-cell transplantation appears to benefit selected groups of patients and is still investigational. Whole abdominal radiotherapy for relapsed microscopic disease should be studied in prospective randomized trials. Women with advanced ovarian carcinoma should continue to be encouraged to participate in well-designed clinical trials.