Chemotherapy resistance as a predictor of progression-free survival in ovarian cancer patients treated with neoadjuvant chemotherapy and surgical cytoreduction followed by intraperitoneal chemotherapy: a Southwest Oncology Group Study

PURPOSE

In vitro testing of the activity of chemotherapeutic agents has been suggested as 1 method to optimally select drugs for patients with ovarian cancer. There are limited prospectively obtained data examining the clinical utility of this approach. We sought to obtain a preliminary assessment of this strategy in a trial that examined the administration of neoadjuvant chemotherapy followed by surgical cytoreduction and intraperitoneal chemotherapy in women with advanced ovarian cancer.

METHODS

Women with stage III/IV epithelial ovarian carcinoma that presented with large-volume disease were treated with neoadjuvant intravenous paclitaxel and carboplatin for three 21-day cycles followed by cytoreductive surgery. If optimally debulked, patients received intravenous paclitaxel, intraperitoneal carboplatin and intraperitoneal paclitaxel for six 28-day cycles. Tumor cloning assay results (Oncotech) were correlated with progression-free survival.

RESULTS

Sixty-two patients (58 eligible) were registered from March 2001 to February 2006. Thirty-six eligible patients had interval debulking and 26 received postcytoreduction chemotherapy. Twenty-two patients had tumor cloning assay results available. The clinical features of this population were similar to those of the larger group of women who entered this study. There was no difference in progression-free survival between patients whose cancers were defined as 'resistant' or 'nonresistant' to either platinum or paclitaxel.

CONCLUSIONS

While the small patient numbers in this trial do not permit definitive conclusions, these data fail to provide support for the argument that prospectively obtained in vitro data regarding platinum or paclitaxel resistance will be highly predictive of clinical outcome in advanced ovarian cancer.

Southwest Oncology Group Trial S9912: intraperitoneal cisplatin and paclitaxel plus intravenous paclitaxel and pegylated liposomal doxorubicin as primary chemotherapy of small-volume residual stage III ovarian cancer

OBJECTIVE

While primary cisplatin-based intraperitoneal chemotherapy has been shown to favorably impact survival in small-volume residual advanced ovarian cancer, there is a need to develop strategies that improve the effectiveness of this approach.

METHODS

A multi-center phase 2 trial was conducted that added intravenous pegylated liposomal doxorubicin (day 8; 30-40 mg/m(2)) to a regimen of intraperitoneal cisplatin (day 2; 75 mg/m(2)) and intravenous (day 1; 135 mg/m(2)) plus intraperitoneal (day 8; 60 mg/m(2)) paclitaxel. Treatment was initially delivered on an every 3-week schedule, but was modified to an every 4-week program due to excessive toxicity. Patients were to receive 6 cycles of this regimen.

RESULTS

Of 68 patients entering this trial, 63 patients were eligible and evaluable, of whom 39 (62%) completed 6 cycles. Overall, 32 (51%) experienced at least 1 grade 4 or worse toxicity (most commonly hematologic) including 5 treatment-related deaths. Median progression-free survival (PFS) was 25 months (2-year PFS: 52%) and median overall survival 51 months, an outcome similar to previous reports of cisplatin-based intraperitoneal chemotherapy in comparable patient populations. Seventeen patients (27% of all eligible patients) were without evidence of disease recurrence >4 years following entry into the trial.

CONCLUSION

Both the overall trial outcome, and specifically the excessively severe systemic toxicity of this regimen would prevent its future development in this exact form. The provocative PFS in a subset of individuals should encourage the development of alternative strategies designed to optimize the delivery of regional therapy in ovarian cancer management.

Phase II evaluation of neoadjuvant chemotherapy and debulking followed by intraperitoneal chemotherapy in women with stage III and IV epithelial ovarian, fallopian tube or primary peritoneal cancer: Southwest Oncology Group Study S0009

OBJECTIVE

Intraperitoneal (IP) chemotherapy prolongs survival in optimally reduced ovarian cancer patients. For patients in whom optimal debulking cannot be achieved, one could incorporate IP therapy post-operatively if the cancer was optimally debulked following neoadjuvant chemotherapy. We sought to evaluate overall survival (OS), progression-free survival (PFS), percent of patients optimally debulked and toxicity in patients treated with this strategy.

METHODS

Women with adenocarcinoma by biopsy or cytology with stage III/IV (pleural effusions only) epithelial ovarian, fallopian tube or primary peritoneal carcinoma that presented with bulky disease were treated with neoadjuvant intravenous (IV) paclitaxel 175 mg/m2 and carboplatin AUC 6 q 21 daysx3 cycles followed by surgery (if >/=50% decrease in CA125). If optimally debulked they received IV paclitaxel 175 mg/m2 and IP carboplatin AUC 5 (day 1) and IP paclitaxel 60 mg/m2 (day 8) q 28 daysx6 cycles.

RESULTS

Sixty-two patients were registered. Four were ineligible. Fifty-six were evaluated for neoadjuvant chemotherapy toxicities. One patient died of pneumonia. Five patients had grade 4 toxicity, including neutropenia (3), anemia, leukopenia, anorexia, fatigue, muscle weakness, respiratory infection, and cardiac ischemia. Thirty-six patients had debulking surgery. Two had grade 4 hemorrhage. Twenty-six patients received post-cytoreduction chemotherapy. Four had grade 4 neutropenia. At a median follow-up of 21 months, median PFS is 21 months and median OS is 32 months for all 58 patients. PFS and OS for the 26 patients who received IV/IP chemotherapy is 29 and 34 months respectively.

CONCLUSIONS

These results compare favorably with other studies of sub-optimally debulked patients.

Long natural history of recurrent granulosa cell tumor of the ovary 23 years after initial diagnosis: a case report and review of the literature

BACKGROUND

Granulosa cell tumors (GCTs) of the ovary are rare, hormonally active neoplasms characterized by endocrine manifestations, an indolent course, and late relapse.

CASE

We report a case of a prolonged history of ovarian GCT managed primarily with repeat surgical resections.

CONCLUSION

This case illustrates the benefits of cytoreductive surgery for the management of recurrent disease, the use of serum tumor markers to help guide therapy, and the importance of extended follow-up.

Phase II study of topotecan and paclitaxel for recurrent, persistent, or metastatic cervical carcinoma

OBJECTIVE

This trial investigated the safety and efficacy of paclitaxel and topotecan combination chemotherapy for patients with advanced cervical cancer (ACC).

METHODS

Patients with recurrent, persistent, or metastatic ACC and an ECOG performance status < or =2 were treated with 175 mg/m(2) paclitaxel on Day 1 and 1 mg/m(2) topotecan on Days 1-5 of a 21-day cycle with G-CSF support and the standard pretreatment regimen for paclitaxel. Patients were treated until disease progression or unacceptable toxicity.

RESULTS

Fifteen patients were enrolled, and 86 cycles of therapy (median, 5; range, 1-14) were administered. Grade 3/4 toxicities included anemia (47%), leukopenia (27%), neurotoxicity (13%), thrombocytopenia (13%), and diarrhea (13%). Among 13 evaluable patients, 7 (54%) responded (1 complete and 6 partial; 95% confidence interval = 29.2%, 76.8%). Three (23%) patients experienced stable disease. Progression-free and overall survival were 3.77 and 8.62 months, respectively.

CONCLUSION

The combination of paclitaxel/topotecan was generally well tolerated and active in the relapsed, recurrent, or metastatic ACC setting, with response rates comparable with those of other current ACC systemic therapies.

A phase II trial of docetaxel and estramustine in patients with refractory metastatic breast carcinoma

BACKGROUND

The similarity between the mechanism of action between docetaxel and estramustine generated the hypothesis of synergistic antimicrotubule effects and cytotoxicity when the two agents are combined. In addition, it has been demonstrated that estramustine binds P-glycoprotein in vitro and, thus, may prevent the efflux of taxanes in tumors that over-express P-glycoprotein. To further evaluate the combinations clinical efficacy and safety, a trial was performed in heavily pretreated patients with metastatic breast carcinoma (MBC).

METHODS

Thirty-six patients with MBC were treated with estramustine 900 mg/m(2) per day divided into 3 doses given on Days 1-3 and docetaxel 70 mg/m(2) given by intravenous administration over 1 hour on Day 3 after the first dose of estramustine, every 21 days. Patients may have received any number of prior chemotherapy regimens for MBC.

RESULTS

Nine partial responses were observed in 31 assessable patients, for an objective response rate of 29% (95% confidence interval, 14-48%). The median progression free survival was 4 months (range, 1-41 months), and the median overall survival was 17 months (range, 2-45 months). Severe toxicities (Grade 3 or 4) were neutropenia, hypophosphatemia, and thrombosis. Seventy-five percent of patients experienced either an improvement or no change in quality of life.

CONCLUSIONS

The combination of docetaxel and estramustine produced responses in heavily pretreated women with MBC while maintaining quality of life.

Prospective follow-up for malignant melanoma in patients with atypical-mole (dysplastic-nevus) syndrome

A total of 357 white patients who had melanocytic nevi that fulfilled the clinical criteria for the "classic" atypical-mole (dysplastic-nevus) syndrome (100 or more melanocytic nevi; one or more melanocytic nevi 8 mm or larger in diameter; and, one or more melanocytic nevi with atypical features) were followed for the development of cutaneous malignant melanomas. Seventeen patients (4.8%) developed malignant melanomas during an average follow-up period of 49 months. One patient developed two malignant melanomas. Eight of the malignant melanomas detected were in situ and ten were invasive melanomas (less than 0.86 mm in Breslow thickness), implying an excellent prognosis. The number of malignant melanomas detected in these patients exceeded significantly the number expected to occur in age- and sex-matched white controls. All groups were shown to have an increased risk for the development of malignant melanomas. Total-body photographs were helpful in detecting changes in size, shape, and color that led to the diagnosis of malignant melanoma. These data support the concept that patients with this readily regionalized clinical presentation of classic atypical-mole syndrome are at an increased risk for malignant melanomas and, therefore, should be examined regularly.