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.

Women's issues in mood disorders

Since the introduction of antidepressants in the 1950s, it was assumed for the next several decades that there were no special reasons to look at the application of these medications to women. In the past half-century, particularly in the past decade, since the advent of the selective serotonin re-uptake inhibitors (SSRI), a series of specific foci have developed. Firstly, there appear to be differences in the degree of response to particular antidepressants between the genders. Secondly, there is data concerning hormonal effects of particular relevance to women, i.e. prolactin, which separates out among the antidepressants. Also of concern to women are the potential teratogenic effects of these medications, which impact on their use during pregnancy. Finally, there are certain diagnostic syndromes that are particularly relevant to women: premenstrual dysphoric disorder (PMDD); postpartum depression (PPD) and perimenopausal depression (PMD). It appears that the SSRIs may be more effective, relative to the older tricyclic antidepressants (TCA), in women than in men. The SSRIs have shown to be effective in treating these disorders, with the possibility of intermittent luteal phase treatment of PMDD. Non-antidepressant (AD) approaches have generally been found to be less effective. In the first trimester of pregnancy, there is data available supporting the safe use of SSRIs, particularly those first released, i.e. fluoxetine and sertraline. Finally, all SSRIs, with the exception of sertraline, can increase the risk of hyperprolactinaemia. This can lead to a variety of complications including amenorrhea and osteoporosis. This effect of sertraline, due to its unique profile in blocking re-uptake of dopamine, extends itself into additional relative benefits for sleep and memory. The issues associated for women with bipolar disorder are dealt with in terms of both increased risk of relapse during pregnancy and postpartum periods, as well as the relative risk of use of lithium and mood stabilizers in pregnancy and lactation.

Renal artery stenosis in renal transplantation presentation and management

A review of the angioplasty records between 1990 and 1995 at the King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia revealed ten cases of transplant renal artery stenosis (RAS). The diagnosis in these cases was confirmed by renal angiography and all were treated by angioplasty. All study patients presented with uncontrolled hypertension in spite of multiple medications; eight had renal functional impairment and two patients had recurrent unexplained pulmonary edema in addition. Six patients had undergone end-to-end anastomosis, while four had end-to-side anastomosis of the artery during transplantation. Four had cadaveric renal transplants and six had living donor renal transplants. Eight of these patients responded well to angioplasty with marked improvement in their renal function and reduction in the number of anti-hypertensive medications. In one patient, it was not possible to pass the catheter through the stenosis and the patient underwent surgical reconstruction, while in another patient there were multiple stenotic lesions involving the external iliac and the transplant renal arteries suggesting atherosclerotic changes. We conclude that renal artery stenosis should be suspected in patients after renal transplant if they have uncontrolled or worsening hypertension, unexplained renal impairment or presentation with unexplained recurrent pulmonary edema. Renal angiography should be considered as part of the investigation of hypertension in renal transplant patients, and if the RAS is confirmed, angioplasty should be the procedure of choice.