First-line treatment of advanced ovarian cancer with paclitaxel/carboplatin with or without epirubicin (TEC versus TC)--a gynecologic cancer intergroup study of the NSGO, EORTC GCG and NCIC CTG.

BACKGROUND: The addition of anthracyclines to platinum-based chemotherapy may provide benefit in survival in ovarian cancer patients. We evaluated the effect on survival of adding epirubicin to standard carboplatin and paclitaxel. PATIENTS AND METHODS: We carried out a prospectively randomized phase III study comparing carboplatin plus paclitaxel (TC; area under the curve 5 and 175 mg/m(2)) with the same combination and epirubicin (TEC; 75 mg/m(2) i.v.). Between March 1999 and August 2001, 887 patients with epithelial ovarian, tubal or peritoneal cancer International Federation of Gynecology and Obstetrics stages IIB-IV were randomized to receive either TC (442 patients) or TEC (445 patients). RESULTS: Median time to progression was 16.4 months in the TEC arm and 16.0 months in the TC arm (hazard ratio 0.99; 95% confidence interval [CI]: 0.9-1.2). Median overall survival time was 42.4 months for the TEC arm and 40.2 for the TC arm (hazard ratio 0.96; 95% CI: 0.8-1.1). Grade 3/4 hematologic toxic effects and most grade 3/4 non-hematologic toxic effects were more frequent in the TEC arm. Accordingly, a quality-of-life analysis showed inferiority of TEC versus TC. CONCLUSION: The addition of epirubicin to standard carboplatin and paclitaxel treatment did not improve survival in patients with advanced ovarian, tubal or peritoneal cancer.

Optimized sequence of drug administration and schedule leads to improved dose delivery for gemcitabine and paclitaxel in combination: a phase I trial in patients with recurrent ovarian cancer.

We examined appropriate sequence, schedule, and doses of gemcitabine (G) and paclitaxel (T) in patients with persistent or recurrent epithelial ovarian cancer. Patients received a maximum of six cycles of gemcitabine on days 1 and 8 (starting 1000 mg/m(2)), and paclitaxel (starting 135 mg/m(2)) on day 8 (groups A and B) or day 1 (group C). Drug sequences (G-->T and T-->G) were tested in group A. In group A, changing sequences of gemcitabine and paclitaxel infusion were evaluated. Sequence G-->T raised grade 3 alanine transaminase in two of three patients leading to use of T-->G sequence for remainder of study. In group B, maximum tolerable dose was reached at gemcitabine 1000 mg/m(2) and paclitaxel 175 mg/m(2). Reducing paclitaxel to 150 mg/m(2) allowed escalation of gemcitabine to 1250 mg/m(2), but neutropenia-related treatment delays occurred. Giving paclitaxel on day 1 (group C) enabled administration of paclitaxel 175 mg/m(2) and gemcitabine 1250 mg/m(2) with minimal dose adjustments. The overall response rate was 41.0%, with 2 complete responses and 14 partial responses in 39 eligible patients. The schedule of paclitaxel 175 mg/m(2) (day 1) and gemcitabine 1250 mg/m(2) (days 1 and 8), with sequence of T-->G, appears most suitable with tolerable toxicity and promising activity.

One in 10 ovarian cancer patients carry germ line BRCA1 or BRCA2 mutations: results of a prospective study in Southern Sweden.

At least 10% of all ovarian cancers are estimated to have a hereditary background. Hereditary breast-ovarian cancer (HBOC) due to mutations in the BRCA genes is a major cause of hereditary ovarian cancer, although its frequency and relationship to age and family history in unselected series of ovarian cancers is not completely known. We report here the results of a full mutational screening analysis for germ line BRCA1 and BRCA2 mutations in 161 patients with invasive epithelial ovarian carcinomas. Age at diagnosis ranged from 22 to 82 years (mean 59 years). Deleterious (frame-shift, nonsense and missense) mutations were detected in 13/161 (8%) of the patients and affected BRCA1 in 12 cases and BRCA2 in one case. Four additional missense variants (one in BRCA1 and three in BRCA2) with a possible association with an increased risk ovarian cancer were revealed, resulting in a total frequency of BRCA gene alterations of 17/161 (11%). The 13 patients with deleterious mutations had a mean age of 57 years (range 41-76 years) and only three of these patients were below 50 years of age. A family history of at least one breast cancer and/or ovarian cancer was reported in all but 1 of the patients with BRCA mutations compared with only 24% of patients without mutations. Our findings in this prospective study confirm approximately 1 in 10 patients with ovarian cancer carry a germ line BRCA gene mutation associated with HBOC, and also indicate that a large number of these patients are over 50 years of age at diagnosis.

First-line treatment of ovarian cancer FIGO stages IIb-IV with paclitaxel/epirubicin/carboplatin versus paclitaxel/carboplatin.

The objective of this study was to compare the safety and efficacy of carboplatin plus epirubicin and paclitaxel (TEC) to carboplatin and paclitaxel (TC), in the treatment of epithelial ovarian, peritoneal, or tubal carcinoma. Between March 1999 and August 2001, 887 patients were randomized to receive six to nine cycles of paclitaxel (175 mg/m2, 3 h intravenously) followed by carboplatin (AUC 5, Calvert formula) with or without epirubicin (75 mg/m2 intravenously prior to paclitaxel), on a 3-weekly schedule. The primary endpoint was progression-free survival. Demographic information: Residual disease <1 cm was reported on 41% of patients. At the end of treatment, 65% in the TEC and 55% in the TC arm had achieved a clinical complete response, and 18 and 25% a clinical partial response resulting in an overall response rate of 83% in the TEC and 80% in the TC arm, whereas 7 and 9% had progressive disease, respectively. The three-drug combination produced a markedly higher myelotoxicity, resulting in a higher frequency of febrile neutropenia (12.5% of the TEC and 1.5% of the TC patients) and a higher number of dose reductions and treatment delays. Cycle prolongation above seven days was seen in 7 and 5% of cycles in the TEC and TC arm, respectively. Stomatitis > or = grade 3 was also higher with TEC (4% TEC and 0.5% TC). Reductions in left ventricular ejection fraction of more than 15% after six courses were slightly more common with the TEC regimen (3% versus 1.5%), but the difference was not statistically significant (P = 0.2). In conclusion, treatment with the TEC combination produced a higher rate of complete responses than treatment with the TC combination. Toxicity was manageable. Long-term survival data are awaited.

TP53 protein expression analysis by luminometric immunoassay in comparison with gene mutation status and prognostic factors in early stage endometrial cancer.

Mutations in the TP53 tumor suppressor gene have been shown to significantly correlate with poor prognosis in endometrial cancer. In the present study we have evaluated a luminometric immunoassay (LIA) for quantitative estimation of TP53 protein expression in 65 cytosol preparations from endometrial cancer, previously analyzed for mutations in TP53 exons 4-10. LIA showed high (> or = 0.6 ng/mg protein) expression of TP53 protein in all eight tumors with missense mutation, but high protein levels were also detected in 15 tumors with normal TP53 sequence. All four tumors with nonsense or frameshift mutations had low or no TP53 protein expression. LIA was further evaluated in a retrospective study of 201 cytosol samples from endometrial cancer. TP53 overexpression (> = 0.6 ng/mg protein) was observed in 22% of the tumors and correlated with nonendometrioid histology types (P = 0.005), poorly differentiated tumors (P = 0.001), higher FIGO grade (P = 0.001), DNA nondiploidy (P = 0.002), and high S-phase fraction (P = 0.03). After a median follow-up time of 6.8 years (range 0.7-9.9 years), 22 (13%) progressions were observed in the 175 patients with early stage (I-II) disease. TP53 overexpression (P = 0.04), FIGO grade 3 vs. 1 + 2 (P = 0.01), higher age (P = 0.02), and DNA nondiploidy (P < 0.001) showed significant correlation to shorter progression-free survival in these patients. We conclude that TP53 protein analysis by LIA provides an incomplete correlation to mutation status and cannot substitute for mutation analysis in assessment of prognosis in endometrial carcinoma. In comparison to TP53 overexpression and higher FIGO grades, DNA nonploidy status seems to be a better prognostic indicator to define a subset of early stage endometrial cancer patients who may benefit by adjuvant chemotherapy/radiotherapy.

Steroid receptors and hormones in relation to cell proliferation and apoptosis in poorly differentiated epithelial ovarian tumors.

The purpose of this study was to further investigate the role of estrogen but especially progesterone on epithelial ovarian tumor development since previous studies have suggested a relationship between serum progesterone, progesterone receptor expression and prognosis. Serum progesterone concentration, the immunohistochemical expression of estrogen receptor alpha (ER), progesterone receptor A/B (PR), Ki-67, Bcl-2, p53, apoptosis and morphology were determined in 33 patients, all with poorly differentiated surface epithelial ovarian tumors of different types. ER was expressed in 79% and PR in 33% of the tumors. This group of aggressive tumors was highly proliferative as indicated by Ki-67 index (mean 38.9%), and in some cases proliferation appeared to be mainly located to areas with a high ER density. The majority of cases (76%), both receptor-positive and -negative, overexpressed p53. High ER expression was related to a lower apoptotic activity as compared with tumors with a low expression of the ER (p = 0.008). Serum progesterone in itself did not show any clear relationship to steroid receptor status, expression of Ki-67, p53, Bcl-2 or signs of apoptosis. Survival in this small but homogeneous group of advanced epithelial ovarian cancers, showed an improved survival rate in patients with high serum progesterone, especially in combination with expression of progesterone receptors (p = 0.04). In conclusion, estrogen and progesterone receptors in parallel with deranged p53 and Ki-67 were expressed to a great extent. The finding of a lower apoptotic activity in tumors with a high expression of ER and an indication of increased proliferation in areas with high ER density gives a rationale for antiestrogen therapy even in poorly differentiated epithelial ovarian cancers. Improved survival is related to serum progesterone, especially in combination with PR expression.

Two BRCA1-positive epithelial ovarian tumors with metastases to the central nervous system: a case report.

BACKGROUND: Cerebral metastasis secondary to ovarian cancer is a rare phenomenon. While no clear relationship to known prognostic factors is found, others suggest this as a biologically diverse behavior of ovarian cancer. CASES: In a pilot study, 37 invasive epithelial ovarian cancer samples were analyzed to detect the frequency of BRCA1/BRCA2 mutations in the south of Sweden (results published). A retrospective follow-up revealed that 2 of these (2/37; 5.4%) patients developed central nervous system metastases during the course of their disease. Both patients had advanced surgical stage disease at the time of diagnosis, with histopathological serous type tumors that were negative for estrogen and progesterone receptors. One of these patients carried a germline BRCA1 mutation, whereas a somatic BRCA1 mutation was identified in the other patient. CONCLUSIONS: To the best of our knowledge the molecular genetic profile of these tumors is not found in the literature and it is suggested that such analyses could provide some insight for a better understanding of this rare phenomenon.

BRCA1 and BRCA2 mutations in ovarian cancer: Covariation with specific cytogenetic features.

We analyzed 37 primary invasive carcinomas for BRCA1 and BRCA2 mutations by screening the entire coding regions of both genes. Seven predicted truncating mutations (four in BRCA1 and three in BRCA2) and one novel BRCA1 missense variant (S1542C) were identified (8/37, 22%). Two of the BRCA1 mutations were somatic changes, whereas the remaining three BRCA1 changes and all mutations of BRCA2 were found to be of germline origin. All eight BRCA-positive tumors were serous or seropapillary carcinomas (8/27 serous tumors, 30%), and all but one were poorly differentiated. The correlation between tumor karyotype and BRCA status showed that clonal chromosomal aberrations were present in all BRCA-positive tumors (8/8) compared with 20 of 29 BRCA-negative ones. The most consistently affected region in BRCA-positive tumors was the long arm of chromosome 6; alterations within this arm with a breakpoint in band 6q21 were seen in four of five BRCA1-positive and in two of three BRCA2-positive tumors, but only in four of 20 karyotypically abnormal tumors without BRCA mutations, suggesting that the genetic pathways of tumor progression differ in the two groups. The high frequency of germline BRCA mutations detected in this pilot study (16% of 37 invasive carcinomas) points to the need for more extended analyses of population-based series of patients to determine the true contribution of these predisposing genes to the overall incidence of ovarian cancer in this population.

Isolation and culture of ovarian tumour cells, cytological and cell survival evaluation.

The purpose of this study was to evaluate the reproducibility and reliability of the fluorometric microculture cytotoxicity assay (FMCA). Emphasis was placed on obtaining pure tumour cell cultures which were subjected to careful cytological evaluation. Preparations of 39 ovarian tumours, malignant, borderline and benign were made, of which 37 were successfully cultured. In 34 of the 37 tumour cell cultures, the epithelial cell fraction was > 90%, and in 30 of 39 cultures the epithelial cell fraction was > 95%. Transportation within 24 h and the 72 h incubation did not change the yield or epithelial cell fraction. There was a linear relationship between fluorescence and the number of viable cells. The fluorescence increased with time, making only comparisons within each assay plate possible. The sensitivity of the method makes it possible to perform many analyses on a small amount of material. The method also makes it possible to study cells derived from all stages of the disease, including benign tumours.

Steroid-hormone production and receptors in relation to ki-67, p53, s-phase fraction and ploidy in epithelial ovarian-tumors.

In this investigation, the in vitro production of progesterone and estradiol in ovarian tissues was studied for the first time in relation to the immunohistochemical expression of steroid hormone receptors, Ki-67, p53, DNA ploidy and S-phase fraction. Ovarian tissue from 44 women was examined. Steroid receptors were found more frequently in normal than in tumor ovaries. A substantial focal staining heterogeneity was demonstrated. Mucinous tumors were always progesterone receptor negative. Furthermore, the Ki-67 index was negatively correlated to the progesterone production of the tumor ovaries. Among the malignant tumors, all the high producers of progesterone expressing PR were low proliferating, diploid and p53-negative.

Progesterone and estradiol stimulate release of epidermal growth factor/transforming growth factor alpha by ovarian tumours in vitro.

Previous studies have demonstrated locally increased steroid production and release of EGF/TGF-alpha in ovarian carcinomas. The influence of added steroid hormones on EGF-like activity in ovarian tumours in vitro was investigated. Using radioreceptor assay, EGF-like activity was measured in media from incubations of postmenopausal ovaries, benign and malignant epithelial ovarian tumours from 27 patients. The 3-hour incubations were performed with and without addition of progesterone, testosterone or estradiol. Addition of progesterone and estradiol significantly increased the release of EGF/TGF-a from benign tumour tissue but did not stimulate release from control ovaries. A stimulating effect was also noted for malignant tumour tissue but the increase was not significant. Addition of EGF or IGF-1 did not affect the release of steroid hormones from ovarian tumours. A positive correlation between progesterone and EGF-like activity was found in incubation media of peritoneal fluid cells from cancer patients.

EGF/TGF-alpha and progesterone in urine of ovarian cancer patients.

EGF/TGF-alpha and progesterone were measured in the urine of 74 ovarian carcinoma patients, 21 postmenopausal women with non-gynecological disseminated cancer, 20 premenopausal and 20 postmenopausal controls. Radically operated women excreted significantly less EGF/TGF-alpha into urine than women with residual tumour mass. The patients who died from ovarian carcinoma had significantly higher concentrations of growth factor in urine than patients who were alive and disease-free at follow-up. The highest urinary concentrations were found in the premenopausal control group and among women with non-ovarian malignancies. A significant correlation between concentrations of progesterone and EGF/TGF-alpha in urine was noted.

Peritoneal fluid and HCG influence on steroid production from ovarian tumor tissue, in vitro.

Steroids are produced by malignant and benign epithelial ovarian tumor tissue in vitro, but the regulation is unknown. The effect of peritoneal fluid and beta-HCG on steroid production was analysed. Tissue from 17 malignant or benign epithelial ovarian tumors and 6 normal postmenopausal ovaries were incubated. In 11 cases tissue was incubated with and without addition of the patient's own peritoneal fluid (Part I). Tissue from 22 ovaries was incubated with and without HCG (100 IU/ml medium), (Part II). Furthermore, the release from tumorous and control ovaries of beta-HCG, progesterone, androstenedione and estradiol measured using radioimmunoassay (Part III). Peritoneal fluid stimulated the release of progesterone from both malignant and benign tissue and androstenedione or estradiol stimulated release from benign tissue (Part I). There was no stimulatory effect of HCG on steroid release from malignant tissue. HCG stimulated release of estradiol in benign tissue (Part II). All malignant tumors and 4 out of 6 benign tumors released beta-HCG (Part III). There seems to exist factors in peritoneal fluid which are able to stimulate steroid production from ovarian tumors.

Release of epidermal growth-factor transforming growth-factor-alpha by ovarian-tumors in-vitro.

EGF-like activity was measured in media from 3-hour incubations of ovarian tissue from 27 patients with normal postmenopausal ovaries, malignant or benign epithelial tumours. EGF-like activity in the medium was measured using a radioreceptor assay. Malignant tumour tissue released significantly more EGF/TGF-alpha than benign tissues and aneuploid carcinomas more than diploid carcinomas. In spite of varying amounts of tumour cells there was a strong correlation in EGF/TCF-alpha release from the different tissue samples of each patient suggesting paracrine rather than autocrine regulation. The level of EGF-like activity may be a feature of the patient rather than of the tumour cells.

Expression and prognostic significance of platelet-derived growth factor and its receptors in epithelial ovarian neoplasms.

The expression of platelet-derived growth factor (PDGF), PDGF-alpha receptor (PDGFR alpha) and PDGF-beta receptor (PDGFR beta) was studied in normal ovaries and ovarian neoplasms by immunohistochemical analysis. PDGF was detected in tumor cells in 33 of 45 malignant tumor samples but in none of 20 benign tumors (P < 0.001) or 11 normal ovaries (P < 0.001). In borderline tumors, 4 of 7 tissues stained positive in tumor cells. PDGFR alpha was detected in tumor cells in 16 of 45 malignant tumors, while no epithelial staining was found in 16 benign tumors (P = 0.002) or in 10 normal ovaries (P = 0.023). In 1 of 7 borderline neoplasms, tumor cells expressed PDGFR alpha. Neither normal epithelium nor tumor cells stained positive with antibodies against PDGFR beta. Patients with ovarian cancer and PDGFR alpha-positive tumor cells demonstrated an overall shorter survival compared to those who had negatively stained tumors (P < 0.005). A similar correlation was found in patients having stage III ovarian cancer (P < 0.01), which further supports an independent role for PDGFR alpha as a prognostic factor. Thus, the concomitant expression of PDGF and PDGFR alpha in tumor cells is related to progression of malignant ovarian tumors, indicating a functional role of PDGF via autocrine growth stimulation.

Steroid production in different parts of malignant and benign ovarian tumors in vitro.

Pieces of ovaries and tumors from 45 patients (19 with malignant epithelial tumors, 14 with benign epithelial tumors, and 12 with normal postmenopausal ovaries) were incubated, and the release of steroid hormones from different parts of the tumors and from the contralateral ovaries was measured. Tumor tissue (mainly tumor cells with a small number of stromal cells), tumor base tissue (more stromal cells than tumor cells), and control ovaries were preincubated in oxygenated 4-(2-hydroxyethyl)-1-piperazineethanesulfonic acid-minimum essential medium buffer at 37 degrees C for 30 min followed by a 3-h incubation in fresh, oxygenated medium. Progesterone, androstenedione, testosterone, and estradiol were measured in the medium by radioimmunoassay at the end of the incubation period. Malignant tumors released more progesterone and androstenedione than benign tumors or postmenopausal control ovaries. In contrast, benign tumors released more testosterone than malignant tumors or control ovaries. Release of estradiol was low and not significantly different among control ovaries and malignant and benign tumor tissue. Different parts of the tumors differed in steroid hormone release. Tissue samples containing more tumor cells than stromal cells released more progesterone than those with predominantly stromal cells. Thus, malignant tumors had an active steroid secretion. Progesterone was the main steroid released.