GYNECOLOGIC
ONCOLOGY
38, 442-445 (1990)
Bone Marrow Involvement in Epithelial Ovarian Cancer by lmmunocytochemical Assessment JOANNA M. CAIN, HISHAM K. TAMIMI,
M.D.,* GEORGIANA K. ELLIS, M.D.,? CAROLYN COLLINS, M.D.,? BENJAMIN E. GREER, M.D. ,* M.D.,* DAVID C. FIGGE, M.D., * ALLEN M. GOWN, M.D.,* AND ROBERT B. LIVINGSTON, M.D.?
Divisions of *Gynecologic Oncology, tMedica1 Oncology:y,and SPathology, University of Washington Medical Center, Seattle, Washington 98195 Received January 26, 1990
The incidenceof bonemarrowinvolvementwith epithelial ovarian cancer has been evaluated as a continuation of interest in autologousbone marrow support. Fifty-eight aspirateswere obtained on 50 patients and 53 aspirateswere evaluable. Immunocytochemistry with the monoclonal cytokeratin antibodies 35PHll and 34PE12was performed.There have beenno complications. Twelve (23%) were positive and three were indeterminate. Stage,grade, and CA-125level werenot different in the two groups.No patient had a positivebiopsyat the time of initial diagnosis.The majority of patientsweredrawn from second-look procedures;of these,7 of 19 were positive. Five of twelve with positive aspiratesdied from diseaseversus5 of 38 with negative aspirates,and patientswith a positiveaspiratehad a longer overall survival time until death from disease.We can confirm the presenceof epithelial ovarian cancerin 23%of patientsat varying timesin the courseof their disease.Wecannotidentify risk factors for the developmentof this finding nor the viability of thosecells when found in this data set. 0 W90 Academic Press, Inc. INTRODUCTION
The availability of autologous bone marrow transplantation and the development of new technology for the detection of micrometastases in the bone marrow have raised new questions about the true nature of ovarian cancer. The studies with escalating chemotherapy doses and chemoradiotherapy supported by autologous bone marrow transplantation (ABMT) in other solid tumors, such as small cell lung cancer, colon cancer, and breast cancer, are now being extended to ovarian cancer [l31. While we have been aware of the potential for ovarian cancer to metastasize to distant sites [4,5], the devasPresented at the annual meeting of the Society of Gynecologic Oncologists, San Francisco, CA, February 4-7, 1990.
tating local intraperitoneal effects of progressive disease have held our attention. Indeed, the magnitude of the local problem and the assumption that disease, at least early in its course, remains localized to the peritoneal cavity have had a major impact on the focus of research efforts. If we are to utilize the availability of ABMT to try to improve the course of disease we must know, as is actively being researched for breast cancer, whether or not this disease has potentially viable tumor cells in the bone marrow. This study was initiated to answer the question of whether or not there are detectable micrometastases in the bone marrow of patients with ovarian cancer. Also, if there are such metastases, is there an identifiable set of risk factors or time sequence that would dictate when harvested bone marrow would be optimally free of these metastases. Finally, is there presently any clinical significance, separate from the issues raised by ABMT, that can be attached to the presence of these metastases? MATERIALS
Candidates for bone marrow aspiration were drawn from the population of patients seen by the gynecologic oncology and medical oncology services at the University of Washington Medical School. They must have had a diagnosis of epithelial ovarian cancer or must have been suspected of having an epithelial ovarian malignancy. Stages were assigned using FIG0 staging criteria including revisions to 1988 [6]. The aspirate was optional and was offered as part of a planned surgical procedure or as part of the workup for potential chemoradiotherapy with ABMT but not associated with surgery. The total number of bone marrow samplings done between January 1988 and October 15, 1989, was 58 on 50 patients. 442
OWO-8258/90 $1.50 Copyright 0 1990by Academic Press,Inc. All rights of reproductionin any form reserved.
AND METHODS
BONE MARROW INVOLVEMENT TABLE
Positive
Negative
Stage 1” 11 III IV Grade 0” 1 2 3
1
Number
%
Number
%
Overall % positive
3 4 25 6 38
1.9 10.5 65.8 15.8
2 0 I 3 12
16.7 0 58.3 25.0
40 0 21 33
I 3 4 30 38
2.6 7.9 10.5 7x.9
0 I I IO 12
0 8.3 8.3 83.3
0 2s 20 40
” All are stage IC. ” Borderline. P = NS all groups. x’.
To obtain the bone marrow aspirate from patients undergoing surgery, patients were placed in the left lateral decubitus position after induction of anesthesia but prior to the surgical procedure. Two milliliters of bone marrow was aspirated from one or both iliac crests into 2 ml of 6% sodium citrate using a 15-gauge modified Illinois sternal-iliac aspiration needle. A pressure dressing was placed and the patient repositioned for the surgical procedure. There were no infections or local complications from this procedure. The details of the techniques for processing the bone marrow have been reported previously [7]. In summary the bone marrow is separated on a Ficol/Hypaque gradient. Cell suspensions are placed onto glass slides and dried overnight. They are incubated with the monoclonal cytokeratin antibodies 3SPHll and 34PE12 [8] and localized with an avidin-biotin immunoglucose-oxidase method. Positive control slides are prepared using monkey bone marrow contaminated with variable concentrations (0.01-l%) of MCF-7 breast carcinoma cells. Slides are then screened by an immunocytochemical technologist and read by one or both of two of the authors, A. Gown or G. Ellis. Of the 58 samples, 1 was rejected as it was performed after the surgical procedure, 2 were rejected because of inadequate cell volume, and 2 were rejected for pathology reasons (one benign neoplasm, one mesodermal mixed ovarian cancer), leaving 53 samples for analysis. TABLE 2 Time to Bone Marrow Sample from Diagnosis Mean All patients Negative bone marrow Positive bone marrow
12.5 11.6 15.5
IN OVARIAN
CANCER
443
Follow-up has been obtained to October 1989. All times are from date of diagnosis. Eight patients were sampled twice at different times in the course of their disease. Three of these repeats were done at primary then second-look laparotomies at 8-, 8-, and 7-month intervals. Three were done at second, then third-look laparotomies at 3-, 4-, and 4-month intervals. One was done at the time of recurrence and then at a third-look in 6 months. One was done at second look and then in 8 months with small bowel obstruction. All patients received a platinum-containing regimen for their first cycle of chemotherapy. For those receiving therapy prior to a bone marrow aspirate, the interval from the last dose to the sampling ranged from 4 to 8 weeks (one patient), with 6 weeks the most common interval. Statistical analysis was performed using the x’ test, Wilcoxon signed ranks test, Mann-Whitney test 191,and survival curves on a life-table analysis with confidence limits described by Rothman [lo]. Significance was set at P = 0.05. RESULTS
Of the 53 aspirates, 38 were negative, 12 were positive, and 3 were indeterminate. For most analyses only positive and negative results were analyzed unless otherwise noted. The mean age of all patients was 52 (range 26-73). The ages were not statistically different between patients with positive and negative aspirates. The mean age of negative bone marrow was 55 and that of positive bone marrow, 42.2. Neither stage nor grade was significantly different between the two groups. These clinical features are outlined in Table 1. CA-125 levels showed a mean of 733.9 in the negative group and 1153.6 in the positive group and were not significantly different. There was no significant difference in the time from diagnosis to a finding of a negative or positive aspirate (Table 2) (P = 0.35, Mann-Whitney). There was, however, a difference in bone marrow findings with respect to the intervention point in the course of the disease. No patient with a bone marrow aspirate done prior to primary debulking surgery had a positive bone marrow. The majority of positive aspirates were found at the time of second-look surgeries; however, the proportions are not significantly different (x2, Table 3). The survival curves for patients with a positive bone marrow finding and a negative bone marrow finding from the time of diagnosis are shown in Fig. 1. The shorter SD follow-up of the negative group with wide confidence 12.69 intervals at the tail made statistical evaluation of these 12.6 curves premature. The mean time to death from disease 12.9 for negative bone marrow aspirates was 10.8 months
444
CAIN ET AL.
TABLE 3 Findings Based on Surgical Procedure Intervention Negative
Number Primary surgery Second look Third look Recurrent Persistent
8 12
5 8
5
Positive
%
Number
21.1 31.6 13.2 21.1 13.2
-
% -
7
-
58.3 8.3 16.7 16.7
1 2 2 12
38
% of procedures positive 36.8 16.7 20.0 28.6
[standard deviation (SD) 5.4 months] and for positive bone marrow aspirates, 27.6 months (SD 17.05 months), The number dead of disease with negative findings was 5 of 38 and with positive findings, 5 of 12. Of the group with positive bone marrow, 5 patients have died of disease, 1 patient has died of other causes, 3 are alive with disease, and 3 are free of disease. The 3 free of disease include the patient described separately below, one patient who received continued treatment and had a subsequent negative bone marrow aspirate and negative third-look surgery, and one patient who had a negative follow-up bone marrow aspirate after two cycles of chemotherapy without ABMT. Of the group with negative bone marrow, 5 patients have died of disease, 1 patient died of other causes, 17 are alive with disease, and 14 are free of disease. The 2 free of disease are the 2 patients who had negative bone marrow aspirates after receiving the treatment described above following a previous positive bone marrow. Patients who were initially negative have not been found positive on repeat sampling although this group is small (6 patients). The three patients with indeterminate findings did include one patient at the time of primary debulking. She has progressive disease at 12 months. The other two were
- Bone Marrow Aspirate
04 0
10
20
30
40
50
60
Months
FIG. 1. Survival from time of diagnosis for patients with a negative or positive bone marrow aspirate.
found at second-look laparotomy and both have progressive disease at 37 and 15 months. No further analysis was done on this group. The two patients with stage I disease and positive bone marrow aspirates are worth individual review. The first patient had a positive bone marrow at the time of surgery for complications of progressive stage IC, grade 3 disease despite numerous chemotherapeutic regimens over 44 months. She died of disease 6 months from the positive bone marrow aspirate. The second patient represents the only patient with a positive bone marrow without clinical or histologic suspicion of disease. She had stage IC, grade 3 papillary serous adenocarcinoma and was histologically free of disease at a second-look staging procedure after six cycles of cisplatin and Cytoxan. She is now 4 months post-second look with no evidence of disease.
DISCUSSION By means of an extremely sensitive immunocytochemical test, cells consistent with metastatic ovarian carcinoma can be found in 23% of women at varying times in the course of their disease. That no patient at primary debulking has been found to have an anticytokeratinpositive finding (there was one indeterminate result) and that the time to death from diagnosis in these positive patients is much longer suggest that this may occur late in the course of the disease. The primary debulking group is also the only group not exposed to chemotherapy. The effect that exposure to chemotherapy can have on selection of cells more likely to metastasize by hematogenous or lymphatic routes is unknown but may play a role in these findings. These data are too early to evaluate this question adequately. Therapy of ovarian epithelial cancer has been directed at controlling the local intraperitoneal effects of the disease to prevent death from malnutrition and chronic bowel obstruction. The fact that the passive and repeated exposure of exfoliated cancer cells to the peritoneal cavity leads to a high percentage of patients with gross peritoneal disease at diagnosis is not surprising. This is not, however, the only modality of spread. At initial diagnosis, patients may have retroperitoneal or distant node metastases, hepatic parenchymal metastases, or other distant metastases that suggest lymphatic and hematologic spread. Furthermore, Dauplat et al. [41 have reported that 38% of patients develop clinically apparent distant metastases, including bone marrow and bone metastases (1.9%), during the course of their disease. Finally, the reports of generally late central nervous system (CNS) metastases in patients [5,11,12] support the ability of this disease to spread by hematogenous routes. Indeed, one report suggests consideration of prophylactic
BONE MARROW INVOLVEMENT
craniospinal radiotherapy for patients achieving complete remission to decrease the possibility of late CNS recurrence [ 131. Our improving ability to control local disease may well require confronting other sites of potential metastases, including bone marrow. Our ability to utilize these data is still in its infancy. While we know for other solid tumors such as breast tumors that the presence of positive cells in the marrow correlates with high risk factors for recurrence [7,14], we are, as yet, unable to show a similar pattern in ovarian cancer. There are suggestions that aspirates suggesting contaminated marrow may contain viable cells in breast cancer [I51 but this is unknown for ovarian cancer. The present policy at our institution is to exclude patients with positive bone marrow aspirates from ABMT protocols. The delineation of risk for bone marrow micrometastases from this population base is not possible due to low numbers in important groups such as initial diagnosis. The fact that the mean time to death with disease is so prolonged in the positive bone marrow group suggests that this is a finding more common in patients in whom the fatal peritoneal complications have been, to some degree, controlled over time, allowing the emergence and identification of distant metastases. However, whether these cells represent cells in transit with variable viability or established metastatic disease will be answered only by continued observation and study of these patients. If ABMT becomes a major supportive technique for the therapy of ovarian cancer, consideration of storage of bone marrow at the time of diagnosis for patients at high risk for persistent disease should be given. True estimates of the false-positive and false-negative rates of this technique for ovarian cancer cannot be given. The one patient with a positive aspirate in the face of negative histology raises concern about falsepositive findings. In addition, the small sample volume (2-4 ml of bone marrow) may also lend itself to an unknown number of false-negative results. This has been addressed for breast cancer with a relatively low rate of false-positive and false-negative findings [7]. In summary, 23% of patients had evidence of epithelial ovarian cancer cells in their bone marrow aspirates. This raises the specter of transfusion of potentially viable malignant cells in ABMT with high-dose therapy for this disease. The real risk of this is unknown although it has been suggested for breast cancer therapy supported by ABMT [15]. We cannot yet identify the risk group for presence of micrometastases but the time of initial diagnosis may be that of lowest risk based on these data and the previous literature on distant metastases with this disease. As more data become available, the utility of early bone marrow harvest and the patient population requiring more than local therapy (e.g., intraperitoneal
445
IN OVARIAN CANCER
chemotherapy or whole-abdomen radiotherapy) may become better established. REFERENCES I. Dauplat, J., Legros, M., Condat, P., Ferriere, J. P., and Plagne,
R. High dose melphalan and autologous bone marrow support for treatment of ovarian cancer with positive second look, in Society of Gynecologic
Oncologists,
20th Annual Meeting (February
1989).
Abstract 9. 2. Ellis, G., Collins,-C., and Cain. J. High dose cyclophosphamide, etoposide and cisplatin in refractory/recurrent ovarian carcinoma, Proc. Asco. 9, I65 (1990). 3. Peters, W., Eder, J. P., Henner, W. D., Schryber, D., Wilmore, D., Finberg, R., Schlolenfeld, D., Bast, R., Gargone, B., Antman, K., Anderson, J., Anderson, K., Kruskall, M. S., Schnipper, L., and Frei. E. High dose combination alkylating agents with autologous bone marrow support: A phase I trial, J. Clin. Oncol. 4, 646-654 (1986). 4. Dauplat, J., Hacker, N.. Nieberg, R., Berek, J., Rose, T., and Sagae, S. Distant metastases in ovarian cancer, Cancer 60, l5611566 (1987). 5. Mayer, R., Berkowitz, R., and Griffiths, C. T. Central nervous system involvement by ovarian cancer, Cancer 41,776-783 (1978). 6. Announcements, FIG0 stages-1988 revision, Gynecol. Oncol. 35, 125-127 (1989). 7. Ellis, Cl., Ferguson. M., Yamanaka, E., Livingston, and R., Gown. A. Monoclonal antibodies for detection of occult carcinoma cells in bone marrow of breast cancer patients, Cancer 63, 2509-2515 (1989). 8. Gown, A., and Vogel. A. Monoclonal antibodies to human intermediate filament proteins, Amer. J. C/in. Pathol. 84, 413-424 (1985). 9 Mann, H. B., and Whitney, D. On a test of whether one of two random variables is statistically larger than the other, Anal. Muth. Statist. 18, 50-60 (1947). 10 Rothman, K. J. Estimation of confidence limits for cumulative probability of survival in life table analysis, J. Chron. Dis. 31, 557-560 (1978). II Ross, W., Carmichael, J., and Shelley, W. Advanced carcinoma of the ovary with central nervous system relapse, Gynecol. Oncol. 30, 398-406 (1988). 12 Hoffman, J., and Pera, Y. Central nervous system lesions and advanced ovarian cancer, Gynecol. Oncol. 30, 87-97 (1988). 13. Hardy, J. R., and Harvey, V. J. Cerebral metastases in patients with ovarian cancer treated with chemotherapy, Gynecol. Oncol. 33, 296-300 (1989). 14. Redding, W., Coombes. R. C., Monaghan, P., McD. Clink, H., Imrie, S. F., Dearnaley, D. P., Ormerod, M. D., Sloane, J. P., Gazet, J., Powles, T. J., and Neville, A. M. Detection of micrometastases in patients with breast cancer, Lancet, 1271-1273 (Dec. 3, 1983). 15. Peters, W., Shpall, E., Jones, R., Olsen, G., Bast, R., Gockerman, J., and Moore, J. 0. High dose alkylating agents with bone marrow support as initial treatment for metastatic breast cancer, J. C/in. Oncol. 6, 1368-1376 (1988). 16. Spitzer, G., Durnphy. A., Buzdar, G., Hortobagyi, M., Auber, M., Holmes, F., Jabboury, K., Horwitz, L., Jagannath, S., and Dicke, K. High dose Cytoxan/VP-16/platinum intensification for hormonally unresponsive metastatic breast cancer, Proc. ASCO 7, I4 (1988).
ONCOLOGY
38, 442-445 (1990)
Bone Marrow Involvement in Epithelial Ovarian Cancer by lmmunocytochemical Assessment JOANNA M. CAIN, HISHAM K. TAMIMI,
M.D.,* GEORGIANA K. ELLIS, M.D.,? CAROLYN COLLINS, M.D.,? BENJAMIN E. GREER, M.D. ,* M.D.,* DAVID C. FIGGE, M.D., * ALLEN M. GOWN, M.D.,* AND ROBERT B. LIVINGSTON, M.D.?
Divisions of *Gynecologic Oncology, tMedica1 Oncology:y,and SPathology, University of Washington Medical Center, Seattle, Washington 98195 Received January 26, 1990
The incidenceof bonemarrowinvolvementwith epithelial ovarian cancer has been evaluated as a continuation of interest in autologousbone marrow support. Fifty-eight aspirateswere obtained on 50 patients and 53 aspirateswere evaluable. Immunocytochemistry with the monoclonal cytokeratin antibodies 35PHll and 34PE12was performed.There have beenno complications. Twelve (23%) were positive and three were indeterminate. Stage,grade, and CA-125level werenot different in the two groups.No patient had a positivebiopsyat the time of initial diagnosis.The majority of patientsweredrawn from second-look procedures;of these,7 of 19 were positive. Five of twelve with positive aspiratesdied from diseaseversus5 of 38 with negative aspirates,and patientswith a positiveaspiratehad a longer overall survival time until death from disease.We can confirm the presenceof epithelial ovarian cancerin 23%of patientsat varying timesin the courseof their disease.Wecannotidentify risk factors for the developmentof this finding nor the viability of thosecells when found in this data set. 0 W90 Academic Press, Inc. INTRODUCTION
The availability of autologous bone marrow transplantation and the development of new technology for the detection of micrometastases in the bone marrow have raised new questions about the true nature of ovarian cancer. The studies with escalating chemotherapy doses and chemoradiotherapy supported by autologous bone marrow transplantation (ABMT) in other solid tumors, such as small cell lung cancer, colon cancer, and breast cancer, are now being extended to ovarian cancer [l31. While we have been aware of the potential for ovarian cancer to metastasize to distant sites [4,5], the devasPresented at the annual meeting of the Society of Gynecologic Oncologists, San Francisco, CA, February 4-7, 1990.
tating local intraperitoneal effects of progressive disease have held our attention. Indeed, the magnitude of the local problem and the assumption that disease, at least early in its course, remains localized to the peritoneal cavity have had a major impact on the focus of research efforts. If we are to utilize the availability of ABMT to try to improve the course of disease we must know, as is actively being researched for breast cancer, whether or not this disease has potentially viable tumor cells in the bone marrow. This study was initiated to answer the question of whether or not there are detectable micrometastases in the bone marrow of patients with ovarian cancer. Also, if there are such metastases, is there an identifiable set of risk factors or time sequence that would dictate when harvested bone marrow would be optimally free of these metastases. Finally, is there presently any clinical significance, separate from the issues raised by ABMT, that can be attached to the presence of these metastases? MATERIALS
Candidates for bone marrow aspiration were drawn from the population of patients seen by the gynecologic oncology and medical oncology services at the University of Washington Medical School. They must have had a diagnosis of epithelial ovarian cancer or must have been suspected of having an epithelial ovarian malignancy. Stages were assigned using FIG0 staging criteria including revisions to 1988 [6]. The aspirate was optional and was offered as part of a planned surgical procedure or as part of the workup for potential chemoradiotherapy with ABMT but not associated with surgery. The total number of bone marrow samplings done between January 1988 and October 15, 1989, was 58 on 50 patients. 442
OWO-8258/90 $1.50 Copyright 0 1990by Academic Press,Inc. All rights of reproductionin any form reserved.
AND METHODS
BONE MARROW INVOLVEMENT TABLE
Positive
Negative
Stage 1” 11 III IV Grade 0” 1 2 3
1
Number
%
Number
%
Overall % positive
3 4 25 6 38
1.9 10.5 65.8 15.8
2 0 I 3 12
16.7 0 58.3 25.0
40 0 21 33
I 3 4 30 38
2.6 7.9 10.5 7x.9
0 I I IO 12
0 8.3 8.3 83.3
0 2s 20 40
” All are stage IC. ” Borderline. P = NS all groups. x’.
To obtain the bone marrow aspirate from patients undergoing surgery, patients were placed in the left lateral decubitus position after induction of anesthesia but prior to the surgical procedure. Two milliliters of bone marrow was aspirated from one or both iliac crests into 2 ml of 6% sodium citrate using a 15-gauge modified Illinois sternal-iliac aspiration needle. A pressure dressing was placed and the patient repositioned for the surgical procedure. There were no infections or local complications from this procedure. The details of the techniques for processing the bone marrow have been reported previously [7]. In summary the bone marrow is separated on a Ficol/Hypaque gradient. Cell suspensions are placed onto glass slides and dried overnight. They are incubated with the monoclonal cytokeratin antibodies 3SPHll and 34PE12 [8] and localized with an avidin-biotin immunoglucose-oxidase method. Positive control slides are prepared using monkey bone marrow contaminated with variable concentrations (0.01-l%) of MCF-7 breast carcinoma cells. Slides are then screened by an immunocytochemical technologist and read by one or both of two of the authors, A. Gown or G. Ellis. Of the 58 samples, 1 was rejected as it was performed after the surgical procedure, 2 were rejected because of inadequate cell volume, and 2 were rejected for pathology reasons (one benign neoplasm, one mesodermal mixed ovarian cancer), leaving 53 samples for analysis. TABLE 2 Time to Bone Marrow Sample from Diagnosis Mean All patients Negative bone marrow Positive bone marrow
12.5 11.6 15.5
IN OVARIAN
CANCER
443
Follow-up has been obtained to October 1989. All times are from date of diagnosis. Eight patients were sampled twice at different times in the course of their disease. Three of these repeats were done at primary then second-look laparotomies at 8-, 8-, and 7-month intervals. Three were done at second, then third-look laparotomies at 3-, 4-, and 4-month intervals. One was done at the time of recurrence and then at a third-look in 6 months. One was done at second look and then in 8 months with small bowel obstruction. All patients received a platinum-containing regimen for their first cycle of chemotherapy. For those receiving therapy prior to a bone marrow aspirate, the interval from the last dose to the sampling ranged from 4 to 8 weeks (one patient), with 6 weeks the most common interval. Statistical analysis was performed using the x’ test, Wilcoxon signed ranks test, Mann-Whitney test 191,and survival curves on a life-table analysis with confidence limits described by Rothman [lo]. Significance was set at P = 0.05. RESULTS
Of the 53 aspirates, 38 were negative, 12 were positive, and 3 were indeterminate. For most analyses only positive and negative results were analyzed unless otherwise noted. The mean age of all patients was 52 (range 26-73). The ages were not statistically different between patients with positive and negative aspirates. The mean age of negative bone marrow was 55 and that of positive bone marrow, 42.2. Neither stage nor grade was significantly different between the two groups. These clinical features are outlined in Table 1. CA-125 levels showed a mean of 733.9 in the negative group and 1153.6 in the positive group and were not significantly different. There was no significant difference in the time from diagnosis to a finding of a negative or positive aspirate (Table 2) (P = 0.35, Mann-Whitney). There was, however, a difference in bone marrow findings with respect to the intervention point in the course of the disease. No patient with a bone marrow aspirate done prior to primary debulking surgery had a positive bone marrow. The majority of positive aspirates were found at the time of second-look surgeries; however, the proportions are not significantly different (x2, Table 3). The survival curves for patients with a positive bone marrow finding and a negative bone marrow finding from the time of diagnosis are shown in Fig. 1. The shorter SD follow-up of the negative group with wide confidence 12.69 intervals at the tail made statistical evaluation of these 12.6 curves premature. The mean time to death from disease 12.9 for negative bone marrow aspirates was 10.8 months
444
CAIN ET AL.
TABLE 3 Findings Based on Surgical Procedure Intervention Negative
Number Primary surgery Second look Third look Recurrent Persistent
8 12
5 8
5
Positive
%
Number
21.1 31.6 13.2 21.1 13.2
-
% -
7
-
58.3 8.3 16.7 16.7
1 2 2 12
38
% of procedures positive 36.8 16.7 20.0 28.6
[standard deviation (SD) 5.4 months] and for positive bone marrow aspirates, 27.6 months (SD 17.05 months), The number dead of disease with negative findings was 5 of 38 and with positive findings, 5 of 12. Of the group with positive bone marrow, 5 patients have died of disease, 1 patient has died of other causes, 3 are alive with disease, and 3 are free of disease. The 3 free of disease include the patient described separately below, one patient who received continued treatment and had a subsequent negative bone marrow aspirate and negative third-look surgery, and one patient who had a negative follow-up bone marrow aspirate after two cycles of chemotherapy without ABMT. Of the group with negative bone marrow, 5 patients have died of disease, 1 patient died of other causes, 17 are alive with disease, and 14 are free of disease. The 2 free of disease are the 2 patients who had negative bone marrow aspirates after receiving the treatment described above following a previous positive bone marrow. Patients who were initially negative have not been found positive on repeat sampling although this group is small (6 patients). The three patients with indeterminate findings did include one patient at the time of primary debulking. She has progressive disease at 12 months. The other two were
- Bone Marrow Aspirate
04 0
10
20
30
40
50
60
Months
FIG. 1. Survival from time of diagnosis for patients with a negative or positive bone marrow aspirate.
found at second-look laparotomy and both have progressive disease at 37 and 15 months. No further analysis was done on this group. The two patients with stage I disease and positive bone marrow aspirates are worth individual review. The first patient had a positive bone marrow at the time of surgery for complications of progressive stage IC, grade 3 disease despite numerous chemotherapeutic regimens over 44 months. She died of disease 6 months from the positive bone marrow aspirate. The second patient represents the only patient with a positive bone marrow without clinical or histologic suspicion of disease. She had stage IC, grade 3 papillary serous adenocarcinoma and was histologically free of disease at a second-look staging procedure after six cycles of cisplatin and Cytoxan. She is now 4 months post-second look with no evidence of disease.
DISCUSSION By means of an extremely sensitive immunocytochemical test, cells consistent with metastatic ovarian carcinoma can be found in 23% of women at varying times in the course of their disease. That no patient at primary debulking has been found to have an anticytokeratinpositive finding (there was one indeterminate result) and that the time to death from diagnosis in these positive patients is much longer suggest that this may occur late in the course of the disease. The primary debulking group is also the only group not exposed to chemotherapy. The effect that exposure to chemotherapy can have on selection of cells more likely to metastasize by hematogenous or lymphatic routes is unknown but may play a role in these findings. These data are too early to evaluate this question adequately. Therapy of ovarian epithelial cancer has been directed at controlling the local intraperitoneal effects of the disease to prevent death from malnutrition and chronic bowel obstruction. The fact that the passive and repeated exposure of exfoliated cancer cells to the peritoneal cavity leads to a high percentage of patients with gross peritoneal disease at diagnosis is not surprising. This is not, however, the only modality of spread. At initial diagnosis, patients may have retroperitoneal or distant node metastases, hepatic parenchymal metastases, or other distant metastases that suggest lymphatic and hematologic spread. Furthermore, Dauplat et al. [41 have reported that 38% of patients develop clinically apparent distant metastases, including bone marrow and bone metastases (1.9%), during the course of their disease. Finally, the reports of generally late central nervous system (CNS) metastases in patients [5,11,12] support the ability of this disease to spread by hematogenous routes. Indeed, one report suggests consideration of prophylactic
BONE MARROW INVOLVEMENT
craniospinal radiotherapy for patients achieving complete remission to decrease the possibility of late CNS recurrence [ 131. Our improving ability to control local disease may well require confronting other sites of potential metastases, including bone marrow. Our ability to utilize these data is still in its infancy. While we know for other solid tumors such as breast tumors that the presence of positive cells in the marrow correlates with high risk factors for recurrence [7,14], we are, as yet, unable to show a similar pattern in ovarian cancer. There are suggestions that aspirates suggesting contaminated marrow may contain viable cells in breast cancer [I51 but this is unknown for ovarian cancer. The present policy at our institution is to exclude patients with positive bone marrow aspirates from ABMT protocols. The delineation of risk for bone marrow micrometastases from this population base is not possible due to low numbers in important groups such as initial diagnosis. The fact that the mean time to death with disease is so prolonged in the positive bone marrow group suggests that this is a finding more common in patients in whom the fatal peritoneal complications have been, to some degree, controlled over time, allowing the emergence and identification of distant metastases. However, whether these cells represent cells in transit with variable viability or established metastatic disease will be answered only by continued observation and study of these patients. If ABMT becomes a major supportive technique for the therapy of ovarian cancer, consideration of storage of bone marrow at the time of diagnosis for patients at high risk for persistent disease should be given. True estimates of the false-positive and false-negative rates of this technique for ovarian cancer cannot be given. The one patient with a positive aspirate in the face of negative histology raises concern about falsepositive findings. In addition, the small sample volume (2-4 ml of bone marrow) may also lend itself to an unknown number of false-negative results. This has been addressed for breast cancer with a relatively low rate of false-positive and false-negative findings [7]. In summary, 23% of patients had evidence of epithelial ovarian cancer cells in their bone marrow aspirates. This raises the specter of transfusion of potentially viable malignant cells in ABMT with high-dose therapy for this disease. The real risk of this is unknown although it has been suggested for breast cancer therapy supported by ABMT [15]. We cannot yet identify the risk group for presence of micrometastases but the time of initial diagnosis may be that of lowest risk based on these data and the previous literature on distant metastases with this disease. As more data become available, the utility of early bone marrow harvest and the patient population requiring more than local therapy (e.g., intraperitoneal
445
IN OVARIAN CANCER
chemotherapy or whole-abdomen radiotherapy) may become better established. REFERENCES I. Dauplat, J., Legros, M., Condat, P., Ferriere, J. P., and Plagne,
R. High dose melphalan and autologous bone marrow support for treatment of ovarian cancer with positive second look, in Society of Gynecologic
Oncologists,
20th Annual Meeting (February
1989).
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