Ann Surg Oncol DOI 10.1245/s10434-015-4623-z
ORIGINAL ARTICLE – GYNECOLOGIC ONCOLOGY
Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery and the Risk of Platinum Resistance in Epithelial Ovarian Cancer Alexandre A. B. A. da Costa, MD1, Camila V. Valadares, MD1, Glauco Baiocchi, MD, PhD2, Henrique Mantoan, MD2, Augusto Saito, MD1, Solange Sanches, MD1, Andre´ia P. Guimara˜es, MD1, and Maria Isabel W. Achatz, MD, PhD3 Medical Oncology Department, A.C. Camargo Cancer Center, Sao Paulo, SP, Brazil; 2Gynecology Oncology Department, A.C. Camargo Cancer Center, Sao Paulo, SP, Brazil; 3Oncogenetics Department, A.C. Camargo Cancer Center, Sao Paulo, SP, Brazil
1
ABSTRACT Background. Interval debulking surgery (IDS) is an option for treating patients with advanced ovarian carcinoma. Two randomized trials have shown similar survival rates for primary debulking surgery (PDS) and IDS. One of the concerns with IDS is the potentially higher risk of inducing platinum resistance when treating patients with greater disease volume. Methods. A retrospective review of data on 237 patients with stage IIIC and IV ovarian carcinoma who were treated at a single institution from 2000 to 2013. We analyzed the association of IDS with time to first platinum resistant relapse (TTPR); platinum-resistant disease at first relapse, defined as a platinum-free interval (PFI) after first-line chemotherapy of \6 months; and overall response rate (ORR) to chemotherapy at first platinum-sensitive relapse. Results. The TTPR was 60 months, and the median TTPR was longer for the PDS (80.8 months) versus IDS group (39.3 months; p = 0.012) and for patients with residual disease (RD) B10 mm (80.8 months) compared with those with RD [10 mm (26.1 months; p \ 0.001). In the multivariate analysis, IDS [hazard ratio (HR) 1.92; p = 0.009] and RD [10 mm (HR 1.65; p \ 0.001) retained an
Electronic supplementary material The online version of this article (doi:10.1245/s10434-015-4623-z) contains supplementary material, which is available to authorized users. Ó Society of Surgical Oncology 2015 First Received: 24 March 2015 A. A. B. A. da Costa, MD [email protected]; [email protected]
increased risk of developing platinum-resistant disease. IDS was not associated with a greater risk of PFI \6 months at first relapse, and the ORR to platinum-based chemotherapy at first platinum-sensitive relapse was 87.2 % for patients who were treated with PDS compared with 68.0 % for those who underwent IDS (p = 0.051). Conclusions. IDS correlates with a higher risk of the development of platinum resistance.
Ovarian cancer is the 11th most frequent cancer among women in the United States, with 21,980 estimated cases developing in 2014. Moreover, ovarian cancer-related 14,270 deaths to are expected to have occurred in 2014, constituting the fifth leading cause of deaths from cancer in women.1 Nearly 70 % of cases have advanced disease (stage III or IV) at diagnosis, the cornerstone treatment of which is cytoreductive surgery (CRS), because residual disease (RD) after initial surgery is one of the most important prognostic factors for survival.2,3 Although the value of CRS is well established, the ideal time for primary treatment is unknown. At least two trials have compared primary debulking surgery (PDS) with interval debulking surgery (IDS) in patients with FIGO stage IIIC and IV ovarian cancer, neither of which reported a difference in survival with regard to the timing of CRS, reporting fewer surgical complications and more patients undergoing complete CRS in favor of IDS.4,5 Yet, IDS cannot be considered the standard of care for all patients with stage IIIC or IV disease.6 A subgroup analysis of the EORTC trial demonstrated worse survival for patients with stage IIIC disease and
A. A. B. A. da Costa et al.
largest metastatic tumor diameter \5 cm who were treated with IDS, suggesting a detrimental effect when administering neoadjuvant chemotherapy (NACT) to certain stage IIIC patients.7 One explanation is the theoretical risk of platinum resistance when chemotherapy is used to treat large-volume disease before surgery versus chemotherapy for small or microscopic RD after CRS. Platinum compounds acts primarily through the formation of covalent bonds in nuclear DNA, whereas other cytoplasmic mechanisms also might be involved. Similarly, drug resistance generally is multifactorial and might be related to changes in DNA repair machinery and to preand post-target alterations.8 The most widely accepted hypothesis of platinum resistance implicates the outgrowth of resistant clones, which are usually present at low rates before initial treatment.9 According to this hypothesis, the likelihood of platinum-resistant clones developing is greater in large tumor volumes that are treated with platinum compounds. Two retrospective trials have suggested that patients in whom IDS is performed have higher rates of platinum-resistant recurrence than those who undergo PDS.10,11 Our goal was to correlate the timing of CRS and the development of platinum-resistant relapse in advancedstage epithelial ovarian cancer (EOC) patients. METHODS We performed a retrospective review of the medical records of 237 patients with stage IIIC and IV EOC who were treated at AC Camargo Cancer Center from 2000 to 2013. We excluded patients with unavailable data regarding primary surgery and chemotherapy. At our institution, these patients underwent CRS that was performed by a surgeon with expertise in gynecologic oncology. For patients who did not have surgery at AC Camargo Cancer Center, we had no data regarding specialization of surgeons. The decision between PDS and IDS was made per the assistant’s discretion. Medical oncologists prescribed chemotherapy per international guidelines. The clinical data included age at diagnosis, tumor stage and histological subtype, type of surgery (PDS or IDS), volume of RD after surgery (B1 or [1 cm), CA125 levels before first treatment, type of chemotherapy (NACT or adjuvant chemotherapy), number of chemotherapy cycles before and after surgery, chemotherapy regimens, date of last platinum-based chemotherapy, date of recurrences after each treatment until last follow-up, and response to platinum retreatment after recurrence. Recurrence was defined per GCIG criteria after evaluating RECIST and CA125 progression in the medical charts, and the date of the earlier event was considered for
progression. CA125 progression by GCIG is considered if there is a doubling in CA 125 from the upper limit of normal and for those patients whose CA 125 never fell to the normal range, a doubling from the nadir is considered progression.12,13 Progression-free survival (PFS) was defined as the interval between the dates of diagnosis and disease progression. Platinum-free interval (PFI) was considered the interval between the date of the last platinum compound infusion and the date of disease progression. Platinum-resistant recurrence was defined as recurrence with a PFI of \6 months. Time to platinum-resistant disease (TTPR) was the interval between the date of diagnosis and the date of first recurrence with a PFI of \6 months. Data on the response to treatment of recurrent disease were retrieved from medical charts, and GCIG criteria were used to evaluate RECIST and CA125 responses. CA125 response by GCIG is defined as at least 50 % reduction in CA 125 levels from a pretreatment sample. Response was categorized as a ‘‘response’’ in the case of a complete response or partial response and ‘‘no response’’ if there was stable disease or disease progression.13 Overall survival (OS) was defined as the interval between the date of diagnosis and death by any cause. We correlated the time of CRS (PDS or IDS) with TTPR, platinum-resistant disease at first recurrence, and overall response rate (ORR) to chemotherapy after the first platinum-sensitive relapse. This study was approved by the ethics committee of our institution. Statistical Analysis The database was generated in SPSS, version 21.0. The association between categorical variables was analyzed by v2 or Fischer’s exact test. Survival curves were constructed by Kaplan–Meier life-table analysis. A multivariate analysis was performed by Cox regression. All variables with p value \0.20 in the univariate analysis were entered into the multivariate analysis.14 For all tests, an alpha error of up to 5 % (p \ 0.05) was considered significant. We excluded patients with a follow-up \6 months for the analysis of platinum-resistant disease at first recurrence. RESULTS Of the 237 patients, 147 (62.0 %) were treated with PDS and 90 patients (38.0 %) underwent IDS. The clinical and pathological characteristics are summarized in Table 1. Patients who were treated with PDS were younger, had higher pretreatment CA125 levels, were less likely to have an RD B10 mm, and received fewer cycles of chemotherapy in the first-line treatment. Seven of 237 patients
Interval Cytoreduction and Platinum Resistance TABLE 1 Clinical characteristics of the 237 patients Characteristic
PDS Freq. (%)
IDS Freq. (%)
Total patients
147
90
B60
88 (60.3)
40 (44.9)
[60
58 (39.7)
49 (55.1)
No
102 (70.3)
51 (63.8)
Yes
43 (29.7)
29 (36.3)
IIIC
123 (83.7)
68 (75.6)
IV
24 (16.3)
22 (24.4)
110 (80.9)
80 (90.9)
Endometrioid
4 (2.9)
1 (1.1)
Clear Cell
4 (2.9)
2 (2.3)
Mucinous
6 (4.4)
1 (1.1)
Low-grade serous
4 (2.9)
0 (0)
Mixture
8 (5.9)
4 (4.5)
\590 (median)
58 (56.3)
30 (39.5)
C590 (median)
45 (43.7)
46 (60.5)
B10 mm
91 (62.3)
69 (76.7)
[10 mm
55 (37.7)
21 (23.3)
B6
110 (82.1)
42 (49.4)
[6
24 (17.9)
43 (50.6)
Early death (\1 month after surgery) No
143 (97.3)
85 (94.4)
Yes
4 (2.7)
5 (5.6)
Age (years)
p value*
0.022
Breast or ovarian cancer positive family history
0.310
Stage
0.125
Histology High grade serous
0.296
Pre treatment CA125 (median/range)
0.026
Residual disease
0.022
\0.001
Total chemotherapy cycles
0.306
2
* All p values calculated using v test
were treated with chemotherapy regimens other than the standard platinum-taxane combination, all of whom were administered platinum-based chemotherapy. Time to Platinum-Resistant Recurrence After a median follow-up of 55.7 months, 94 patients experienced platinum-resistant recurrences, corresponding to 36.0 % (53/147) of patients after PDS and 45.6 % (41/ 90) of subjects after IDS. The estimated median TTPR was 60 months [43.1–76.9; 95 % confidence interval (CI)], and the median TTPR was longer for the PDS (80.8 months) versus IDS group (39.3 months; p = 0.012). The TTPR was 80.8 months for patients with RD B10 mm compared with 26.1 months for RD[10 mm (p \ 0.001; Fig. 1).
In the multivariate analysis (including surgical moment, age, stage, RD, and total chemotherapy cycles), IDS and RD [10 mm were the only variables that retained the increased risk of developing platinum-resistant disease. Patients who were treated with IDS had a 1.92-fold greater risk of developing platinum-resistant disease compared with the PDS group, and RD [10 mm was associated with a 1.65-fold higher risk versus RD B10 mm (Table 2). Platinum-Resistant Disease at First Relapse and Response to Platinum Re-exposure One hundred seventy-six (74.3 %) patients had a recurrence. First recurrence was detected within 6 months since the last platinum chemotherapy treatment in 29.5 % of all patients, between 6 and 12 months in 18.1 %, and
A. A. B. A. da Costa et al.
(a) 1.0
(b) 1.0
0.8
0.8
0.6
0.6
TTPR
TTPR
p = 0.012
0.4
0.4
0.2
0.2
0.0
0.0 0
20
40
60
80
100
120
PDS IDS 0
140
20
40
60
80
(c)
120
140
(d) 1.0
1.0 p < 0.001
p = 0.175
0.8
0.8
0.6
0.6
TTPR
TTPR
100
Time (months)
Time (months)
0.4 0.2
0.4 0.2
RD ≤ 10 mm RD > 10 mm
0.0 0
20
40
Stage III Stage IV
0.0 60
80
100
120
140
0
20
Time (months)
40
60
80
100
120
140
Time (months)
FIG. 1 Time to platinum-resistant recurrence in (a) all patients and according to (b) surgical moment, c residual disease, and d stage. All p values calculated by the log-rank test. TTPR time to platinum-
resistant recurrence, PDS primary debulking surgery, IDS interval debulking surgery, RD residual disease
more than 12 months in 22.7 %. RD [10 mm (p = 0.001) and histology other than high-grade serous carcinoma (p = 0.017) correlated with an increased risk of platinumresistant recurrence at first relapse, defined as a PFI \6 months (Table 3). Ninety-seven patients recurred after 6 months since the last platinum chemotherapy (‘‘platinum-sensitive’’); 5 of whom were not treated with platinum compounds and 20 of whom did not have data on their response to platinum reexposure. For the 72 patients with available data on the response to platinum re-exposure, the ORR was 80.6 %. Patients who were initially treated with PDS had an ORR to platinum re-exposure of 87.2 versus 68.0 % for those who underwent IDS (p = 0.051). Patients who were administered more than 6 cycles of chemotherapy at first-line treatment had an ORR of 66.7 % compared with 88.1 % after B6 first-line cycles (p = 0.031). Patients with a family history of ovarian or breast cancer had and ORR of 95.2 versus 75.0 % for those with no family history (p = 0.050). No other factor impacted the ORR to platinum re-exposure. Patients with a PFI [12 months had an
ORR of 88.6 % compared with 76.9 % with a PFI between 6 and 12 months (p = 0.224; Table 3). Progression-Free Survival and Overall Survival The median overall PFS and OS rates were 18.6 months (16.6–20.5 months; 95 % CI) and 48.4 months (40.1– 56.6 months; 95 % CI), respectively. The time of surgery did not impact the PFS or OS; the median PFS after PDS and IDS was 20.0 and 17.6 months, respectively (p = 0.071), and the median OS was 56.1 and 41.4 months (p = 0.088; Fig. 2). In the multivariate analysis for OS, RD [10 mm [hazard ratio (HR) 1.45; 1.19–1.79, 95 % CI; p \ 0.001] and older age (HR 1.03; 1.01–1.05, 95 % CI; p = 0.011) were the only variables that retained a higher risk of death (Table 1, Supplementary Appendix). DISCUSSION The ideal timing of CRS in ovarian cancer remains unknown. Despite the results of two phase III trials that
Interval Cytoreduction and Platinum Resistance TABLE 2 Univariate and multivariate analysis for time to platinum resistant recurrence Characteristic
Multivariate analysisa
Univariate analysis HR (95 % CI)
p value
HR (95 % CI)
p value
PDS
1
0.012
1
0.009
IDS
1.70 (1.12–2.57)
Ageb
1.01 (0.99–1.03)
Surgical moment 1.92 (1.18–3.13) 0.177
1.00 (0.98–1.02)
Breast or ovarian cancer positive family history No
1
Yes Stage
0.839 –
0.296
1.27 (0.82–1.98)
IIIC
1
IV
1.40 (0.86–2.31)
– –
0.178
1
0.836
0.84 (0.49–1.41)
Histology
–
High-grade serous
1
Others
0.407
0.78 (0.43–1.41) b
Pre treatment CA125 (median/range)
– –
1.0 (1.0–1.0)
0.266
–
–
B10 mm
1
\0.001
1
\0.001
[10 mm
1.62 (1.31–1.99)
Residual disease 1.65 (1.33–2.06)
Total chemotherapy cycles B6
1
[6
1.46 (0.95–2.24)
a
Ninety-one events in 212 patients included in the analysis
b
Analyzed as continuous variables
compared PDS and IDS in which there was no impact on survival, limited data exist regarding the association between the timing of surgery and platinum-resistant relapse.4,5 Our series suggests that patients who are treated with IDS have a shorter time to platinum-resistant recurrence than those who undergo PDS (39.3 vs. 80.8 months; p = 0.012). Furthermore, the ORR to platinum re-exposure for recurrent disease was worse for patients who were treated with IDS versus PDS, albeit insignificantly (68.0 vs. 87.02 %; p = 0.051). Thus, our findings suggest that patients who undergo IDS have a higher likelihood of developing platinum-resistant disease compared with those who are treated with PDS. Rauh-Hain et al. analyzed 425 patients with stage IIIC and IV epithelial ovarian cancer who underwent PDS or IDS.10 They compared the platinum-resistant disease rate at first relapse between the groups, which was higher for IDS-treated subjects (44.2 vs. 31.2 %). However, after adjusting for other prognostic factors, the difference was not statistically significant. Conversely, the risk of platinum resistance at second relapse was greater for the IDS group (HR 4.06; p = 0.001). No difference in the ORR to
0.088
1
0.636
1.12 (0.70–1.80)
platinum re-exposure after the first relapse was observed for the IDS (80.4 %) versus PDS group (85 %; p = 0.30). Similarly, Petrillo et al. evaluated 175 stage IIIC and IV epithelial ovarian cancer patients and found a higher rate of platinum-resistant disease at first recurrence after IDS compared with PDS by univariate analysis (35.95 vs. 5.0 %; p = 0.002).11 They also reported a shorter secondary PFI by multivariate analysis (p = 0.006). In our study, the primary endpoint was ‘‘time to platinum-resistant relapse,’’ which is a time-to-event variable that differs from that used by Rauh-Hain et al. and Petrillo et al. The potential advantage of our endpoint is its ability to determine the global effects of PDS and IDS in platinum-resistant relapse, taking into account all recurrence events, whereas using the variable ‘‘rate of platinum-resistant relapse’’ at a defined time, such as first relapse, might be less accurate. No difference in platinum-resistant disease was seen for first relapse in our study or in Rauh-Hain et al. In Petrillo et al., there was a difference in platinum-resistant disease at first recurrence only in the univariate analysis. However, at second relapse, the rate of platinum-resistant disease was higher in Rauh-Hain et al. In our series, IDS was
A. A. B. A. da Costa et al. TABLE 3 Platinum-resistant disease at first recurrence (PFI \6 months) and ORR after platinum reexposure in platinum sensitive relapses according to each variable Characteristic
Platinum-resistant disease at first recurrence (n = 232 patients, 176 recurrences)
ORR to platinum reexposure (n = 72 patients with response evaluation)
Freq. (%)
p value*
Freq. (%)
p value*
PDS
50 (37.3)
0.978
41 (87.2)
0.051
IDS
30 (37.5)
Surgical moment 17 (68.0)
Age (years) B60 (median)
41 (35.0)
[60 (median)
39 (40.2)
0.437
35 (79.5)
0.786
23 (82.1)
Breast or ovarian cancer positive family history
–
No
56 (39.7)
Yes
20 (31.3)
0.245
36 (75.0)
0.050
20 (95.2)
Stage IIIC
61 (35.7)
IV
19 (44.2)
0.302
44 (78.6)
0.426
14 (87.5)
Histology High grade serous Others
58 (33.9) 18 (56.3)
0.017
45 (80.4) 10 (83.3)
0.812
\590 (median)
28 (34.6)
0.204
18 (69.2)
0.243
[590 (median)
38 (44.2)
Pretreatment CA125 (median/range) 20 (83.3)
Residual disease B10 mm
44 (29.9)
[10 mm
36 (54.5)
0.001
42 (79.2)
0.639
16 (84.2)
Total chemotherapy cycles B6
57 (39.6)
[6
22 (33.3)
0.385
37 (88.1)
0.031
18 (66.7)
Platinum-free interval 6–12 months
–
[12 months
–
20 (76.9)
0.224
31 (88.6)
PFI platinum-free interval, ORR overall response rate * All p values calculated with v2 test
independently associated with a shorter time to platinumresistant relapse, even after adjusting for other relevant prognostic factors. (HR 1.92; 1.18–3.13, 95 % CI; p = 0.009). With regard to the ORR to platinum re-exposure at first relapse, Rauh-Hain et al. found it to be better for PDS patients, albeit insignificantly.10 We also noted a difference in the ORR to platinum re-exposure in favor of PDStreated patients (68.0 vs. 87.2 %; p = 0.051). The two other factors that were related to ORR to platinum re-exposure were the number of first-line chemotherapy cycles and a family history of breast or ovarian cancer. These factors have a likely relationship with various tumor biology behaviors at recurrence. Patients who are exposed to more chemotherapy cycles are theoretically
more prone to developing drug resistance, whereas patients with a family history of breast or ovarian cancer might be BRCA1 or BRCA2 mutation carriers, which would explain the greater sensitivity to platinum compounds.9,15 Based on these findings, IDS might be a factor that alters tumor biology at recurrence, as well. Two randomized trials failed to show a negative impact of IDS on overall survival.4,5 Similarly, two large series reported no difference in OS between IDS and PDS.16,17 In contrast, a subgroup analysis from the EORTC trial, one meta-analysis and one recent large series demonstrated worse OS for patients who were treated with IDS.7,18,19 We observed no difference in PFS or OS in our study. Patients who are treated with IDS require fewer radical procedures have a shorter surgical and hospitalization time,
Interval Cytoreduction and Platinum Resistance
(b) 1.0
1.0
Overall Survival Probability
Progression Free Survival Probability
(a)
0.8 0.6 0.4 0.2 0.0
0.8 0.6 0.4 0.2 0.0
0
20
40
60
80
0
20
40
Time (months)
(c)
80
100
120
140
(d) 1.0
1.0
Overall Survival Probability
Progression Free Survival Probability
60
Time (months)
p = 0.071 0.8 0.6 0.4 0.2 PDS IDS
0.0 0
p = 0.088 0.8 0.6 0.4 0.2 PDS IDS 0.0
20
40
60
80
Time (months)
0
20
40
60
80
100
Time (months)
FIG. 2 Progression-free survival and overall survival for all patients (a, b) and according to surgical moment (c, d). All p values calculated by the log-rank test. PDS primary debulking surgery; IDS interval debulking surgery
have fewer surgical complications, and undergo optimal CRS more often compared with PDS-treated patients.20 In our study, there was no difference in mortality rates after surgery: 5.6 % for IDS and 2.7 % for PDS (p = 0.306). An RD B10 mm was achieved in 76.7 % of patients in the IDS group versus 62.3 % for PDS (p \ 0.001). The RD rate of B10 mm was lower than recent series that have shown rates of between 63 and 82 % for patients with stage IIIC and IV who undergo PDS.10,17,19,21 Nevertheless, such rates were higher than in the EORTC trial (80.6 % in the IDS arm and 41.6 % in the PDS arm).4 One reason for the lower rate of RD B10 mm in our study is that in other institutions, PDS was performed by surgeons who were not trained in gynecologic oncology. Notably, the low rate of RD B10 mm in the PDS group could bias the survival analysis toward a worse OS. Overall, our series is comparable in size with the most notable studies on this topic and contributes with valuable data. However, the chief limitation of this study is its retrospective nature. A selection bias for PDS or IDS might exist, even after controlling for confounding factors by
multivariable analysis. The present study should be considered as a hypothesis-generating study harder than a definitive conclusion. The decision regarding whether to undergo PDS or IDS might be simple for patients without clinical conditions for upfront surgery and for those with small-volume stage III disease, in which complete CRS can be safely achieved. For all other stage IIIC and IV disease patients, there is no standard method for identifying those who are at higher risk of RD [10 mm after CRS.22 Before selecting the timing of CRS for these patients, we should weigh the risk of not achieving a complete CRS and that of inducing platinum resistance with neoadjuvant chemotherapy. In conclusion, our study corroborates the hypothesis of a greater risk of developing platinum-resistant disease for patients who undergo IDS versus PDS. An exploratory analysis of endpoints that are related to platinum resistance from randomized trials should be performed to better define the impact of IDS on the development of platinum resistance.
A. A. B. A. da Costa et al. DISCLOSURE
None. 12.
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ORIGINAL ARTICLE – GYNECOLOGIC ONCOLOGY
Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery and the Risk of Platinum Resistance in Epithelial Ovarian Cancer Alexandre A. B. A. da Costa, MD1, Camila V. Valadares, MD1, Glauco Baiocchi, MD, PhD2, Henrique Mantoan, MD2, Augusto Saito, MD1, Solange Sanches, MD1, Andre´ia P. Guimara˜es, MD1, and Maria Isabel W. Achatz, MD, PhD3 Medical Oncology Department, A.C. Camargo Cancer Center, Sao Paulo, SP, Brazil; 2Gynecology Oncology Department, A.C. Camargo Cancer Center, Sao Paulo, SP, Brazil; 3Oncogenetics Department, A.C. Camargo Cancer Center, Sao Paulo, SP, Brazil
1
ABSTRACT Background. Interval debulking surgery (IDS) is an option for treating patients with advanced ovarian carcinoma. Two randomized trials have shown similar survival rates for primary debulking surgery (PDS) and IDS. One of the concerns with IDS is the potentially higher risk of inducing platinum resistance when treating patients with greater disease volume. Methods. A retrospective review of data on 237 patients with stage IIIC and IV ovarian carcinoma who were treated at a single institution from 2000 to 2013. We analyzed the association of IDS with time to first platinum resistant relapse (TTPR); platinum-resistant disease at first relapse, defined as a platinum-free interval (PFI) after first-line chemotherapy of \6 months; and overall response rate (ORR) to chemotherapy at first platinum-sensitive relapse. Results. The TTPR was 60 months, and the median TTPR was longer for the PDS (80.8 months) versus IDS group (39.3 months; p = 0.012) and for patients with residual disease (RD) B10 mm (80.8 months) compared with those with RD [10 mm (26.1 months; p \ 0.001). In the multivariate analysis, IDS [hazard ratio (HR) 1.92; p = 0.009] and RD [10 mm (HR 1.65; p \ 0.001) retained an
Electronic supplementary material The online version of this article (doi:10.1245/s10434-015-4623-z) contains supplementary material, which is available to authorized users. Ó Society of Surgical Oncology 2015 First Received: 24 March 2015 A. A. B. A. da Costa, MD [email protected]; [email protected]
increased risk of developing platinum-resistant disease. IDS was not associated with a greater risk of PFI \6 months at first relapse, and the ORR to platinum-based chemotherapy at first platinum-sensitive relapse was 87.2 % for patients who were treated with PDS compared with 68.0 % for those who underwent IDS (p = 0.051). Conclusions. IDS correlates with a higher risk of the development of platinum resistance.
Ovarian cancer is the 11th most frequent cancer among women in the United States, with 21,980 estimated cases developing in 2014. Moreover, ovarian cancer-related 14,270 deaths to are expected to have occurred in 2014, constituting the fifth leading cause of deaths from cancer in women.1 Nearly 70 % of cases have advanced disease (stage III or IV) at diagnosis, the cornerstone treatment of which is cytoreductive surgery (CRS), because residual disease (RD) after initial surgery is one of the most important prognostic factors for survival.2,3 Although the value of CRS is well established, the ideal time for primary treatment is unknown. At least two trials have compared primary debulking surgery (PDS) with interval debulking surgery (IDS) in patients with FIGO stage IIIC and IV ovarian cancer, neither of which reported a difference in survival with regard to the timing of CRS, reporting fewer surgical complications and more patients undergoing complete CRS in favor of IDS.4,5 Yet, IDS cannot be considered the standard of care for all patients with stage IIIC or IV disease.6 A subgroup analysis of the EORTC trial demonstrated worse survival for patients with stage IIIC disease and
A. A. B. A. da Costa et al.
largest metastatic tumor diameter \5 cm who were treated with IDS, suggesting a detrimental effect when administering neoadjuvant chemotherapy (NACT) to certain stage IIIC patients.7 One explanation is the theoretical risk of platinum resistance when chemotherapy is used to treat large-volume disease before surgery versus chemotherapy for small or microscopic RD after CRS. Platinum compounds acts primarily through the formation of covalent bonds in nuclear DNA, whereas other cytoplasmic mechanisms also might be involved. Similarly, drug resistance generally is multifactorial and might be related to changes in DNA repair machinery and to preand post-target alterations.8 The most widely accepted hypothesis of platinum resistance implicates the outgrowth of resistant clones, which are usually present at low rates before initial treatment.9 According to this hypothesis, the likelihood of platinum-resistant clones developing is greater in large tumor volumes that are treated with platinum compounds. Two retrospective trials have suggested that patients in whom IDS is performed have higher rates of platinum-resistant recurrence than those who undergo PDS.10,11 Our goal was to correlate the timing of CRS and the development of platinum-resistant relapse in advancedstage epithelial ovarian cancer (EOC) patients. METHODS We performed a retrospective review of the medical records of 237 patients with stage IIIC and IV EOC who were treated at AC Camargo Cancer Center from 2000 to 2013. We excluded patients with unavailable data regarding primary surgery and chemotherapy. At our institution, these patients underwent CRS that was performed by a surgeon with expertise in gynecologic oncology. For patients who did not have surgery at AC Camargo Cancer Center, we had no data regarding specialization of surgeons. The decision between PDS and IDS was made per the assistant’s discretion. Medical oncologists prescribed chemotherapy per international guidelines. The clinical data included age at diagnosis, tumor stage and histological subtype, type of surgery (PDS or IDS), volume of RD after surgery (B1 or [1 cm), CA125 levels before first treatment, type of chemotherapy (NACT or adjuvant chemotherapy), number of chemotherapy cycles before and after surgery, chemotherapy regimens, date of last platinum-based chemotherapy, date of recurrences after each treatment until last follow-up, and response to platinum retreatment after recurrence. Recurrence was defined per GCIG criteria after evaluating RECIST and CA125 progression in the medical charts, and the date of the earlier event was considered for
progression. CA125 progression by GCIG is considered if there is a doubling in CA 125 from the upper limit of normal and for those patients whose CA 125 never fell to the normal range, a doubling from the nadir is considered progression.12,13 Progression-free survival (PFS) was defined as the interval between the dates of diagnosis and disease progression. Platinum-free interval (PFI) was considered the interval between the date of the last platinum compound infusion and the date of disease progression. Platinum-resistant recurrence was defined as recurrence with a PFI of \6 months. Time to platinum-resistant disease (TTPR) was the interval between the date of diagnosis and the date of first recurrence with a PFI of \6 months. Data on the response to treatment of recurrent disease were retrieved from medical charts, and GCIG criteria were used to evaluate RECIST and CA125 responses. CA125 response by GCIG is defined as at least 50 % reduction in CA 125 levels from a pretreatment sample. Response was categorized as a ‘‘response’’ in the case of a complete response or partial response and ‘‘no response’’ if there was stable disease or disease progression.13 Overall survival (OS) was defined as the interval between the date of diagnosis and death by any cause. We correlated the time of CRS (PDS or IDS) with TTPR, platinum-resistant disease at first recurrence, and overall response rate (ORR) to chemotherapy after the first platinum-sensitive relapse. This study was approved by the ethics committee of our institution. Statistical Analysis The database was generated in SPSS, version 21.0. The association between categorical variables was analyzed by v2 or Fischer’s exact test. Survival curves were constructed by Kaplan–Meier life-table analysis. A multivariate analysis was performed by Cox regression. All variables with p value \0.20 in the univariate analysis were entered into the multivariate analysis.14 For all tests, an alpha error of up to 5 % (p \ 0.05) was considered significant. We excluded patients with a follow-up \6 months for the analysis of platinum-resistant disease at first recurrence. RESULTS Of the 237 patients, 147 (62.0 %) were treated with PDS and 90 patients (38.0 %) underwent IDS. The clinical and pathological characteristics are summarized in Table 1. Patients who were treated with PDS were younger, had higher pretreatment CA125 levels, were less likely to have an RD B10 mm, and received fewer cycles of chemotherapy in the first-line treatment. Seven of 237 patients
Interval Cytoreduction and Platinum Resistance TABLE 1 Clinical characteristics of the 237 patients Characteristic
PDS Freq. (%)
IDS Freq. (%)
Total patients
147
90
B60
88 (60.3)
40 (44.9)
[60
58 (39.7)
49 (55.1)
No
102 (70.3)
51 (63.8)
Yes
43 (29.7)
29 (36.3)
IIIC
123 (83.7)
68 (75.6)
IV
24 (16.3)
22 (24.4)
110 (80.9)
80 (90.9)
Endometrioid
4 (2.9)
1 (1.1)
Clear Cell
4 (2.9)
2 (2.3)
Mucinous
6 (4.4)
1 (1.1)
Low-grade serous
4 (2.9)
0 (0)
Mixture
8 (5.9)
4 (4.5)
\590 (median)
58 (56.3)
30 (39.5)
C590 (median)
45 (43.7)
46 (60.5)
B10 mm
91 (62.3)
69 (76.7)
[10 mm
55 (37.7)
21 (23.3)
B6
110 (82.1)
42 (49.4)
[6
24 (17.9)
43 (50.6)
Early death (\1 month after surgery) No
143 (97.3)
85 (94.4)
Yes
4 (2.7)
5 (5.6)
Age (years)
p value*
0.022
Breast or ovarian cancer positive family history
0.310
Stage
0.125
Histology High grade serous
0.296
Pre treatment CA125 (median/range)
0.026
Residual disease
0.022
\0.001
Total chemotherapy cycles
0.306
2
* All p values calculated using v test
were treated with chemotherapy regimens other than the standard platinum-taxane combination, all of whom were administered platinum-based chemotherapy. Time to Platinum-Resistant Recurrence After a median follow-up of 55.7 months, 94 patients experienced platinum-resistant recurrences, corresponding to 36.0 % (53/147) of patients after PDS and 45.6 % (41/ 90) of subjects after IDS. The estimated median TTPR was 60 months [43.1–76.9; 95 % confidence interval (CI)], and the median TTPR was longer for the PDS (80.8 months) versus IDS group (39.3 months; p = 0.012). The TTPR was 80.8 months for patients with RD B10 mm compared with 26.1 months for RD[10 mm (p \ 0.001; Fig. 1).
In the multivariate analysis (including surgical moment, age, stage, RD, and total chemotherapy cycles), IDS and RD [10 mm were the only variables that retained the increased risk of developing platinum-resistant disease. Patients who were treated with IDS had a 1.92-fold greater risk of developing platinum-resistant disease compared with the PDS group, and RD [10 mm was associated with a 1.65-fold higher risk versus RD B10 mm (Table 2). Platinum-Resistant Disease at First Relapse and Response to Platinum Re-exposure One hundred seventy-six (74.3 %) patients had a recurrence. First recurrence was detected within 6 months since the last platinum chemotherapy treatment in 29.5 % of all patients, between 6 and 12 months in 18.1 %, and
A. A. B. A. da Costa et al.
(a) 1.0
(b) 1.0
0.8
0.8
0.6
0.6
TTPR
TTPR
p = 0.012
0.4
0.4
0.2
0.2
0.0
0.0 0
20
40
60
80
100
120
PDS IDS 0
140
20
40
60
80
(c)
120
140
(d) 1.0
1.0 p < 0.001
p = 0.175
0.8
0.8
0.6
0.6
TTPR
TTPR
100
Time (months)
Time (months)
0.4 0.2
0.4 0.2
RD ≤ 10 mm RD > 10 mm
0.0 0
20
40
Stage III Stage IV
0.0 60
80
100
120
140
0
20
Time (months)
40
60
80
100
120
140
Time (months)
FIG. 1 Time to platinum-resistant recurrence in (a) all patients and according to (b) surgical moment, c residual disease, and d stage. All p values calculated by the log-rank test. TTPR time to platinum-
resistant recurrence, PDS primary debulking surgery, IDS interval debulking surgery, RD residual disease
more than 12 months in 22.7 %. RD [10 mm (p = 0.001) and histology other than high-grade serous carcinoma (p = 0.017) correlated with an increased risk of platinumresistant recurrence at first relapse, defined as a PFI \6 months (Table 3). Ninety-seven patients recurred after 6 months since the last platinum chemotherapy (‘‘platinum-sensitive’’); 5 of whom were not treated with platinum compounds and 20 of whom did not have data on their response to platinum reexposure. For the 72 patients with available data on the response to platinum re-exposure, the ORR was 80.6 %. Patients who were initially treated with PDS had an ORR to platinum re-exposure of 87.2 versus 68.0 % for those who underwent IDS (p = 0.051). Patients who were administered more than 6 cycles of chemotherapy at first-line treatment had an ORR of 66.7 % compared with 88.1 % after B6 first-line cycles (p = 0.031). Patients with a family history of ovarian or breast cancer had and ORR of 95.2 versus 75.0 % for those with no family history (p = 0.050). No other factor impacted the ORR to platinum re-exposure. Patients with a PFI [12 months had an
ORR of 88.6 % compared with 76.9 % with a PFI between 6 and 12 months (p = 0.224; Table 3). Progression-Free Survival and Overall Survival The median overall PFS and OS rates were 18.6 months (16.6–20.5 months; 95 % CI) and 48.4 months (40.1– 56.6 months; 95 % CI), respectively. The time of surgery did not impact the PFS or OS; the median PFS after PDS and IDS was 20.0 and 17.6 months, respectively (p = 0.071), and the median OS was 56.1 and 41.4 months (p = 0.088; Fig. 2). In the multivariate analysis for OS, RD [10 mm [hazard ratio (HR) 1.45; 1.19–1.79, 95 % CI; p \ 0.001] and older age (HR 1.03; 1.01–1.05, 95 % CI; p = 0.011) were the only variables that retained a higher risk of death (Table 1, Supplementary Appendix). DISCUSSION The ideal timing of CRS in ovarian cancer remains unknown. Despite the results of two phase III trials that
Interval Cytoreduction and Platinum Resistance TABLE 2 Univariate and multivariate analysis for time to platinum resistant recurrence Characteristic
Multivariate analysisa
Univariate analysis HR (95 % CI)
p value
HR (95 % CI)
p value
PDS
1
0.012
1
0.009
IDS
1.70 (1.12–2.57)
Ageb
1.01 (0.99–1.03)
Surgical moment 1.92 (1.18–3.13) 0.177
1.00 (0.98–1.02)
Breast or ovarian cancer positive family history No
1
Yes Stage
0.839 –
0.296
1.27 (0.82–1.98)
IIIC
1
IV
1.40 (0.86–2.31)
– –
0.178
1
0.836
0.84 (0.49–1.41)
Histology
–
High-grade serous
1
Others
0.407
0.78 (0.43–1.41) b
Pre treatment CA125 (median/range)
– –
1.0 (1.0–1.0)
0.266
–
–
B10 mm
1
\0.001
1
\0.001
[10 mm
1.62 (1.31–1.99)
Residual disease 1.65 (1.33–2.06)
Total chemotherapy cycles B6
1
[6
1.46 (0.95–2.24)
a
Ninety-one events in 212 patients included in the analysis
b
Analyzed as continuous variables
compared PDS and IDS in which there was no impact on survival, limited data exist regarding the association between the timing of surgery and platinum-resistant relapse.4,5 Our series suggests that patients who are treated with IDS have a shorter time to platinum-resistant recurrence than those who undergo PDS (39.3 vs. 80.8 months; p = 0.012). Furthermore, the ORR to platinum re-exposure for recurrent disease was worse for patients who were treated with IDS versus PDS, albeit insignificantly (68.0 vs. 87.02 %; p = 0.051). Thus, our findings suggest that patients who undergo IDS have a higher likelihood of developing platinum-resistant disease compared with those who are treated with PDS. Rauh-Hain et al. analyzed 425 patients with stage IIIC and IV epithelial ovarian cancer who underwent PDS or IDS.10 They compared the platinum-resistant disease rate at first relapse between the groups, which was higher for IDS-treated subjects (44.2 vs. 31.2 %). However, after adjusting for other prognostic factors, the difference was not statistically significant. Conversely, the risk of platinum resistance at second relapse was greater for the IDS group (HR 4.06; p = 0.001). No difference in the ORR to
0.088
1
0.636
1.12 (0.70–1.80)
platinum re-exposure after the first relapse was observed for the IDS (80.4 %) versus PDS group (85 %; p = 0.30). Similarly, Petrillo et al. evaluated 175 stage IIIC and IV epithelial ovarian cancer patients and found a higher rate of platinum-resistant disease at first recurrence after IDS compared with PDS by univariate analysis (35.95 vs. 5.0 %; p = 0.002).11 They also reported a shorter secondary PFI by multivariate analysis (p = 0.006). In our study, the primary endpoint was ‘‘time to platinum-resistant relapse,’’ which is a time-to-event variable that differs from that used by Rauh-Hain et al. and Petrillo et al. The potential advantage of our endpoint is its ability to determine the global effects of PDS and IDS in platinum-resistant relapse, taking into account all recurrence events, whereas using the variable ‘‘rate of platinum-resistant relapse’’ at a defined time, such as first relapse, might be less accurate. No difference in platinum-resistant disease was seen for first relapse in our study or in Rauh-Hain et al. In Petrillo et al., there was a difference in platinum-resistant disease at first recurrence only in the univariate analysis. However, at second relapse, the rate of platinum-resistant disease was higher in Rauh-Hain et al. In our series, IDS was
A. A. B. A. da Costa et al. TABLE 3 Platinum-resistant disease at first recurrence (PFI \6 months) and ORR after platinum reexposure in platinum sensitive relapses according to each variable Characteristic
Platinum-resistant disease at first recurrence (n = 232 patients, 176 recurrences)
ORR to platinum reexposure (n = 72 patients with response evaluation)
Freq. (%)
p value*
Freq. (%)
p value*
PDS
50 (37.3)
0.978
41 (87.2)
0.051
IDS
30 (37.5)
Surgical moment 17 (68.0)
Age (years) B60 (median)
41 (35.0)
[60 (median)
39 (40.2)
0.437
35 (79.5)
0.786
23 (82.1)
Breast or ovarian cancer positive family history
–
No
56 (39.7)
Yes
20 (31.3)
0.245
36 (75.0)
0.050
20 (95.2)
Stage IIIC
61 (35.7)
IV
19 (44.2)
0.302
44 (78.6)
0.426
14 (87.5)
Histology High grade serous Others
58 (33.9) 18 (56.3)
0.017
45 (80.4) 10 (83.3)
0.812
\590 (median)
28 (34.6)
0.204
18 (69.2)
0.243
[590 (median)
38 (44.2)
Pretreatment CA125 (median/range) 20 (83.3)
Residual disease B10 mm
44 (29.9)
[10 mm
36 (54.5)
0.001
42 (79.2)
0.639
16 (84.2)
Total chemotherapy cycles B6
57 (39.6)
[6
22 (33.3)
0.385
37 (88.1)
0.031
18 (66.7)
Platinum-free interval 6–12 months
–
[12 months
–
20 (76.9)
0.224
31 (88.6)
PFI platinum-free interval, ORR overall response rate * All p values calculated with v2 test
independently associated with a shorter time to platinumresistant relapse, even after adjusting for other relevant prognostic factors. (HR 1.92; 1.18–3.13, 95 % CI; p = 0.009). With regard to the ORR to platinum re-exposure at first relapse, Rauh-Hain et al. found it to be better for PDS patients, albeit insignificantly.10 We also noted a difference in the ORR to platinum re-exposure in favor of PDStreated patients (68.0 vs. 87.2 %; p = 0.051). The two other factors that were related to ORR to platinum re-exposure were the number of first-line chemotherapy cycles and a family history of breast or ovarian cancer. These factors have a likely relationship with various tumor biology behaviors at recurrence. Patients who are exposed to more chemotherapy cycles are theoretically
more prone to developing drug resistance, whereas patients with a family history of breast or ovarian cancer might be BRCA1 or BRCA2 mutation carriers, which would explain the greater sensitivity to platinum compounds.9,15 Based on these findings, IDS might be a factor that alters tumor biology at recurrence, as well. Two randomized trials failed to show a negative impact of IDS on overall survival.4,5 Similarly, two large series reported no difference in OS between IDS and PDS.16,17 In contrast, a subgroup analysis from the EORTC trial, one meta-analysis and one recent large series demonstrated worse OS for patients who were treated with IDS.7,18,19 We observed no difference in PFS or OS in our study. Patients who are treated with IDS require fewer radical procedures have a shorter surgical and hospitalization time,
Interval Cytoreduction and Platinum Resistance
(b) 1.0
1.0
Overall Survival Probability
Progression Free Survival Probability
(a)
0.8 0.6 0.4 0.2 0.0
0.8 0.6 0.4 0.2 0.0
0
20
40
60
80
0
20
40
Time (months)
(c)
80
100
120
140
(d) 1.0
1.0
Overall Survival Probability
Progression Free Survival Probability
60
Time (months)
p = 0.071 0.8 0.6 0.4 0.2 PDS IDS
0.0 0
p = 0.088 0.8 0.6 0.4 0.2 PDS IDS 0.0
20
40
60
80
Time (months)
0
20
40
60
80
100
Time (months)
FIG. 2 Progression-free survival and overall survival for all patients (a, b) and according to surgical moment (c, d). All p values calculated by the log-rank test. PDS primary debulking surgery; IDS interval debulking surgery
have fewer surgical complications, and undergo optimal CRS more often compared with PDS-treated patients.20 In our study, there was no difference in mortality rates after surgery: 5.6 % for IDS and 2.7 % for PDS (p = 0.306). An RD B10 mm was achieved in 76.7 % of patients in the IDS group versus 62.3 % for PDS (p \ 0.001). The RD rate of B10 mm was lower than recent series that have shown rates of between 63 and 82 % for patients with stage IIIC and IV who undergo PDS.10,17,19,21 Nevertheless, such rates were higher than in the EORTC trial (80.6 % in the IDS arm and 41.6 % in the PDS arm).4 One reason for the lower rate of RD B10 mm in our study is that in other institutions, PDS was performed by surgeons who were not trained in gynecologic oncology. Notably, the low rate of RD B10 mm in the PDS group could bias the survival analysis toward a worse OS. Overall, our series is comparable in size with the most notable studies on this topic and contributes with valuable data. However, the chief limitation of this study is its retrospective nature. A selection bias for PDS or IDS might exist, even after controlling for confounding factors by
multivariable analysis. The present study should be considered as a hypothesis-generating study harder than a definitive conclusion. The decision regarding whether to undergo PDS or IDS might be simple for patients without clinical conditions for upfront surgery and for those with small-volume stage III disease, in which complete CRS can be safely achieved. For all other stage IIIC and IV disease patients, there is no standard method for identifying those who are at higher risk of RD [10 mm after CRS.22 Before selecting the timing of CRS for these patients, we should weigh the risk of not achieving a complete CRS and that of inducing platinum resistance with neoadjuvant chemotherapy. In conclusion, our study corroborates the hypothesis of a greater risk of developing platinum-resistant disease for patients who undergo IDS versus PDS. An exploratory analysis of endpoints that are related to platinum resistance from randomized trials should be performed to better define the impact of IDS on the development of platinum resistance.
A. A. B. A. da Costa et al. DISCLOSURE
None. 12.
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