Survivin expression as a prognostic factor in patients with epithelial ovarian cancer or primary peritoneal cancer treated with neoadjuvant chemotherapy.

ORIGINAL STUDY

Survivin Expression as a Prognostic Factor in Patients With Epithelial Ovarian Cancer or Primary Peritoneal Cancer Treated With Neoadjuvant Chemotherapy Agnieszka Ga˛sowska-Bodnar, PhD, MD,* Lubomir Bodnar, PhD, MD,Þ Andrzej Da˛bek, MD,þ Marzena Cichowicz, MSc,þ Malgorzata Jerzak, PhD, MD,* Szczepan Cierniak, MD,þ Wojciech Kozlowski, PhD, MD,þ and Wlodzimierz Baranowski, PhD, MD* =

=

Background: The aim of this study was to evaluate association of expression of survivin and p53 with the effects of neoadjuvant chemotherapy (NAC) in patients with advanced ovarian cancer (AOC). Methods: We retrospectively evaluated 60 consecutive patients with AOC (International Federation of Gynecology and Obstetrics stage IIIC-IV) treated with NAC. The expression of p53 and survivin was assessed immunohistochemically. The median of expression total score survivin equals 2 was adopted to dichotomize the group. The positive and negative expression of p53 was used to dichotomize the group. Results: The expression of survivin in tumor tissue taken before and after NAC was a significant difference in the percentage of stained nuclei (P = 0.0002), the intensity of staining (P = 0.0003), and total score (P = 0.0001). There was a significant difference in p53 expression in tumor tissue before and after NAC in the percentage of stained nuclei (P = 0.0424). Survivin expression, in contrast to p53 expression, was a prognostic factor in patients with AOC treated with NAC (P = 0.0484). The expression of survivin and p53 was not a predictive factor. Independent adverse predictor factors were as follows: lack of optimal interval debulking surgery and the lack of an objective response (the respective hazard ratio was 3.93 [95% confidence interval, 2.07Y7.46; P G 0.0001] and 2.36 [95% confidence interval,1.25Y4.47; P = 0.0080]). The suboptimal range of interval debulking surgery, resistance to platinum, and the lack of paclitaxel in the NAC were adverse prognostic factors (the respective hazard ratio was 2.61 [95% confidence interval, 1.17Y5.83], 2.72 [95% confidence interval, 1.07Y6.89], and 2.56 [95% confidence interval, 1.06Y6.18]; P G 0.05]). Conclusions: High expression of survivin could be a prognostic factor in patients treated with NAC for AOC. Key Words: Ovarian cancer, Survivin, p53, Neoadjuvant chemotherapy, Interval debulking surgery Received November 17, 2013, and in revised form January 14, 2014. Accepted for publication January 14, 2014. (Int J Gynecol Cancer 2014;24: 687Y696)

Departments of *Gynecology and Gynecologic Oncology, †Oncology, and ‡Pathology, Military Institute of Medicine, Warsaw, Poland. Address correspondence and reprint requests to Lubomir Bodnar, PhD, MD, Department of Oncology, Military Institute of Medicine, 04-141 Warsaw, 128 Szaserow Str, Poland. E-mail: [email protected]. The authors declare no conflicts of interest. Copyright * 2014 by IGCS and ESGO ISSN: 1048-891X DOI: 10.1097/IGC.0000000000000108 International Journal of Gynecological Cancer

cancer is a serious diagnostic, therapeutic, and O varian social problem. It is the most common cause of death

in women with gynecologic cancer and accounts for 30% of malignant tumors derived from female sexual organs. According to GLOBOCAN, ovarian cancer is at the sixth place in terms of morbidity and is the seventh highest cause of death in women. The incidence ranges from 9 to 17 per 100,000 and is the highest in industrialized countries, with the exception

& Volume 24, Number 4, May 2014

Copyright © 2014 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.

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Ga˛sowska-Bodnar et al

International Journal of Gynecological Cancer

of Japan, and the lowest in developing countries. Worldwide, there is a growing trend in the incidence of the disease.1 The current standard treatment for advanced ovarian cancer (AOC) is primary debulking surgery followed by postsurgical chemotherapy. Interval debulking surgery (IDS) has been proposed as an alternative approach to primary debulking, to improve the quality of life by performing a less aggressive surgical procedure in patients with AOC. Factors used to predict surgical resectability might include clinical characteristics of the patients, the extent and size of the tumor in diagnostic imaging, serum levels of biomarkers, or the results of direct visual examination by laparoscopy. The higher patient’s age, worse general condition, and increased complexity of the operation are associated with a high risk of perioperative complications. Another factor contributing to the results of treatment of ovarian cancer is the surgical skill of the operator, especially in the upper abdomen. According to the data European Organisation for Research and Treatment of Cancer (EORTC), approximately 60% (ranges from 40% to 80%) of patients with AOC may achieve an optimal range of debulking surgery.2 The main problem encountered in selecting patients with AOC for neoadjuvant chemotherapy (NAC) is defining the patient selection criteria to determine those who could potentially benefit from IDS. Survivin is a protein family of inhibitors of apoptosis (inhibitor of apoptosis protein [IAP]), with 7 other proteins: XIAP, cIAP1, cIAP2, NAIP, livin, Ts-IAP, and apollon. It is encoded by a gene located on chromosome 17 (17q25).3 This protein, first described in 1997 by Ambrosini et al,4 is composed of 142 amino acids and has a molecular weight of 16.5 kd. In contrast to other IAPs, it contains 1 baculovirus IAP repeat domain in the amino terminus and does not have the zinc finger motif at the carboxyl terminus. There are 5 different transcript isoforms of the human gene encoding survivin: survivin, survivin 2A, survivin 2B, survivin DEx3, and survivin 3B. There are different cellular localizations for this protein: cytoplasmic, nuclear, and mitochondrial. The cytoplasm has an antiapoptotic function by inhibiting caspase, whereas nuclear survivin promotes cell proliferation.5 The aim of our study was to evaluate the changes in expression of survivin and p53 as a potential predictive and prognostic factor in patients with epithelial ovarian cancer or primary peritoneal carcinoma who were eligible for IDS.

MATERIALS AND METHODS Patients Based on the database of the Military Institute of Medicine in Warsaw, Poland, we found 66 patients diagnosed with ovarian cancer in International Federation of Gynecology and Obstetrics (FIGO) stage IIIC/IV, which have undergone NAC with platinum analogs between April 2003 and November 2010. The exploratory surgery in 6 patients was performed outside our institute, and there was no access to the tissues of primary tumor. Finally, we retrospectively analyzed 60 consecutive patients treated at the Department of Gynecology and Gynecologic Oncology and Department of Oncology at the Military Institute of Medicine who met the following criteria: (1) histologically confirmed ovarian carcinoma or primary peritoneal serous carcinoma; (2) AOC or primary peritoneal serous carcinoma in FIGO stage IIIC

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or IV; (3) the patients received NAC containing platinum analogs; (4) access to the tissues of the primary tumor and/or peritoneal taken during exploratory and interval surgery and access to full medical records. This study was approved by the institutional review board of the Military Institute of Medicine in Warsaw (154/WIM/2008). In the study, exploratory laparotomy or laparoscopy was defined as an initial surgery, with the collection of specimen for histopathologic examination (diagnostic excision of both ovaries was allowed). Interval debulking surgery was performed 3 to 6 weeks after administering the third (the last cycle) of NAC unless there was a disease progression occurring during the chemotherapy. The disease was defined as unresectable when our team of surgeons, comprising at least 2 experienced gynecologists, stated that the optimal debulking (tumor of G1 cm) was impossible to achieve in a standard procedure. Neoadjuvant chemotherapy was defined as the initial treatment before the IDS. It consisted of paclitaxel and platinum analog, and in 10 cases, liposomal doxorubicin was also added. The IDS was performed 3 to 6 weeks after administration of the last cycle of NAC unless disease progression occurred during NAC. Standard procedures of IDS consisted of a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, systematic pelvic and/or aortic lymphadenectomies, and the maximal debulking of metastatic tumors. After IDS, all patients received 3 cycles of adjuvant chemotherapy consisted of paclitaxel and platinum analog. Then, patients were followed up every 3 monthly by clinical and radiological examination and cancer antigen 125 (CA-125) levels to detect local or systemic failure. The surgery was defined as optimal when the tumors remaining in the abdominal cavity did not exceed 1 cm in diameter; the outcome of surgery was defined as suboptimal if the dimensions of residual tumor exceeded 1 cm. Responses to chemotherapy were determined for patients according to Response Evaluation Criteria In Solid Tumors (RECIST) criteria (version 1.0).6 To assess the impact of the concentration of the marker CA-125, regression coefficient (RYCA-125) was used, which was calculated for patients with an initially higher value, more than twice the upper limit of normal (70 U/mL), as follows: log10 (CA-125 levels measured before chemotherapy/after 2 cycles of NAC). The median RYCA-125 value of 0.7484 was used for dichotomization of the group.

Histology Primary tumor tissue specimens of ovarian cancer prepared for routine pathological analysis were examined in the study. Serial 4-Hm-thick sections of a paraffin block corresponding to 1 representative area of the tumor were stained with hematoxylin-eosin. Subsequently, tissue samples from at least 3 serial sections were macrodissected to ensure that specimens contained at least 80% tumor cells. Slides were reviewed by 2 independent pathologists to confirm the diagnosis and evaluate survivin and p53 status. Pathologists were blinded to each other and had no prior knowledge to clinicopathologic data. In case of discrepancies between investigators, the definitive diagnosis was achieved by consensus. Tissues were incubated with mouse monoclonal antisurvivin antibody (dilution 1:100, clone 12C4; DAKO) and mouse monoclonal anti-p53 antibody (dilution 1:100, clone DO-7; DAKO). * 2014 IGCS and ESGO




Immunohistochemistry Formalin-fixed, paraffin-embedded primary tumors were immunohistochemically stained for expression of p53 and survivin in patients given platinum-based NAC undergoing primary exploratory surgery and IDS. Then, we assessed the correlation between these proteins and the histological and clinical parameters and also examined the predictive and prognostic value of these proteins. The expression of survivin and p53 was adopted from the Allred scoring system,7 which was used for assessing the expression of steroid hormone receptors in breast cancer. Immunohistochemical interpretation of PS (proportion score) and IS (intensity score) on histopathologic material was performed. The percentage ratio of positive p53 and survivin-stained tumor cells to the total number of cells determined as PS was classified as follows: PS0: 0%, PS1: 90% to 1%, PS2: Q1% to 10%, PS3: 910% to 33%, PS4: 933% to 66%, and PS5: 966% to 100%. Staining intensity was assessed visually and was scored as 0 (negative), 1+ (weak), 2+ (moderate), or 3+ (strong). Total score (TS) was calculated from the sum of PS and IS ranging from 0 to 8. The median expression of survivin was adopted for dichotomization of the study group. Low expression of survivin was defined as TS of 2 or less, whereas a high TS was TS greater than 2. The positive and lack of expression of p53 were used for dichotomization of the study group. Tissues were not evaluated for a second time to determine the expression of survivin and p53 in 7 patients, because 5 patients had not received IDS, and 2 patients achieved a complete pathological response.

Statistical Analysis Progression-free survival (PFS) was defined as the time elapsed between the date of start of NAC and the date of disease progression or the date of last follow-up. Overall survival (OS) was defined as the time elapsed between the date of start of NAC and the date of death or the date of last follow-up. The cutoff date for our analysis was established in April 2010. To compare results that did not meet the criteria of a normal distribution, a nonparametric Mann-Whitney test (U test) was used. Median and life tables were computed using the product-limit estimate by the Kaplan-Meier method, and the log-rank test was used to assess statistical significance; P G 0.05 was considered to indicate statistical significance. Multivariate analyses of PFS and OS were performed by Cox proportional hazards regression using the forward stepwise method; all variables found to be significant in the univariate analysis were included in the multivariate analysis. We performed the analysis using the statistical package STATISTICA-PL (version 7.0, STAT-SOFT; Statistica, Tulsa, OK).

RESULTS Patient Characteristics Clinicopathologic data of the 60 AOC patients are reported in Table 1. The median patient age was 60 years (range, 39Y80 years). Most patients presented a good performance status (Eastern Cooperative Oncology Group scale of performance status [ECOG] 0%Y8% [5/60], ECOG 1%Y70% [42/60]). The most common cancer histological type was serous (71%); the next most common types were endometrial (10%) and mucinous

Survivin and Epithelial Ovarian Cancer

(7%). At diagnosis, most of the patients were in FIGO IIIC stage (83%), and the rest were in FIGO IV (17%). The majority of patients (72%) underwent 3 courses of NAC before IDS; others (28%) required more cycles of preoperative therapy.

Assessment of IDS Table 2 shows data on the extent and the most important parameters relating to IDS in 55 patients. Five patients were excluded because IDS had not been performed because of disease progression. Optimal debulking was achieved in 69% (38/55) of patients. The remaining 31% (17/55) of patients achieved suboptimal range of IDS. The median operative time was 135 minutes (range, 48Y275 minutes). Average blood loss was 877 mL (95% confidence interval [CI], 617Y1136 mL), which usually required transfusion of 2 U of packed red cells. The median duration of hospital stay after IDS was 6 days (range, 4Y35 days). The most common complication of surgery was bleeding, which occurred in 5 patients (9%). In these patients, re-laparotomy was performed. To achieve optimal cytoreduction, it was necessary to perform resection of the abdominal organs such as the colon in 14% of patients, partial resection of the bladder in 8% of patients, and partial resection of the spleen in 4% patients. There were no deaths within 30 days following IDS.

Survivin Expression Positive nuclear survivin expression before NAC was observed in 58% of patients. In this group, 1 patient (2%) had very high expression of this protein (TS: 8 points). In 42% of patients, we observed negative expression of survivin in ovarian cancer cells (TS: 0 points). We observed significant decrease in nuclear survivin expression in ovarian cancer cells in the tumor tissues taken after NAC compared with that collected before NAC. In 79% of patients, we found negative expression of this protein. The other patients (21%) showed positive expression of survivin in tumor cells (TS: 2Y3 points). The expression of survivin in ovarian cancer cells in tissues collected before and after NAC was highly significantly different in PS (P = 0.0002), IS (P = 0.0003), and TS (P = 0.0001). The data are presented in Table 3.

p53 Expression In the tumor tissues taken during exploratory surgery, positive expression of p53 was found in 60% of patients. In the remaining 40% of patients, we observed no expression of this protein. In 43% of patients, we did not find expression of p53 protein after NAC in ovarian cancer cells in tissues collected during IDS. In the remaining 57% of patients, we found a positive result for the presence of this protein in ovarian cancer cells, in 25% of which high expression of p53 was observed (TS: 8 points). The expression of p53 in ovarian cancer cells in the tumor tissues taken before and after NAC was significantly different in PS (P = 0.0424). However, we did not observe significant differences in IS or TS (Table 3).

Association Between Survivin Expression and Clinicopathologic Parameters We only observed a trend in the age of diagnosis of ovarian cancer in patients with high expression of survivin in

* 2014 IGCS and ESGO


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TABLE 1. Patient characteristics (n = 60) and parameters of IDS (n = 55) Parameter

n

Age, median (range), y Performance status (ECOG) 0 1 2 NAC Paclitaxel/cisplatin Paclitaxel/carboplatin Paclitaxel/carboplatin/PLD Carboplatin No. cycles of NAC 3 4 5 6 FIGO stage IIIC IV Histology Serous Endometrial Mucinous Clear cell Undifferentiated Mixed Unclassified Histological differentiation Well Moderately Poorly CA-125 before NAC, mean (95% CI) CA-125 after 2nd cycle of NAC, mean (95% CI) Optimal debulking (e1 cm) (n = 55) Suboptimal debulking (91 cm) (n = 55) Operation time, median (range), min Intraoperative blood loss, mean (95% CI), dL No. transfused units of packed red blood cells, median (range) Hospitalization days, median (range) Bowel obstruction (n = 55) Hemorrhage (n = 55) Re-laparotomy (n = 55) Organ resection necessary to achieve optimal cytoreduction (n = 55) Spleen Bowel Bladder (partial resection) Pancreas Gastric (partial resection)

% 60 (39Y80)

5 42 13

8% 70% 22%

5 37 10 8

8% 62% 17% 13%

42 3 2 12

72% 5% 3% 20%

50 10

83% 17%

43 6 4 1 1 2 3

72% 10% 7% 2% 2% 3% 5%

0 0% 42 70% 18 30% 3247.36 (1257.48Y5237.23) 929.98 (188.71Y2048.68) 38 69% 17 31% 135 (48Y275) 87 (61.7Y113.6) 2 (0Y11) 6 (4Y35) 2 4% 5 9% 5 9% 2 8 4 1 1

4% 15% 7% 2% 2%

PLD, Pegylated liposomal doxorubicin.

690






TABLE 2. Comparison of survivin and p53 expression before and after NAC in ovarian cancer cells in tissues collected during the primary and IDS Survivin Before NAC

After NAC

PS

n

%

n

%

P

0 1 2 3 4 5

25 27 7 0 0 1

42 45 12 0 0 2

42 10 1 0 0 0

79 19 2 0

0.0002*

After NAC

IS

n

%

n

%

P

TS

0 1 2 3

25 19 15 1

42 32 25 2

42 9 2 0

79 17 4 0

0.0003*

0 2 3 4 5 6 7 8

0

Before NAC

After NAC

PS

n

%

n

%

P

0 1 2 3 4 5

24 1 3 7 25 24

40 2 5 12 42 40

26 1 5 5 16 26

43 2 8 8 27 43

0.1698

P 53

Before NAC

Before NAC

After NAC

n

n

%

%

25 42 18 30 10 17 6 10 0 0 0 0 0 0 1 2 Before NAC

42 79 8 15 3 6 0 0 0 0 0 0 0 0 0 0 After NAC

P 0.0001*

Before NAC

After NAC

IS

n

%

n

%

P

TS

n

%

n

%

P

0 1 2 3

24 3 7 26

40 5 12 43

26 2 4 21

43 3 7 35

0.0424*

0 2 3 4 5 6 7 8

25 18 1 2 1 2 9 21

42 30 2 3 2 3 15 35

26 1 1 1 5 4 15 26

43 2 2 2 8 7 25 43

0.0865

*Thee value of the probability of a statistically significant (P G 0.05).

comparison with patients with low expression of survivin (the median ages were 56 and 61 years, respectively; P = 0.0529). Other variables showed no significant difference between patients with high and low expression of survivin, such as performance status, FIGO stage, the use of paclitaxel in NAC, the number of cycles of NAC, histological subtype, tumor grade, the response by RECIST criteria, the regression of marker CA-125, the expression of p53, platinum sensitivity, and the extent of IDS. The comparison of selected clinicopathologic parameters in patients according to the expression of survivin is shown in Table 4.

Association Between Survivin Expression and PFS In the univariate analysis, we found that the following clinical parameters correlated with PFS: RECIST response (P = 0.0027), regression coefficient RYCA-125 (P = 0.0313), and residual tumor size after debulking surgery (P G 0.0001). Age, the use of paclitaxel in NAC, the number of cycles of NAC, performance status, FIGO stage, histological subtype, grade G, the expression of survivin and its changes after NAC, and the expression of p53 before NAC were not correlated with PFS. Multivariate analysis showed that among the factors correlated with PFS in the univariate analysis, residual tumor

size and RECIST response were independently associated with PFS (hazard ratio [HR], 3.93 [95% CI, 2.07Y7.46; P G 0.0001] and HR, 2.36 [95% CI, 1.25Y4.47; P = 0.0080], respectively). The results are presented in Table 4.

Association Between Survivin Expression and OS The clinical parameters that correlated with OS identified in the univariate analysis are presented in Table 5. Statistical significance was found for the following factors: survivin expression status (Fig. 1), residual tumor size, the use of paclitaxel in NAC, RECIST response, regression of marker CA-125 status, and platinum sensitivity. Age, p53 expression, histology, tumor grade, number of cycles of NAC, change in survivin expression after NAC, and performance status were not correlated with OS. In the multivariate analysis, the lack of optimal IDS, resistance to platinum analogs, and the lack of paclitaxel in NAC (HR, 2.61 [95% CI, 1.17Y5.83; P = 0.0188], 2.72 [95% CI, 1.07Y6.89; P = 0.0353], and 2.56 [95% CI, 1.06Y6.18; P = 0.0358], respectively) were independent adverse prognostic factors (Table 5).

DISCUSSION Advanced ovarian cancer, despite the progress in surgical techniques and the implementation of new treatment



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TABLE 3. Association between survivin expression and clinicopathologic parameters in patients with AOC treated by NAC (n = 60) High Expression of Survivin (TS 92) Low Expression of Survivin (TS e2) Parameter

n = 17

n = 43

56 (39Y70)

61 (40Y80)

14 3

33 10

15 2

35 8

13 4

30 13

9 8

30 13

13 4

30 13

16 1

36 7

11 6

26 17

6 9

21 18

7 10

27 16

4 13

14 29

7 10

17 26

P

Age, median (range), y Performance status (ECOG) e1 2 FIGO stage IIIC IV Histology Serous Other Histologic differentiation Moderately (G2) Poorly (G3) No. cycles of NAC 3 93 Paclitaxel in NAC Yes No Extent of IDS Optimal (G1 cm) Suboptimal (91 cm) or not done RYCA-125 (n = 54) Low High Platinum response Sensitive (96 months) Refractory (e6 months) Response by RECIST criteria PD, SD PR, CR p53 expression before NAC p53 (j) p53 (+)

0.0529* 0.8986†

0.7978†

0.8404†

0.2221‡

0.8404†

0.5182†

0.1101‡

0.3665‡

0.1311‡

0.7076†

0.9077‡

*Mann-Whitney U test. †W2; Yates corrected test. ‡V2 test. CR, Complete response; PD, progressive disease; PR, partial response; SD, stable disease.

strategies, remains a disease with poor prognosis and high mortality ratio. This is a result of the late appearance of symptoms and the diagnosis of disease in the majority of patients in the advanced stages. The range of residual disease after primary debulking surgery is one of the most important prognostic factors in patients with ovarian cancer. The use of NAC and IDS until the reduction of cancer lesions has become a method to increase the percentage of optimally

692

operated patients. This approach reduces both the range of the surgery and the number of postoperative complications and improves the quality of life of treated patients.8 In our study, we achieved optimal debulking surgery in 69% of patients, leaving residual lesions with a diameter of less than 1 cm in patients with initially unresectable disease. This result is consistent with the meta-analysis described by Bristow and Chi,9 in which 65% of the patients were operated * 2014 IGCS and ESGO





TABLE 4. Effect of variables on PFS in patients with ovarian cancer treated with NAC (n = 60) Patients Parameter

n

Extent of IDS Optimal (G1 cm) Suboptimal (91 cm) Not done RECIST response SD/PD PR/CR Age G65 y Q65 y Performance status (ECOG) e1 2 FIGO stage IIIC IV Histology Serous Other Histologic differentiation G2 G3 No. cycles of NAC 3 93 Paclitaxel in NAC Yes No RYCA-125 (n = 54) High Low Survivin expression before NAC High Low Change of survivin expression after the NAC (n = 53) Decrease Stable/increase p53 Expression p53 (j) p53 (+)

Median PFS, mo

%

Multivariate Analysis P

HR (95% CI)

P

G0.0001* 3.93 (95% CI, 2.07Y7.46) G0.0001* 38 63% 17 28% 5 8%

14.0 8.3 6.6

18 30% 42 70%

7.5 13.7

40 67% 20 33%

11.0 11.5

47 78% 13 22%

12.8 10.4

50 83% 10 17%

11.9 8.3

0.0027* 2.36 (95% CI, 1.25Y4.47) 0.0080*

0.5296

NS

NS

0.41276

0.7492

0.1683 43 72% 17 28%

12.7 6.8

39 65% 21 35%

12.0 10.8

43 72% 17 28%

11.9 11.0

0.8183

0.7542

0.4360 52 87% 8 13%

11.9 10.9

27 50% 27 50%

13.7 10.1

17 28% 43 72%

12.2 10.5

47 89% 6 11%

12.5 10.9

24 40% 36 60%

10.5 11.6

0.0313*

0.8026

0.7175

0.3190

*Value of the probability of a statistically significant (P G 0.05). CR, Complete response; PD, progressive disease; PR, partial response; SD, stable disease.

on optimally after NAC. The authors of this study concluded that the increase of 10% in cytoreduction was associated with an increase in median survival of about 5.5 months. In an

earlier phase II prospective study conducted in a group of 63 patients with ovarian cancer in FIGO IIIC stage and treated with NAC, Kuhn et al10 reported a degree of optimal



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TABLE 5. Impact of clinicopathologic parameters on OS in patients treated with NAC Patients Parameter Paclitaxel in NAC Yes No Extent of IDS Optimal (G1 cm) Suboptimal (91 cm) Not done Platinum response Sensitivity resistant Age G65 y Q65 y Performance status (ECOG) e1 2 FIGO stage IIIC IV Histology Serous Other Histologic differentiation G2 G3 No. cycles of NAC 3 93 RYCA-125 (n = 54) High Low Survivin expression before NAC High Low Change of survivin expression after the NAC (n = 53) Decrease Stable/ increase P53 expression p53 (j) p53 (+) RECIST response SD/PD PR/CR

Multivariate Analysis

n

%

Median of OS, mo

52 8

87% 13%

28.5 11.9

G0.0169**

38 17 5

63% 28% 8%

33.5 13.4 11.0

0.0002

34 26

57% 43%

41.4 15.3

G0.0001*

40 20

67% 33%

23.4 17.0

0.1165

47 13

78% 22%

28.3 12.4

0.0845

50 10

83% 17%

21.8 23.0

0.9291

43 17

72% 28%

22.3 23.4

0.8074

39 21

65% 35%

20.2 25.2

0.2848

43 17

72% 28%

25.7 21.8

0.7715

27 27

50% 50%

29.5 14.0

0.0083*

17 43

28% 72%

31.3 20.0

0.0484*

47 6

89% 11%

27.6 18.4

0.4565

24 36

40% 60%

20.0 24.7

0.9962

18 42

30% 70%

13.4 29.1

0.0087*

P

HR (95% CI)

P

2.56 (1.06Y6.18)

0.0358*

2.61 (1.17Y5.83)

0.0188*

2.72 (1.07Y6.89)

0.0353*

NS

NS

*Value of the probability of a statistically significant (P G 0.05). CR, Complete response; PD, progressive disease; PR, partial response; SD, stable disease.

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FIGURE 1. Overall survival in patients with AOC who underwent NAC by survivin expression. cytoreduction of 84%, which is higher than that described here, but the authors adopted as the criterion of optimal surgery of residual lesions less than 2 cm in diameter. However, in a randomized phase III study assessing the effects of NAC, the authors compared the perioperative and postoperative results in 670 patients divided into groups of patients who underwent primary surgery or IDS. In the arm of the study that used NAC, the percentage of optimal cytoreduction achieved (80.7%) was higher than that achieved in our study. This percentage was 2-fold higher than that in the other arm of the study where patients underwent primary cytoreduction (41.6% achieved optimal treatment).11 One of the aims of our study was to evaluate the expression of survivin and p53 in ovarian cancer patients undergoing NAC. We found nuclear survivin expression in approximately 60% of patients in the cancer cells in tissues collected during exploratory surgery. After NAC, we noticed significant decrease in nuclear survivin expression in ovarian cancer cells in the tumor tissues compared with that collected before NAC output to about 20%. Comparing the expression of survivin in cancer cells in tissue taken before and after NAC, we observed a highly significant difference in the percentage of PS, IS, and TS. The nuclear expression of survivin in our patients with ovarian cancer was lower than that estimated by Cohen et al,12 who reported the expression of this protein in 74% of patients. In contrast to our analysis, the expression of survivin correlated with known prognostic factors such as tumor grade, histological subtype, and TP53 mutation. Ferrandina et al13 observed the expression of survivin in a smaller proportion of patients with ovarian cancer, only in 29% of 110 patients who underwent primary surgery. The authors also determined the expression of p53, which was observed in 60% of patients. They did not find a relationship between the expression of either proteins and clinicopathologic parameters. The expression of p53 found in the present study is consistent with that obtained by Darcy et al,14 who assessed p53 expression in the material derived from 2 prospective studies, GOG-157 and GOG-111. The authors observed the


expression of p53 in 51% and 66% of patients, respectively. In the first study, the expression of p53 was not correlated with any analyzed clinicopathologic parameters, whereas in the second study, the expression of this protein was associated with performance status and histological grading. No relationship with the other analyzed variables was observed. The eligibility of patients with AOC for primary surgery or IDS is a subject of controversy. This is mainly because of the lack of reliable predictors for patients who would benefit from NAC. The study by Darcy et al14 assessed the importance of predictive p53 in 2 clinical trials. The authors found that the expression of p53 was associated with a shorter PFS in the subgroup of patients from the study GOG-154. However, the GOG-111 did not show p53 status to be an independent predictive factor for PFS in patients receiving first-line chemotherapy. In the study by the Polish Ovarian Cancer Group, an association between TP53 dysfunction and high nuclear expression of survivin was found. In patients with positive expression of p53, high nuclear expression of survivin was a favorable predictor for PFS and increased the likelihood of platinum sensitivity. No independent predictive and prognostic significance of survivin was observed in the group without p53 protein expression.15 In our study, which assessed selected proteins of apoptosis, we found that high expression of survivin was a favorable prognostic factor in patients with AOC treated with NAC. As in the study by the Polish Ovarian Cancer Group, the effect was more significant in the group of patients with positive expression of p53. The median OS in patients with high expression of survivin and who were p53 positive was 34.6 months, whereas for patients with low expression of survivin it was only 22.2 months. Green et al16 showed the results of analysis of expression p53 in tumor tissues taken from 169 of 425 ovarian cancer patients included in the randomized phase III EORTC GCG 55865 study, which compared the results of primary surgery and IDS. The authors did not observe a predictive and prognostic significance expression of p53 in the study group. To the best of our knowledge, our study is the first to evaluate survivin expression as a potential predictive and prognostic factor in patients with ovarian cancer undergoing NAC. In the literature, there are single research studies on the predictive and prognostic role of survivin for NAC in other cancers, such as breast cancer, colorectal cancer, and gastric cancer.17Y19 The results of these studies on the role of survivin are inconclusive. Among other analyzed clinicopathologic parameters in our study, we found that the extent of IDS, high regression coefficient of marker CA-125, and objective response were significant predictive factors for PFS. Multivariate analysis found that 2 variables, the extent of IDS and the lack objective response, were independent adverse predictive factors. Our results on the role of regression of CA-125 are different from the observation of Le et al,20 which defined the predictive and prognostic value of this marker. The authors of this article adopted as a criterion response to treatment the decrease in serum CA-125 after 3 courses of NAC greater



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than 50% of the value of the initial. According to the adopted rule, 83% of patients achieved an objective response. In the multivariate analysis, this parameter was not a relevant predictive or prognostic factor. In another study, Tate et al21 evaluated the usefulness of the regression coefficient of CA-125 in patients with advanced serous ovarian cancer, calculated on the basis of successive measurements of the concentration of the marker from the day of NAC as day 0 until the day of normalization of CA-125 level (G35 IU/mL) or the day of standard surgery. As the cutoff point, the authors adopted a coefficient of j0.039, which divided the study group into responders and nonresponders. Patients with a regression coefficient of CA-125 belonging to the first group reached a higher percentage of 3-year survival compared with the nonresponders (P = 0.012). In conclusion, although in the overall group of patients with ovarian cancer in the EORTCYNational Cancer Institute of Canada trial, survival was similar after primary surgery and NAC, the discussion on the optimal sequence of treatment for AOC is still open. This study shows that NAC can be used as an alternative approach to primary surgery in patients with bulky stage IIIC or IV ovarian cancer. The paramount consideration in the planning process of therapy is a precise selection of patients who can achieve the benefits of NAC. The results of our study suggest that high survivin expression could be a favorable prognostic factor especially in the group of patients with positive expression of p53. Obviously, these results should be validated by larger-scale studies.

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