Health-related quality of life in recurrent platinum-sensitive ovarian cancer--results from the CALYPSO trial.

BACKGROUND: In the CALYPSO trial, carboplatin-pegylated liposomal doxorubicin (CD) demonstrated superior therapeutic index versus carboplatin-paclitaxel (CP) in patients with recurrent ovarian cancer. This paper reports the health-related quality of life (HRQoL) findings. MATERIALS AND METHODS: HRQoL was measured with the EORTC QoL-QC30 questionnaire and OV28 ovarian cancer module. Mean change scores from baseline in HRQoL subscales (five functional scales and global health status) in each arm and the proportion of patients improved or worsened were calculated every 3 months until 12 months. RESULTS: Compliance was 90% at baseline and 76%, 64%, 57% at 3, 6, and 9 months, respectively. Baseline HRQoL showed already impaired global scores (mean 62/100) and considerable symptom burden (90% of patients reporting nonzero scores). Global QoL and abdominal symptom scores improved over time in both arms; at 6 months, 36% of patients met criteria for improved symptoms. Treatment with CD resulted in less peripheral neuropathy (9.8 versus 24.2), fewer other chemotherapy side-effects (9.5 versus 16.2), and less impact on body image (3.8 versus 10.4) versus CP (all P<0.02) at 6 months. CONCLUSIONS: These patient-reported outcomes confirm the overall lower toxicity of CD versus CP. The improved disease-related outcomes achieved with CD were not at the expense of QoL.

[Diagnosis and treatment of malignant ovarian tumors 2005: recommendations of the Kommission Ovar of the AGO]. / Diagnostik und Therapie maligner Ovarialtumoren 2005: Die Empfehlungen der Kommission Ovar der AGO.

Recommendations for diagnosis and treatment of malignant ovarian tumors with regard to the most recent data were worked out in a consensus process and valued by level of evidence (LoE) and grade of recommendation (GoR) of the Canadian Task Force for Preventive Health Care by the members of the Kommission Ovar der Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) in June 2005. A short version of these guidelines is presented.

The role of surgery in recurrent ovarian cancer.

The role of cytoreductive surgery (CS) in recurrent ovarian cancer (ROC) has not been clearly defined. We performed a retrospective study evaluating criteria for CS in ROC. Twenty-five institutions documented their patients with CS for invasive epithelial ROC performed 2000-2003. Two hundred sixty-seven patients were included. Complete tumor removal was achieved in 133 patients (50%). Complete resection was associated with prolonged survival compared to surgeries with residual tumor. Median survival of patients without residual tumor was 45.3 months and of patients with residual tumor, irrespective of its size, 19.0 months (HR 4.33; 95% CI 2.53-7.43; P < 0.0001). In a multivariate analysis, the following factors showed a significant influence on the probability to achieve a postoperative residual tumor of 0 mm: absence of ascites (<500 vs > or =500 mL: HR 4.63; 95% CI: 1.81-11.76; P= 0.0001), good performance status Eastern Cooperative Oncology Group (ECOG) 0 vs >0: HR: 2.41; 95% CI: 1.41-4.08; P= 0.001, and low FIGO stage at primary diagnosis (FIGO I/II vs III/IV: HR 1.87; 95% CI: 1.04-3.37; P= 0.036). Significant factors for survival after surgery for recurrence in a multivariate analysis were achievement of complete resection (residual tumor at surgery for recurrence 0 vs >0 mm: HR 2.86; 95% CI: 1.66-4.93; P < 0.001), absence of ascites (<500 vs > or =500 mL: HR 2.09; 95% CI: 1.18-3.71; P= 0.012), and application of a platinum-containing chemotherapy (platinum-containing chemotherapy vs others: HR 1.83; 95% CI: 1.16-2.88; P= 0.009). Only patients with complete resection seem to benefit from CS. This new panel of selection criteria will be evaluated in a prospective study.

Non-enrolment of ovarian cancer patients in clinical trials: reasons and background.

BACKGROUND: Some retrospective analyses have suggested that participation in clinical trials is associated with better outcome. However, it is not clear to what extent selection bias contributes to this observation. PATIENTS AND METHODS: We evaluated the reasons for non-enrolment of ovarian cancer patients in clinical trials. All patients with ovarian cancer not enrolled in clinical studies and treated in 2001 in the participating centres were documented retrospectively and compared with patients enrolled in clinical trials at the same institutions during the same time period. RESULTS: Two hundred and seventy-four patients with advanced ovarian cancer (FIGO stage IIB-IV) were included, of whom 139 (51%) and 135 (49%) patients were enrolled in this study and in prospective clinical trials, respectively. Ninety-four of 274 patients (34%) did not meet the inclusion criteria for clinical trials. Of 180 eligible patients, 28 (16%) refused participation and a further 17 patients (9%) were not recruited although they met the inclusion criteria. The non-study patients were older (66.7 versus 57.2 years; P <0.0001), underwent less radical surgery (hysterectomy, oophorectomy and omentectomy performed: 61.2% versus 80.7%; P = 0.001; rate of lymphadenectomy 30.9% versus 45.2%; P = 0.015) and more frequently had bulky residual disease (residual disease >2 cm: 36.2% versus 20%; P = 0.016). However, 62% of the non-study patients were treated with the same chemotherapy as in the standard arm of the respective clinical studies. CONCLUSIONS: Study patients differ substantially from non-study patients, thus hampering generalisation of study results. Our results suggest that at least some inclusion criteria for clinical trials should be modified to increase study participation without compromising safety.

Association of urokinase-type plasminogen activator and its inhibitor with disease progression and prognosis in ovarian cancer.

PURPOSE: Urokinase-type plasminogen activator (uPA) and its inhibitor, plasminogen activator inhibitor (PAI)-1, have been shown to be related to poor prognosis in a variety of malignant solid tumors. Studies on the prognostic relevance of uPA and PAI-1 in ovarian cancer, however, have been inconclusive. The current study tests the hypothesis that elevated expression of uPA and PAI-1 is associated with prognosis and disease progression. EXPERIMENTAL DESIGN: uPA and PAI-1 were prospectively measured by quantitative ELISA in tumor samples from 103 ovarian cancer patients (82 primary invasive epithelial carcinomas, 9 low malignant potential tumors, and 12 recurrent ovarian carcinomas). RESULTS: uPA but not PAI-1 levels were consistently associated with malignant progression, with levels increased from low malignant potential tumors to primary tumors (uPA, P = 0.04; PAI-1, P = 0.019), from early to advanced disease stages (uPA, P = 0.014; PAI-1, P = 0.23), and from primary to intra-abdominal metastatic tumors (uPA, P = 0.001; PAI-1, P = 0.16). High uPA and PAI-1 levels were associated with residual tumor volumes of >1 cm (P = 0.001 and P = 0.016, respectively). Among invasive International Federation of Gynecologists and Obstetrician stages I-IV tumors, elevated levels of uPA (>5.5 ng/mg) and PAI-I (>18.8 ng/ml) were associated with a shortened progression-free survival (uPA, P = 0.003; PAI-1, P = 0.039) and overall survival (uPA, P = 0.0002; PAI-1, P = 0.007). In multivariate analysis, uPA retained prognostic independence for progression-free survival (P = 0.037) and overall survival (P = 0.006). CONCLUSIONS: These data suggest that the uPA/PAI-1 axis may play an important role in the intra-abdominal spread and reimplantation of ovarian cancer cells. The prognostic relevance of uPA and PAI-1 supports their possible role in the malignant progression of ovarian cancer.

Regulation of Escherichia coli RelA requires oligomerization of the C-terminal domain.

The E. coli RelA protein is a ribosome-dependent (p)ppGpp synthetase that is activated in response to amino acid starvation. RelA can be dissected both functionally and physically into two domains: The N-terminal domain (NTD) (amino acids [aa] 1 to 455) contains the catalytic domain of RelA, and the C-terminal domain (CTD) (aa 455 to 744) is involved in regulating RelA activity. We used mutational analysis to localize sites important for RelA activity and control in these two domains. We inserted two separate mutations into the NTD, which resulted in mutated RelA proteins that were impaired in their ability to synthesize (p)ppGpp. When we caused the CTD in relA(+) cells to be overexpressed, (p)ppGpp accumulation during amino acid starvation was negatively affected. Mutational analysis showed that Cys-612, Asp-637, and Cys-638, found in a conserved amino acid sequence (aa 612 to 638), are essential for this negative effect of the CTD. When mutations corresponding to these residues were inserted into the full-length relA gene, the mutated RelA proteins were impaired in their regulation. In attempting to clarify the mechanism through which the CTD regulates RelA activity, we found no evidence for competition for ribosomal binding between the normal RelA and the overexpressed CTD. Results from CyaA complementation experiments of the bacterial two-hybrid system fusion plasmids (G. Karimova, J. Pidoux, A. Ullmann, and D. Ladant, Proc. Natl. Acad. Sci. USA 95:5752-5756, 1998) indicated that the CTD (aa 564 to 744) is involved in RelA-RelA interactions. Our findings support a model in which RelA activation is regulated by its oligomerization state.

Immunohistochemical analysis of drug resistance-associated proteins in ovarian carcinomas.

Loss of function of the tumor suppressor gene p53, increased expression of glutathione-S-transferase pi (GST7pi) and the major vault protein are involved in drug resistance of ovarian carcinomas. However, a study comparing these factors has not yet been performed. Therefore, paraffin-embedded material of 213 ovarian tumors with well-documented follow-up was used for immunohistochemical analysis of p53 protein, GSTpi, and major vault protein (antibodies LRP-56, LMR-5). Forty-six percent of the cases showed nuclear p53 accumulation. Strong immunoreactivity for GSTpi, LRP-56, and LMR-5 was seen in 50%, 36%, and 47%, respectively. p53 positivity was most often found in serous carcinomas (p < 0.05). Strong GSTpi expression was the only factor that correlated with clinical resistance to chemotherapy (p = 0.04). In the whole group, as well as in FIGO III cases stratified for residual disease < or = and >2 cm, p53 and GSTpi correlated with an adverse outcome (p = 0.01 for p53 and p = 0.04 for GSTpi). Strong LRP-56 or LMR-5 staining was associated with a tendency towards poorer prognosis, without reaching statistical significance. In multivariate analysis for FIGO III, only residual disease and p53 proved to be independent prognostic factors. Our observations confirm the prognostic significance of p53 accumulation in ovarian carcinomas. Only GSTpi immunoreactivity was significantly correlated with drug resistance.

[Cerebral ischemia as initial manifestation of neoplastic low-malignancy changes. 2 case reports and review of the literatures]. / Zerebrale Ischämien als Erstmanifestation neoplastischer Veränderungen niedriger Malignität. 2 Fallberichte und Ubersicht über die Literatur.

Thrombembolic events as paraneoplastic complications in malignant disease account for severe morbidity and mortality in these patients. In some cases disturbance in hemostasis is the first manifestation of a neoplastic process. We report the cases of two patients with cerebral and extracerebral vessel occlusions, in whom epithelial tumors of low malignant potential (borderline-tumors) of ovary and peritoneum were diagnosed later on. In one case the removal of the tumor stopped the coagulation problems. The second patient died a few days after the first symptoms with devastating multiple vessel occlusion. In stroke of unknown aetiology a paraneoplastic process should be kept in mind. The diagnosis is more probable with recurrent thrombembolism in different body regions and when warfarin therapy was ineffective. Thoughtful coagulation studies and a tumor search program is recommended in these cases.

[Secondary debulking after dose-intensified chemotherapy of ovarian carcinoma]. / Sekundäres Debulking nach dosisintensivierter Chemotherapie beim Ovarialkarzinom.

Only 20-40% of patients with advanced ovarian cancer have no residual disease after primary cytoreductive surgery. For patients with residual tumor and good response to chemotherapy new therapeutic procedures have to be discussed. In our study the role of secondary debulking surgery, especially after G-CSF supplied dose intensification was evaluated. Between January 1986 and December 1995, 506 patients with primary ovarian cancer were treated at our institution. 117 patients with residual tumor after primary surgery had secondary debulking after four to six cycles of platinum based chemotherapy, 26 of them had G-CSF supplemented dose intensification by shortened therapy intervals. After secondary debulking 43% had no residual disease, 37% had residual tumor less than 2 cm and 20% more than 2 cm. Mean survival in patients without residual disease was 47 months and significantly longer than in patients without secondary debulking with only 35 months. In 25 to 26 patients with dose intensification chemotherapy cycles could be applied regularly, the results were in the expected range. Secondary debulking surgery can prolong survival in those patients without residual tumor after secondary surgery. Dose intensification is possible without remarkable side effects. In our study the percentage of patients without residual tumor could not be increased by dose intensification.

Treosulfan as an effective second-line therapy in ovarian cancer.

Despite radical surgery and aggressive platinum-containing primary chemotherapy, the outcome of patients with advanced ovarian cancer remains extremely poor; most of them suffer from recurrent or progressive disease. These patients should be treated with an effective second-line therapy showing only few toxic side effects so as not to affect quality of life. From July 1992 to August 1996, 88 patients with recurrent or progressive ovarian cancer have been treated with treosulfan, an alkylating agent, in our department. All of them could be evaluated for toxicity and 80 for response. There were 2 complete and 13 partial responses, giving an objective response rate of 19%. Among responding patients, median survival time was 41 months. Thirty-four percent of the patients had stable disease with median survival of 18 months. Thirty-eight (47%) nonresponding patients showed a survival time of only 5 months. In 48 women with progressive disease within 12 months after primary therapy, a response rate of 19% and stable disease in 31% could be achieved. Toxic side effects were rare and moderate in intensity. Life-threatening myelosuppression, emesis resistant to therapy, and alopecia were not observed. It can be concluded that tresosulfan is an effective drug in second-line therapy for patients with recurrent or progressive ovarian cancer without affecting quality of life.

Prognostic significance of CA125 in patients with ovarian cancer and secondary debulking surgery.

Prognostic outcome of patients with bulky disease after primary surgery in ovarian cancer remains extremely poor. One possible approach to achieve prolonged survival is secondary debulking surgery, but only in those patients without residual tumor after the second surgery. In 79 patients with secondary debulking surgery preoperative CA125 values were determined. In 52% of the patients with CA125 values below 35 U/ml a tumor free situation could be achieved at secondary debulking. In contrast, the percentage of patients macroscopically free of disease with levels above 35 U/ml was only 22%. Furthermore, there was a significant difference in survival time depending on CA125 values at the time of secondary debulking. Patients with levels below 35 U/ml survived 49 months, women with values above 35 U/ml survived only 30 months respectively. In conclusion, CA125 is an important prognostic tool for predicting a tumor free situation at secondary debulking surgery. In patients with values above 35 U/ml secondary debulking should be indicated restrictively, even if other preoperative diagnostic tools would predict a tumor free situation after secondary cytoreductive surgery.

A relA(S) suppressor mutant allele of Bacillus subtilis which maps to relA and responds only to carbon limitation.

The histidine analog 3-amino-1,2,4-triazole (AT) was used for the selection of spontaneous AT-resistant revertants of a relA mutant of Bacillus subtilis. One of these revertants, L3, showed a unique phenotype; it did not respond to amino acid starvation, like the relA mutant, but it did respond to glucose starvation by the accumulation of (p)ppGpp, unlike its parent. Genetic analysis revealed that this suppressor mutant (relA(S)) allele mapped to the relA locus at 239 degrees on the B. subtilis chromosome.

Antiasthmatic effects of Picrorhiza kurroa: androsin prevents allergen- and PAF-induced bronchial obstruction in guinea pigs.

In the Ayurvedic medicine, Picrorhiza kurroa Royle ex Benth. is used for the treatment of liver and lung diseases. Using different chemical and pharmacological methods, we could identify the phenol glycoside androsin as active compound preventing allergen and platelet-activating factor induced bronchial obstruction in guinea pigs in vivo (10 mg/kg p.o.; 1 h prior to the inhalation challenge). Histamine release from human polymorphonuclear leukocytes in vitro was inhibited by other compounds yet to be identified.