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{{Ovarian cancer}}
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==Overview==
==Overview==
Medical therapies, such as chemotherapy and radiation, are often employed post-surgerical therapy as a means to treat residual disease. The success of medical therapy often hinges on the histology of the tumor.
Medical therapies, such as [[chemotherapy]] and [[radiation]], are often employed post-surgical therapy as a means to treat residual disease. The success of medical therapy often hinges on the [[histology]] of the [[tumor]].


==MedicalTherapy==
==Medical Therapy==
[[Chemotherapy]] is used after surgery to treat any residual disease, if appropriate. This depends on the [[histology]] of the tumor;  some kinds of tumor (particularly [[teratoma]]) are not sensitive to chemotherapy.  In some cases, there may be reason to perform chemotherapy first, followed by surgery. 


Many oncologists recommend [[intravenous]] (IV) chemotherapy including a [[platinum]] drug with a [[taxane]] as a preferred method of treating advanced ovarian cancer.  However, three recent randomized studies [http://www.cancer.gov/newscenter/pressreleases/IPchemotherapyrelease clinical trials] suggest that chemotherapy that is partly IV and partly via direct infusion into the [[abdominal cavity]] (intraperitoneal or IP) may improve median survival time.  IP chemotherapy generally has higher toxicity and its advantages are still debated among specialists.  Currently for Stage IIIC ovarian adenocarcinomas after optimal debulking, median time for survival is statistically significantly longer for patient receiving intraperitoneal chemotherapy. Patients in this clincial trial did report less compliance with IP chemotherapy, and fewer than half of the patients received all six cycles of IP chemotherapy. Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP chemotherpy treatment) survived longer on average than patients who received intravenous chemotherapy alone.  These results can be interpreted in couple of ways.  One could argue if the IP chemotherapy treatment group had completed the six cycles of chemotherapy their lives would have been prolonged even longer.  Or the advantages of receiving IP chemotherapy are significant in the early phases of chemotherapy.  Some specialists believe the IP chemotherapy toxicities will be unnecessary with improved IV chemotherapy drugs currently being developed.
*[[Epithelial ovarian cancer]] includes [[ovarian]], [[fallopian tube]], and peritoneal cancer and the combination of the three is referred to as (EOC) due to the similarity in their clinical behavior and characteristics.
*EOC is usually diagnosed in its late stages due to its subclinical or nonspecific [[symptoms]].
*The mainstay of definitive [[diagnosis]] and initial management of [[ovarian]] cancer is surgical operation to determine if it is [[benign]] or [[malignant]], determine its stage and grade, and then treat it accordingly.
*The medical management of [[ovarian cancer]] is usually done as an [[adjuvant]] to the [[surgical]] therapy which means surgery first then [[adjuvant]] [[chemotherapy]].
*Based on the [[surgical]] staging and grading of the tumor the management can be one of the following:
**[[Adjuvant]] [[intravenous]] [[chemotherapy]] is not recommended in:<ref name="pmid2181310">{{cite journal| author=Young RC, Walton LA, Ellenberg SS, Homesley HD, Wilbanks GD, Decker DG et al.| title=Adjuvant therapy in stage I and stage II epithelial ovarian cancer. Results of two prospective randomized trials. | journal=N Engl J Med | year= 1990 | volume= 322 | issue= 15 | pages= 1021-7 | pmid=2181310 | doi=10.1056/NEJM199004123221501 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2181310  }} </ref><ref name="pmid8918494">{{cite journal| author=Ahmed FY, Wiltshaw E, A'Hern RP, Nicol B, Shepherd J, Blake P et al.| title=Natural history and prognosis of untreated stage I epithelial ovarian carcinoma. | journal=J Clin Oncol | year= 1996 | volume= 14 | issue= 11 | pages= 2968-75 | pmid=8918494 | doi=10.1200/JCO.1996.14.11.2968 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8918494  }} </ref><ref name="HsiehLau2019">{{cite journal|last1=Hsieh|first1=Shu-Feng|last2=Lau|first2=Hei-Yu|last3=Wu|first3=Hua-Hsi|last4=Hsu|first4=Heng-Cheng|last5=Twu|first5=Nae-Fang|last6=Cheng|first6=Wen-Fang|title=Prognostic Factors of Early Stage Epithelial Ovarian Carcinoma|journal=International Journal of Environmental Research and Public Health|volume=16|issue=4|year=2019|pages=637|issn=1660-4601|doi=10.3390/ijerph16040637}}</ref>
***Early stage EOC (Stage IA or IB) and/or grade I (well-differentiated) tumor .
****With no high-risk features ([[clear cell]] [[histology]] or high tumor grade)
***The prognosis is excellent with survival rate of 90% after surgery alone
**[[Adjuvant]] [[intravenous]] [[chemotherapy]]:<ref name="pmid19944452">{{cite journal| author=Chan JK, Tian C, Teoh D, Monk BJ, Herzog T, Kapp DS et al.| title=Survival after recurrence in early-stage high-risk epithelial ovarian cancer: a Gynecologic Oncology Group study. | journal=Gynecol Oncol | year= 2010 | volume= 116 | issue= 3 | pages= 307-11 | pmid=19944452 | doi=10.1016/j.ygyno.2009.10.074 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19944452  }} </ref><ref name="pmid18348296">{{cite journal| author=Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J et al.| title=Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study. | journal=Cancer | year= 2008 | volume= 112 | issue= 10 | pages= 2202-10 | pmid=18348296 | doi=10.1002/cncr.23390 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18348296  }} </ref>
***[[Carboplatin]] and [[paclitaxel]] (platinum-based combination)
***Every three weeks for six cycles
***Can be adjusted based on the patient [[tolerance]] and the presence of [[risk factors]]
*Five-year disease-free survival rates range from 40 to 80 percent
***Is recommended for the following:
****Early stage EOC with high-risk features:
****Stage IC (Ovary plus positive [[peritoneal]] washing) or Stage II (involve pelvis) EOC
****([[clear cell]] [[histology]]
****high tumor grade (grade 3)
**First-line chemotherapy for advanced (stage III or IV) epithelial ovarian, fallopian tubal, and peritoneal cancer<ref name="pmid17105988">{{cite journal| author=Kyrgiou M, Salanti G, Pavlidis N, Paraskevaidis E, Ioannidis JP| title=Survival benefits with diverse chemotherapy regimens for ovarian cancer: meta-analysis of multiple treatments. | journal=J Natl Cancer Inst | year= 2006 | volume= 98 | issue= 22 | pages= 1655-63 | pmid=17105988 | doi=10.1093/jnci/djj443 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17105988  }} </ref><ref name="pmid25800756">{{cite journal| author=Tewari D, Java JJ, Salani R, Armstrong DK, Markman M, Herzog T et al.| title=Long-term survival advantage and prognostic factors associated with intraperitoneal chemotherapy treatment in advanced ovarian cancer: a gynecologic oncology group study. | journal=J Clin Oncol | year= 2015 | volume= 33 | issue= 13 | pages= 1460-6 | pmid=25800756 | doi=10.1200/JCO.2014.55.9898 | pmc=4404424 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=25800756  }} </ref><ref name="pmid17504373">{{cite journal| author=Hess LM, Benham-Hutchins M, Herzog TJ, Hsu CH, Malone DC, Skrepnek GH et al.| title=A meta-analysis of the efficacy of intraperitoneal cisplatin for the front-line treatment of ovarian cancer. | journal=Int J Gynecol Cancer | year= 2007 | volume= 17 | issue= 3 | pages= 561-70 | pmid=17504373 | doi=10.1111/j.1525-1438.2006.00846.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17504373  }} </ref><ref name="pmid26755441">{{cite journal| author=Jaaback K, Johnson N, Lawrie TA| title=Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer. | journal=Cochrane Database Syst Rev | year= 2016 | volume=  | issue= 1 | pages= CD005340 | pmid=26755441 | doi=10.1002/14651858.CD005340.pub4 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26755441  }} </ref><ref name="pmid31002578">{{cite journal| author=Walker JL, Brady MF, Wenzel L, Fleming GF, Huang HQ, DiSilvestro PA et al.| title=Randomized Trial of Intravenous Versus Intraperitoneal Chemotherapy Plus Bevacizumab in Advanced Ovarian Carcinoma: An NRG Oncology/Gynecologic Oncology Group Study. | journal=J Clin Oncol | year= 2019 | volume= 37 | issue= 16 | pages= 1380-1390 | pmid=31002578 | doi=10.1200/JCO.18.01568 | pmc=6544459 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31002578  }} </ref>
**[[Neoadjuvant]] [[chemotherapy]] is defined as initiating medical or systemic therapy before surgery.
***[[Carboplatin]] and [[paclitaxel]] ([[platinum]]-based combination)
***Followed by debulking surgery
***Then [[adjuvant]] therapy
***It is recommended for:
****Advanced EOC (Stage IIIC or IV)with a low chance of complete or optimal cytoreduction (unresectable [[tumor]])
****[[EOC]] in patients with poor operation outcome due to [[comorbidities]] or poor performance status
**[[Temsirolimus]], [[carboplatin]], and [[paclitaxel]] are used for
***[[Clear cell]] [[ovarian cancer]] (stage III-IV)
**[[Sunitinib]] is used for
***[[Ovarian]] Clear Cell [[Adenocarcinoma]]
***Recurrent Ovarian Carcinoma
*Observation after [[adjuvant]] [[chemotherapy]] is recommended for patients with early-stage EOC
*Maintenance therapy with [[paclitaxel]] for 24 weeks after completion of the [[adjuvant]] therapy is recommended for patients with advanced EOC
*Management of patients with EOC recurrence:
**[[Platinum]]-sensitive: more than 6 months disease-free interval after completion of therapy
*** Secondary [[chemotherapy]] with or without bavacizumab and secondary cytoreduction
** [[Platinum]]-resistant EOC: less than 6 months disease-free interval after completion of therapy and includes the following:
** * [[Platinum]]-refractory EOC: disease progression while on [[platinum]] therapy
**Both treated with
*** [[Paclitaxel]] as a single agent
*** Pegylated liposomal [[doxorubicin]] (PLD)
**** If patient is not [[Paclitaxel]] candidate
*** [[Bevacizumab]] plus single agent [[chemotherapy]]
**** For patients with [[platinum]]-resistant recurrent disease
*[[Chemotherapy]] is used after surgery to treat any residual disease, if appropriate. This depends on the [[histology]] of the tumor;  some kinds of tumor (particularly [[teratoma]]) are not sensitive to chemotherapy.  In some cases, there may be a reason to perform chemotherapy first, followed by surgery.
* Many [[oncologists]] recommend [[intravenous]] (IV) chemotherapy including a [[platinum]] drug with a [[taxane]] as a preferred method of treating advanced ovarian cancer.  However, three recent randomized studies [http://www.cancer.gov/newscenter/pressreleases/IPchemotherapyrelease clinical trials] suggest that chemotherapy that is partly IV and partly via direct infusion into the [[abdominal cavity]] ([[intraperitoneal]] or IP) may improve median survival time.   
* IP [[chemotherapy]] generally has higher toxicity and its advantages are still debated among specialists.   
* Currently for Stage IIIC [[ovarian]] [[adenocarcinomas]] after optimal [[debulking]], the median time for survival is statistically significantly longer for patient receiving intraperitoneal chemotherapy.  
* Patients in this clinical trial did report less compliance with IP [[chemotherapy]], and fewer than half of the patients received all six cycles of IP [[chemotherapy]].  
* Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP [[chemotherapy]] treatment) survived longer on average than patients who received [[intravenous]] [[chemotherapy]] alone.  These results can be interpreted in a couple of ways.  One could argue if the IP [[chemotherapy]] treatment group had completed the six cycles of [[chemotherapy]] their lives would have been prolonged even longer.  Or the advantages of receiving IP [[chemotherapy]] are significant in the early phases of [[chemotherapy]].  Some specialists believe the IP [[chemotherapy]] [[Toxicity|toxicities]] will be unnecessary with improved IV [[chemotherapy]] drugs currently being developed.


[[Radiation therapy]] is not effective for advanced stages because when vital organs are in the radiation field, a high dose cannot be safely delivered.
* [[Radiation therapy]] is not effective for advanced stages because when vital organs are in the [[radiation]] field, a high [[dose]] cannot be safely delivered.


==References==
==References==
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Latest revision as of 22:16, 11 October 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Huda A. Karman, M.D.

Overview

Medical therapies, such as chemotherapy and radiation, are often employed post-surgical therapy as a means to treat residual disease. The success of medical therapy often hinges on the histology of the tumor.

Medical Therapy

  • Epithelial ovarian cancer includes ovarian, fallopian tube, and peritoneal cancer and the combination of the three is referred to as (EOC) due to the similarity in their clinical behavior and characteristics.
  • EOC is usually diagnosed in its late stages due to its subclinical or nonspecific symptoms.
  • The mainstay of definitive diagnosis and initial management of ovarian cancer is surgical operation to determine if it is benign or malignant, determine its stage and grade, and then treat it accordingly.
  • The medical management of ovarian cancer is usually done as an adjuvant to the surgical therapy which means surgery first then adjuvant chemotherapy.
  • Based on the surgical staging and grading of the tumor the management can be one of the following:
  • Five-year disease-free survival rates range from 40 to 80 percent
  • Observation after adjuvant chemotherapy is recommended for patients with early-stage EOC
  • Maintenance therapy with paclitaxel for 24 weeks after completion of the adjuvant therapy is recommended for patients with advanced EOC
  • Management of patients with EOC recurrence:
    • Platinum-sensitive: more than 6 months disease-free interval after completion of therapy
      • Secondary chemotherapy with or without bavacizumab and secondary cytoreduction
    • Platinum-resistant EOC: less than 6 months disease-free interval after completion of therapy and includes the following:
    • * Platinum-refractory EOC: disease progression while on platinum therapy
    • Both treated with
  • Chemotherapy is used after surgery to treat any residual disease, if appropriate. This depends on the histology of the tumor; some kinds of tumor (particularly teratoma) are not sensitive to chemotherapy. In some cases, there may be a reason to perform chemotherapy first, followed by surgery.
  • Many oncologists recommend intravenous (IV) chemotherapy including a platinum drug with a taxane as a preferred method of treating advanced ovarian cancer. However, three recent randomized studies clinical trials suggest that chemotherapy that is partly IV and partly via direct infusion into the abdominal cavity (intraperitoneal or IP) may improve median survival time.
  • IP chemotherapy generally has higher toxicity and its advantages are still debated among specialists.
  • Currently for Stage IIIC ovarian adenocarcinomas after optimal debulking, the median time for survival is statistically significantly longer for patient receiving intraperitoneal chemotherapy.
  • Patients in this clinical trial did report less compliance with IP chemotherapy, and fewer than half of the patients received all six cycles of IP chemotherapy.
  • Despite this high "drop-out" rate, the group as a whole (including the patients that didn't complete IP chemotherapy treatment) survived longer on average than patients who received intravenous chemotherapy alone. These results can be interpreted in a couple of ways. One could argue if the IP chemotherapy treatment group had completed the six cycles of chemotherapy their lives would have been prolonged even longer. Or the advantages of receiving IP chemotherapy are significant in the early phases of chemotherapy. Some specialists believe the IP chemotherapy toxicities will be unnecessary with improved IV chemotherapy drugs currently being developed.

References

  1. ↑ Young RC, Walton LA, Ellenberg SS, Homesley HD, Wilbanks GD, Decker DG; et al. (1990). "Adjuvant therapy in stage I and stage II epithelial ovarian cancer. Results of two prospective randomized trials". N Engl J Med. 322 (15): 1021–7. doi:10.1056/NEJM199004123221501. PMID 2181310.
  2. ↑ Ahmed FY, Wiltshaw E, A'Hern RP, Nicol B, Shepherd J, Blake P; et al. (1996). "Natural history and prognosis of untreated stage I epithelial ovarian carcinoma". J Clin Oncol. 14 (11): 2968–75. doi:10.1200/JCO.1996.14.11.2968. PMID 8918494.
  3. ↑ Hsieh, Shu-Feng; Lau, Hei-Yu; Wu, Hua-Hsi; Hsu, Heng-Cheng; Twu, Nae-Fang; Cheng, Wen-Fang (2019). "Prognostic Factors of Early Stage Epithelial Ovarian Carcinoma". International Journal of Environmental Research and Public Health. 16 (4): 637. doi:10.3390/ijerph16040637. ISSN 1660-4601.
  4. ↑ Chan JK, Tian C, Teoh D, Monk BJ, Herzog T, Kapp DS; et al. (2010). "Survival after recurrence in early-stage high-risk epithelial ovarian cancer: a Gynecologic Oncology Group study". Gynecol Oncol. 116 (3): 307–11. doi:10.1016/j.ygyno.2009.10.074. PMID 19944452.
  5. ↑ Chan JK, Tian C, Monk BJ, Herzog T, Kapp DS, Bell J; et al. (2008). "Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study". Cancer. 112 (10): 2202–10. doi:10.1002/cncr.23390. PMID 18348296.
  6. ↑ Kyrgiou M, Salanti G, Pavlidis N, Paraskevaidis E, Ioannidis JP (2006). "Survival benefits with diverse chemotherapy regimens for ovarian cancer: meta-analysis of multiple treatments". J Natl Cancer Inst. 98 (22): 1655–63. doi:10.1093/jnci/djj443. PMID 17105988.
  7. ↑ Tewari D, Java JJ, Salani R, Armstrong DK, Markman M, Herzog T; et al. (2015). "Long-term survival advantage and prognostic factors associated with intraperitoneal chemotherapy treatment in advanced ovarian cancer: a gynecologic oncology group study". J Clin Oncol. 33 (13): 1460–6. doi:10.1200/JCO.2014.55.9898. PMC 4404424. PMID 25800756.
  8. ↑ Hess LM, Benham-Hutchins M, Herzog TJ, Hsu CH, Malone DC, Skrepnek GH; et al. (2007). "A meta-analysis of the efficacy of intraperitoneal cisplatin for the front-line treatment of ovarian cancer". Int J Gynecol Cancer. 17 (3): 561–70. doi:10.1111/j.1525-1438.2006.00846.x. PMID 17504373.
  9. ↑ Jaaback K, Johnson N, Lawrie TA (2016). "Intraperitoneal chemotherapy for the initial management of primary epithelial ovarian cancer". Cochrane Database Syst Rev (1): CD005340. doi:10.1002/14651858.CD005340.pub4. PMID 26755441.
  10. ↑ Walker JL, Brady MF, Wenzel L, Fleming GF, Huang HQ, DiSilvestro PA; et al. (2019). "Randomized Trial of Intravenous Versus Intraperitoneal Chemotherapy Plus Bevacizumab in Advanced Ovarian Carcinoma: An NRG Oncology/Gynecologic Oncology Group Study". J Clin Oncol. 37 (16): 1380–1390. doi:10.1200/JCO.18.01568. PMC 6544459 Check |pmc= value (help). PMID 31002578.


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