Neoadjuvant Therapy for Ovarian Cancer

Initial treatment for ovarian cancer is usually surgical cytoreduction followed by adjuvant platinum and taxane chemotherapy. At the time of diagnosis over 75% of patients present with stage III or IV disease that has spread into the peritoneal cavity or distally. Despite a number of new chemotherapeutic regimens survival has improved only modestly over the preceding two decades. While overall 5-year survival has improved from 30% to 50%, 5-year survival remains only 25% for women with advanced stage disease. Given these findings it is clear that improved strategies for the delivery of cytotoxic and biologic agents are needed for women with advanced stage epithelial ovarian cancer.

A newer drug, called bevacizumab, has been approved by the U.S. Food and Drug Administration (FDA) for use in combination with chemotherapy in patients with colon cancer, lung cancer, and some types of breast cancer that have spread to distant sites in the body. A critical question which will need to be answered is whether or not it is feasible to administer a combination of bevacizumab with standard cytotoxic therapy using a neo-adjuvant approach for patients with epithelial cancer of the ovary, fallopian tube, or primary peritoneum.

Inclusion criteria

• Patients must have Suspected Federation of Gynecology and Obstetrics (FIGO) stage III or IV disease.
• Cytologic or histologic diagnosis of a carcinoma felt by the investigator to be compatible with epithelial cancer of the ovary, fallopian tube, or primary peritoneum
• Patients must have a Performance Status of 0, 1 or 2.
• Patients with prior anthracycline exposure must have a baseline multigated acquisition scan (MUGA) or echocardiogram prior to study entry.
• Patients must have adequate:

• Bone marrow function: Absolute neutrophil count (ANC) greater than or equal to 1500/υl, equivalent to Common Toxicity Criteria for Adverse Events v3.0 (CTCAE) Grade 1. This ANC cannot have been induced or supported by granulocyte colony stimulating factors.
• Platelets greater than or equal to 100,000/υl (CTCAE Grade 0-1).
• Hematocrit > 21%.
• Renal function: Creatinine < 1.5 x institutional upper limit of normal (ULN), CTCAE Grade 1.
• Hepatic function: Bilirubin less than or equal to 1.5 x ULN (CTCAE Grade 1). AST, ALT, and alkaline phosphatase less than or equal to 2.5 x ULN (CTCAE Grade 1). Aspartate transaminase (AST) and alanine transaminase (ALT)
• Neurologic function: Neuropathy (sensory and motor) less than or equal to CTCAE Grade 1.
• Coagulation function: Prothrombin Time (PT) and Partial Thromboplastin Time (PTT) - PT such that international normalized ratio (INR) is ≤ 1.5 (or an in-range INR, usually between 2 and 3, if a patient is on a stable dose of therapeutic warfarin for management of venous thrombosis including pulmonary thromboembolism) and a PTT < 1.2 times the upper limit of normal.
• Patients must have measurable disease. Patients may or may not have cancer-related symptoms.
• Baseline CA-125 must be ≥ 70 units/mL.
• Patients must have met all pre-entry requirements.
• An approved informed consent and authorization permitting release of personal health information must be signed by the patient or guardian.
• Eligible patients should be deemed as likely to be medically fit to undergo surgical cytoreduction after 3 cycles of neoadjuvant chemotherapy by a surgical gynecologic oncologist.
• Patients may receive estrogen +/- progestin replacement.

Exclusion criteria

• Patients should NOT have undergone any prior cancer directed surgery (exploration, debulking, etc), with the exception of a minor procedure such as biopsy or cytology specimen.
• Patients who have received prior chemotherapy, immunotherapy, radiotherapy, hormonal therapy or biologic therapy for their ovarian or primary peritoneal cancer are not eligible.
• Patients with borderline ovarian tumors, recurrent epithelial ovarian or primary peritoneal cancer or non-epithelial ovarian cancer are not eligible.
• Patients with a CA125:CEA ratio <25. Carcinoembryonic Antigen (CEA)
• Patients with other cancers (other than non-melanoma skin cancer) within the last five years.
• Patients with acute hepatitis or end stage liver disease.
• Patients with serious non-healing wound, ulcer or bone fracture. This includes history of abdominal fistula or intra-abdominal abscess within 6 months. Patients with granulating incisions healing by secondary intention with no evidence of fascial dehiscence or infection are eligible but require weekly wound examinations.
• History of prior gastrointestinal perforation.
• Patients with evidence of abdominal free air not explained by paracentesis.
• Patients with signs or symptoms of gastrointestinal obstruction including those receiving total parenteral nutrition (TPN), intravenous hydration or tube feeds.
• Patients with active bleeding or pathologic conditions that carry high risk of bleeding, such as known bleeding disorder, coagulopathy, or tumor involving major vessels by imaging, regardless of whether any chance of requiring vascular reconstruction.
• Patients with history or evidence upon physical examination of CNS disease, including primary brain tumor, seizures not controlled with standard medical therapy, any brain metastases, or history of cerebrovascular accident (CVA, stroke), transient ischemic attack (TIA) or subarachnoid hemorrhage within six months of the first date of treatment on this study. Patients with treated brain metastases can enter the study. Treated brain metastases are defined as having no evidence of progression or hemorrhage after treatment and no ongoing requirement for dexamethasone, as ascertained by clinical examination and brain imaging (MRI or CT) during the screening period. Anticonvulsants (stable dose) are allowed. Treatment for brain metastases may include whole brain radiotherapy (WBRT), radiosurgery (RS; Gamma Knife, LINAC, or equivalent) or a combination as deemed appropriate by the treating physician. Patients with central nervous system (CNS) metastases treated by neurosurgical resection or brain biopsy performed within 3 months prior to Day 1 will be excluded.
• Patients with clinically significant cardiovascular disease. This includes:

• Uncontrolled hypertension, defined as systolic > 140 mm Hg or diastolic > 90 mm Hg.
• Myocardial infarction or unstable angina within 6 months of day 1 prior to registration.
• New York Heart Association (NYHA) Grade II or greater congestive heart failure.
• Serious cardiac arrhythmia requiring medication. This does not include atrial fibrillation.
• CTCAE Grade 3 or greater peripheral vascular disease.
• History of CVA within six months.
• Patients with known hypersensitivity to Chinese hamster ovary cell products or other recombinant human or humanized antibodies including hypersensitivity to any component of bevacizumab
• Patients with clinically significant proteinuria. Urine protein should be screened by urine protein-creatinine ratio (UPCR). The UPCR has been found to correlate directly with the amount of protein excreted in a 24 hour urine collection. Specifically, a UPCR of 1.0 is equivalent to 1.0 grams of protein in a 24 hour urine collection. Obtain at least 4 ml of a random urine sample in a sterile container (does not have to be a 24 hour urine). Send sample to lab with request for urine protein and creatinine levels (separate requests). The lab will measure protein concentration (mg/dL) and creatinine concentration (mg/dL). The UPCR is derived as follows: protein concentration (mg/dL)/creatinine (mg/dL). Patients must have a UPCR < 1.0 to allow participation in the study.
• Patients with hypertensive crises or hypertensive encephalopathy
• History of hemoptysis (≥ ½ teaspoon of bright red blood per episode) within 1 month prior to day 1.
• Patients with or with anticipation of a non-study related invasive procedure defined as followed:

• Major surgical procedure, open biopsy or significant traumatic injury within 28 days prior to the first date of bevacizumab.
• Major non-study related surgical procedure anticipated during the course of the study.
• Core biopsy within 7 days prior to first date of bevacizumab.
• Patients with a Performance Status of Grade 3 or 4 are not eligible.
• Patients who are pregnant or nursing. Subjects of child-bearing age have to use effective means of contraception.
• Patients under the age of 18.
• Patients who have received prior therapy with any anti-VEGF drug, including bevacizumab. Vascular endothelial growth factor (VEGF)
• Patients with human immunodeficiency virus (HIV).
• Patients with medical history or conditions not otherwise previously specified which in the opinion of the investigator should exclude participation in this study. The investigator should consult the Study Chair.