Tr a n s l a t i o n a l O n c o l o g y
Volume 5 Number 6
December 2012
pp. 469–474 469
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Histologic Parameters Predictive of Disease Outcome in Women with Advanced Stage Ovarian Carcinoma Treated with Neoadjuvant Chemotherapy1
Damanzoopinder Samrao*, Dan Wang†, Faith Ough*, Yvonne G. Lin‡, Song Liu†, Teodulo Menesses*, Annie Yessaian‡, Nicole Turner§, Tanja Pejovic§ and Paulette Mhawech-Fauceglia* *Department of Pathology, University of Southern California, Los Angeles, CA; †Department of Biostatistics, Roswell Park Cancer Institute, Buffalo, NY; ‡Department of Gynecologic Oncology, University of Southern California, Los Angeles, CA; §Gynecologic Oncology, Oregon Health and Science University and Knight Cancer Institute, Portland, OR
Abstract The use of neoadjuvant chemotherapy followed by tumor reduction surgery, also called interval debulking surgery (IDS), is considered an alternative therapeutic regimen for selected patients with advanced stage epithelial ovarian cancer (EOC). Although minimal residual disease has been proven to be a prognostic factor in traditional cytoreduction for advanced stage EOC, predictive factors after IDS still remain unexplored. The aim of this study was to determine the prognostic value of post-neoadjuvant histologic changes with clinical outcome. Three pathologists evaluated 67 cases for the following parameters: fibrosis, necrosis, residual tumor, and inflammation. The Cohen's kappa statistic was used to measure agreement among pathologists. Univariate and multivariate Cox proportional hazards models were used to determine the association between histologic parameters and recurrencefree survival (RFS) and overall survival (OS). There was substantial to almost perfect agreement among the three pathologists in all four histologic parameters (k ranged from 0.65 to 0.97). Fibrosis was associated with longer RFS (P = 0.0257) with a median of 20 months for tumors with fibrosis (3+) versus 12 months for tumors with fibrosis (1+, 2+) and longer OS (P = 0.0249) with a median of 51 months for tumors with fibrosis (3+) versus 32 months for tumors with fibrosis (1+, 2+). Our results revealed that patients with tumors exhibiting fibrosis (1+, 2+), as well as necrosis (0, 1+), had significant shorter RFS and OS (P = 0.059 and P = 0.0234, respectively). We suggest that the assessment of fibrosis and necrosis should be implemented in pathologic evaluation and prospectively validated in future studies. Translational Oncology (2012) 5, 469–474
Introduction Epithelial ovarian cancer (EOC) is the most common type of ovarian cancer, representing 80% to 90% of all ovarian cancers. It is the leading cause of death in the United States in women diagnosed with gynecologic malignancies with 21,990 new cases and 15,460 women estimated to die of ovarian cancer in 2011 [1]. The high mortality rate is mainly due to advanced stage disease at initial diagnosis. Primary cytoreduction surgery followed by chemotherapy is considered the standard of care for patients with advanced stage surface EOC [2]. There have been several debates about whether neoadjuvant chemotherapy followed by interval debulking surgery (IDS) is superior to primary tumor reductive surgery. In fact, a recent randomized clinical
trial has shown that the survival rate after neoadjuvant platinum– based chemotherapy followed by IDS is similar to the survival after the standard approach of primary cytoreduction surgery followed by chemotherapy in women with advanced stage (stage IIIC and stage Address all correspondence to: Paulette Mhawech-Fauceglia, MD, Department of Surgical Pathology, LAC+USC Medical Center, 1100 N. State St, Outpatient Tower, Rm 7A116, Los Angeles, CA 90033. E-mail:
[email protected], pfauceglia@ hotmail.com 1 No funding sources to declare. The authors declare that there is no conflict of interest. Received 1 August 2012; Revised 1 August 2012; Accepted 23 August 2012 Copyright © 2012 Neoplasia Press, Inc. Open access under CC BY-NC-ND license. 1944-7124/12 DOI 10.1593/tlo.12265
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IV) EOC [3]. Furthermore, the recent National Comprehensive Cancer Network guidelines for 2012 recommended that physicians should consider neoadjuvant chemotherapy with carboplatin and paclitaxel, rather than immediate surgery, in selected patients. This recommendation was supported by strong clinical data, indicating that using this approach decreases surgical morbidity with equivalent survival times [4]. The morphologic effects on ovarian carcinoma after neoadjuvant chemotherapy have been described and consist of a wide range of changes in both tumor cells and stroma. The changes in tumor cells consist of nuclear and cytoplasmic alterations including nuclear enlargement, hyperchromasia, chromatin clumping and smudging, eosinophilia, and vacuolization and foamy/clear cell changes. The stromal alterations consist of dense fibrosis, inflammation, foamy histiocytes, cholesterol clefts, necrosis, and dystrophic calcifications [5,6]. Similar morphologic effects of neoadjuvant chemotherapy or chemoradiation therapy in other organs such as pancreas, breast, rectum, and esophagus have also been described in the literature [7–13]. In advanced stage EOC treated with standard cytoreduction followed by chemotherapy, the best predictive factor for better disease
Translational Oncology Vol. 5, No. 6, 2012 outcome is still defined by successful tumor reduction (residual disease ≤ 1 cm) [14–16]. However, the predictive factors for disease outcome are still lacking for patients treated with the alternative IDS. Therefore, the aims of this study are two-fold: 1) to assess specific, seemingly reproducible morphologic parameters such as percentage of residual tumor (RT), fibrosis, necrosis, and inflammation on hematoxylin-eosin slides from patients with ovarian cancer treated with neoadjuvant chemotherapy for advanced stage EOC and 2) to determine whether each of these morphologic parameters or any of their combinations might be helpful in predicting patient outcome.
Materials and Methods
Patient Population After institution-specific institutional review board (IRB) approval, patients with advanced stage EOC treated with neoadjuvant therapy between January 2002 and December 2011 were retrospectively identified through the medical and pathology records at the University of Southern California and the Oregon Health and Science University. The initial diagnosis was made by core biopsy or cytology of the ascitic
Figure 1. An example of high-grade serous carcinoma case presenting with ≥50% RT (3+): (A) ×10, (B) ×20, and (C) ×60. A case of ovary with RT of 6% to 50% (2+): (D) ×10, (E) ×20, and (F) ×60. A case of ovary with minimal RT of 0% to 5% (1+): (G) ×10, (H) ×20, and (I) ×60.
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disease burden intraoperatively. Hematoxylin and eosin slides from the debulking surgery were retrieved from the pathology archives, and the clinical and follow-up data were retrieved from medical records. The pathology reports were reviewed to assess tumor sampling; when the ovaries were small and fibrotic, they were submitted entirely. Furthermore, one section for every 1 cm of tumor was submitted for histologic evaluation when tumors were bulky and large. Sixty-seven patients were available for evaluation. Pathology archives and medical records were searched for the time of initial diagnosis and disease status at last follow-up from initial diagnosis. The end point of recurrence-free survival (RFS) was defined as the time of recurrence. The end point of overall survival (OS) was tumor-related death. The RFS was calculated from the time of diagnosis to the time of recurrence. The OS was calculated from the time of diagnosis to the time of last follow-up.
Study Design
Figure 2. (A) A case of ovarian carcinoma with mild fibrosis (1+) ×40, (B) moderate fibrosis (2+) ×40, and (C) severe fibrosis (3+) ×40.
fluid. All patients had imaging studies and serum cancer antigen-125 levels. After diagnosis, the patient was given carboplatin (AUC 5) and paclitaxel (175 mg/m2) for three or four cycles. The patients were then reassessed with computerized tomography scanner (CT scan) and sometimes with serum carcinoembryogenic antigen (CEA) levels. If tumor burden was reduced, the patient underwent IDS, and another three or four cycles was administered after surgery depending on the
There were two American Board–certified pathologists (P.M.F. and F.O.) and one resident trainee in pathology (D.S.) involved in this study. The first pathologist (P.M.F.) is a general pathologist with 12 years of experience and expertise in gynecologic pathology; the second pathologist (F.O.) is a general pathologist with 3 years of experience, and the third pathologist (D.S.) is a fourth-year pathology resident. Of all the histologic changes seen after neoadjuvant therapy, four parameters were considered for assessment, namely, fibrosis, necrosis, percent RT, and inflammation. Fibrosis was scored as mild (1+), moderate (2+), and severe (3+); necrosis was scored as absent (0), 1% to 50% (1+), and present >50 (2+); RT was scored as 50% (3+); and inflammation was scored as mild (1+) and extensive (2+) (Figures 1, A–I , 2, A–C , 3, A and B, and 4, A and B). These grading cutoffs were chosen on the basis of previous studies [16–18]. The grading assessment was performed on the hematoxylin-eosin slides of the primary tumor site. The slides were given to one pathologist at a time for scoring. Afterward, using a multiheaded scope, the scores of each of the four parameters on each case was reviewed, and when there was a discrepancy in scoring, a consensus was reached.
Statistical Study Statistical analyses were performed by R (http://www.r-project.org/). The Cohen kappa statistic was used to measure agreement among the three pathologists for the four histologic parameters studied (fibrosis,
Figure 3. (A) A case of ovarian carcinoma with severe inflammation associated with tumor cells (×60). (B) A case of ovarian carcinoma with mild inflammation association with tumor cells (×60).
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Figure 4. (A) Tumor exhibiting tumoral necrosis ≥ necrosis (2+) (×20). (B) Higher magnification shows ghost cells (×40).
RT, necrosis, and inflammation). Kappa values were interpreted as follows: 50% residual disease, 8 of 67 (11.94%) cases had >50% necrosis, and 31 of 67 (46.27%) cases showed severe inflammation. The intraobserver agreement is illustrated in Table 2. There was substantial agreement for assessment of “fibrosis” with a k value of 0.756, 0.713, and 0.669 for reviewers 1, 2, and 3, respectively (P < .001). There was a substantial to almost perfect agreement for “RT” assessment with a k value of 0.867, 0.646, and 0.736 for reviewers 1, 2, and 3, respectively (P < .001). There was almost a perfect agreement for “necrosis” assessment with a k value of above 0.83 for all three pathologists (P < .001), and finally, Table 2. Interobserver Agreement for Each of the Four Histologic Parameters.
24 (35.82) 16 (23.88) 27 (40.3) Fibrosis 29 (43.28) 22 (32.84) 16 (23.88)
RT
40 (59.7) 19 (28.36) 8 (11.94)
Necrosis
36 (53.73) 31 (46.27)
Inflammation
Pathologist
Agreement
k
95% CI for k
P Value
rev1 rev2 rev3 rev1 rev2 rev3 rev1 rev2 rev3 rev1 rev2 rev3
84.1% 81.2% 78.3% 91.3% 76.8% 82.6% 98.6% 91.3% 92.8% 91.3% 84.1% 85.5%
0.756 0.713 0.669 0.867 0.646 0.736 0.973 0.831 0.859 0.828 0.674 0.713
0.623 0.572 0.521 0.766 0.495 0.601 0.920 0.702 0.740 0.696 0.497 0.548
