Testing Drug Sensitivity of Ovarian, Fallopian and Primary Peritoneal Adenocarcinomas

1. 0 Background and Rationale: Despite the use of aggressive treatment protocols, less than
10% of cancer patients with an advanced disease respond to the therapy. There is a
variety of different cancer drug regimens, all of which have approximately the same
probability of clinical effectiveness. Identification of those patients who will or will
not respond to a specific chemotherapy is important for making decisions regarding
chemotherapy regimens as well as alternative management approaches. A laboratory test
that could help to determine the sensitivity of an individual patient's tumor cells to
specific chemotherapeutic agents would be valuable in choosing the optimal chemotherapy
regimen for that patient with an expectation of increasing the response rate to the
therapy. Several types of in vitro assays that measure tumor cell survival following
exposure to cytotoxic agents have been evaluated for their ability to predict
chemotherapy outcomes. As a group, these assays are referred to as drug resistance
assays. In a resistance assay, the surviving tumor cells can be detected directly by
their exclusion or metabolism of specific dyes. Alternatively, since some of tumor cells
are proliferating, their survival can be detected by measurement of DNA synthesis by
radiolabeled precursor incorporation or demonstration of clonogenic potential by growth
into colonies in semi-solid culture medium. In several clinical studies, these assays
were useful in detecting drug resistance and in predicting a poor prognosis for cancer
patients. However, these resistance assays cannot detect sensitivity of an individual
patient's tumor cells to a specific drug. Therefore, new methods determining
drug-sensitivity of the tumor cells of an individual patient and, thus, capable of both
predicting a positive treatment outcome and guiding chemotherapy, would be of
significant value.

Recently, Dr. Kravtsov has developed an automated microculture kinetic (MiCK) assay for
measuring drug induced apoptosis in tumor cells. Apoptosis is a distinct mode of cell death
which occurs under physiological conditions and yet can be induced in malignant cells by
chemical and physical factors including antitumor drugs. During the last decade, it has been
recognized that chemotherapeutic agents exert their antitumor activity by triggering
apoptosis in susceptible tumor cells. This implies that the MiCK assay for apoptosis provides
a mechanism-based approach to studying effects of cytotoxic agents on tumor cells. Unlike
"resistance" assays that measure a fraction of cells surviving drug exposure, the MiCK assay
measures a fraction of tumor cells killed by a chemotherapeutic agent via mechanism of
apoptosis. Therefore the MiCK assay determines drug sensitivity, rather than resistance.
Recently the MiCK assay has been shown to predict complete remission rate and survival in
acute myeloid leukemia patients better than clinical criteria did. In a limited study, the
MiCK assay has been used to direct chemotherapy of the leukemia patients .

The MiCK assay has also been used to study drug-induced apoptosis in solid tumors, including
neuroblastoma and colon adenocarcinoma cell lines. More recent data accumulated by DiaTech
has demonstrated that the MiCK assay can detect drug induced apoptosis in primary cultures of
tumor cells isolated from patients with ovarian carcinoma, gastric carcinoma, metastatic
breast cancer and high grade soft tissue sarcoma. Based on these data, we suggest that the
MiCK assay may be used to detect drug sensitivity profiles of individual patients with
various types of solid tumors. This, in turn, may provide a way to tailor chemotherapy to an
individual patient's drug sensitivity profile, and, thus, improve treatment outcomes,
decrease adverse effects of the chemotherapy, increase the quality of patient's life, and
reduce the treatment cost.

Inclusion Criteria:

- Patients with pathological diagnoses of ovarian, fallopian and primary peritoneal
adenocarcinomas.

- Patients with de novo malignancies and no previous chemotherapy

- Patients with advanced refractory malignancies who received no more than 2 standard
chemotherapy treatment protocols.

- Patients of any age group.

- Patients must have tumor which is accessible and agree to undergo biopsies, or
drainage of effusions.

- Patients for whom chemotherapy is a treatment option.

- Explanations: We anticipate that newly diagnosed patients will be mostly used to
evaluate the ability of the MiCK assay to predict the outcome of the chemotherapy
(Objective #2.1) and to establish criteria correlating numerical response in the MiCK
assay with probability of the clinically established complete remission. The patients
with refractory malignancies will be mostly used to evaluate the ability of the MiCK
assay to guide cancer chemotherapy (Objective #2.2). Patients will be seen and managed
as outpatients or inpatients, depending on a clinical standard of the institution

Exclusion Criteria:

- Patients with symptomatic/uncontrolled parenchimal brain metastasis and not accessible
tumors.

- Patients with meningeal metastasis.

- Patients for whom chemotherapy clinically is not indicated.

- Pregnancy. During the course of the study, all patients of childbearing potential
should be instructed to contact the treating physician if they suspect they might have
conceived a child; for females, a missing or late menstrual period should be reported
to the treating physician. If pregnancy is confirmed by a pregnancy test, the patient
must not receive study medication and must not be enrolled into the study or, if
already enrolled, must be withdrawn from the study. If a male patient is suspected of
having fathered a child while on the study drugs, the pregnant female partner must be
notified and counseled regarding the risk to the fetus. Pregnancy during the course of
this study will be reported to the Principal Investigator as a serious adverse event.
Women of child bearing potential are defined to include any female who has experienced
menarche and has not undergone successful surgical sterilization (hysterectomy,
bilateral tubal ligation, or bilateral oophorectomy) or is not post-menopausal
(defined as amenorrhea for more than 12 consecutive months); these includes also
females using oral, implanted, or injectable contraceptive hormones, mechanical
devices, or barrier methods to prevent pregnancy.