A multi-institutional study of minimally invasive surgery compared to laparotomy for interval debulking after neoadjuvant chemotherapy in women with advanced ovarian cancer

Abstract

<h3>Objectives:</h3> Neoadjuvant chemotherapy (NAC) is becoming more ubiquitous for treatment of advanced epithelial ovarian cancer (EOC), and mode of interval debulking surgery (IDS) has not been adequately evaluated. A minimally invasive surgical (MIS) approach offers several advantages to an open approach (O-IDS), especially in the current COVID-19 pandemic, but data regarding outcomes are limited. We sought to compare the surgical and oncologic outcomes of MIS and O-IDS in patients (pts) with advanced EOC. <h3>Methods:</h3> All consecutive patients with stages III to IV EOC who underwent NAC followed by IDS from 2008-2018 at 3 tertiary care centers were included in this retrospective cohort study. Demographic, clinical, and pathologic factors were abstracted from electronic medical records. Progression-free survival (PFS) and overall survival (OS) were analyzed on a Kaplan-Meier estimator using the log-rank method, and Cox proportional hazards regression models were used for univariate and multivariate survival analyses. <h3>Results:</h3> A total of 415 pts underwent IDS through MIS (n=122; robotic=78, laparoscopic=44), or O-IDS (n=293). There were no statistically significant differences between age at diagnosis (O-IDS 63.2, MIS 65.3; p=0.1), stage (p=0.3), and grade (p=0.06). There were also no differences between CA-125 levels measured at diagnosis (O-IDS 3145 U/mL, MIS 2247 U/mL; p=0.2) or after completion of NACT (O-IDS 251.7 U/mL, MIS 179.1 U/mL; p=0.4) between the 2 groups. MIS was completed without conversion in 84 of 122 patients (68.8%), with most conversions occurring in the robotic group. Patients undergoing MIS had significantly fewer complex surgeries, with 81% of the cases categorized as low complexity when scored using the Aletti SCS, compared to 64% of open surgeries (p<0.001). Patients undergoing open surgeries had significantly higher estimated blood loss (EBL; 326.2cc vs 181.5cc; p<0.001) and intraoperative transfusion rate (25% vs 4%; p<0.001). These patients also had a longer hospital length of stay (5.9 days vs 2.2 days; p<0.001) as well as 30-day postoperative complication rate (43% vs 20%, p<0.001). There were no observed differences between the 2 groups in terms of operative time (191.1 minutes vs 196.3 minutes; p=0.5) and 30-day hospital readmission rates (10% vs 6%; p=0.2). With regard to surgical cytoreduction, patients undergoing MIS had significantly higher rates of both R0 (66% vs 46%; p<0.001) and optimal, or R0/R1 (93% vs 84%; p=0.02) debulking rates. Patients undergoing open surgery trended towards having a higher rate of recurrence at 24 months after diagnosis, but this difference did not reach significance (70% vs 60%; p=0.06). Finally, there were no differences in the 2 groups in terms of PFS or OS (Figure 2). Median PFS was 15.1 months for O-IDS and 18.2 months for MIS (p=0.051). Median OS was 36.7 months for O-IDS and 40.9 months for MIS (p=0.5). <h3>Conclusions:</h3> MIS is a feasible and potentially effective mode of IDS after NAC in patients with advanced EOC. Surgical outcomes appear to be advantageous in MIS compared with O-IDS, and oncologic outcomes appear to be no different. Further investigation of robotic MIS compared with laparoscopic MIS for IDS is warranted.