Complete Secondary Cytoreduction Research Articles

Robotic Rectosigmoid Resection with Totally Intracorporeal Colorectal Anastomosis (TICA) for Recurrent Ovarian Cancer: A Case Series and Description of the Technique.

Most patients with ovarian cancer relapse within 2 years. Prospective randomized trials, such as DESKTOP III and SOC-I, have shown the role of secondary cytoreduction in improving oncological outcomes in selected patients, when complete tumor resection is achieved. Recent retrospective series suggest that minimally invasive surgery is a feasible option in oligometastatic recurrences, such as rectal ones. Five patients with an isolated rectal recurrence infiltrating the bowel wall underwent a robotic rectosigmoid resection with totally intracorporeal colorectal anastomosis. The procedure began with retroperitoneal access to manage the vascular structures, followed by visceral resection with a minimally invasive approach. The standard steps of an en-bloc pelvic resection, including intracorporeal end-to-end anastomosis, were performed. The treatment data were evaluated. The mean age of the patients was 54 years, and their mean body mass index was 30. All patients had at least one previous abdominal surgery and 60% had high-grade serous ovarian cancer at their initial diagnosis. Their mean platinum-free interval was 17.4 months. Complete secondary cytoreduction was achieved in all cases, with histopathology confirming bowel infiltration. The mean procedure duration was 294 min, with an estimated blood loss of 180 mL. No intraoperative complications occurred. The mean hospital stay was 8 days. One patient had a grade 2 postoperative complication. The mean follow-up period was 14 months, with only one patient experiencing a recurrence at the level of the abdominal wall. Robotic rectosigmoid resection is a viable option for complete cytoreduction in isolated recurrent ovarian cancer.

Can PET-CT predict complete secondary cytoreduction in ovarian cancer?

Objective: To analyze the role of PET-CT (18F-FDG) in predicting complete surgical resection in recurrent ovarian cancer.

Role of Intraoperative Ultrasound to Extend the Application of Minimally Invasive Surgery for Treatment of Recurrent Gynecologic Cancer

Study ObjectiveTo describe the potential role of intraoperative ultrasound (IOUS) in the detection and localization of recurrent disease in gynecologic cancer patients during minimally invasive surgery (MIS). DesignA prospective cohort study (Canadian Task Force classification II-1). SettingA university hospital. PatientsFifty-one gynecologic cancer patients with isolated recurrent disease. InterventionsIOUS during secondary cytoreductive surgery (SCS) by MIS. Measurements and Main ResultsFrom November 2015 to February 2017 51 gynecologic cancer patients with isolated recurrent disease and candidates for SCS were treated by MIS. Recurrent tumor was preoperatively assessed at clinical examination, transvaginal and transabdominal sonography, and radiologic evaluation in all women. Twelve of 51 women (23.5%) needed IOUS. Type of disease was ovarian in 5 women (42%), endometrial in 4 (33%), cervical in 1 (8%), vaginal cancer in 1 (8%), and uterine sarcoma in 1 (8%). Recurrence was localized deep in the pelvis in 7 cases (58%), lymph nodes in 3 (25%), and extraperitoneal in 2 cases (17%). Recurrence was dimmed in the surgical field, due to either presence of adherences, deep anatomic position, small size, and/or lack of tactile feeling. IOUS was able to identify the lesions in all women, allowing MIS (83% laparoscopy and 17% robotic) complete cytoreduction, with no conversion to laparotomy. Median operative time was 150 minutes (range, 77–280). No intraoperative/postoperative complications occurred. Histologic examination confirmed the presence of recurrence in 11 of 12 cases (92%), whereas the remaining case showed inflammatory tissue. With a median follow-up time of 15 months (range, 6–19), all patients except 2 were still alive. ConclusionsAbout 1 of 4 patients (25%) with single gynecologic cancer recurrence needs IOUS to benefit from MIS for complete secondary cytoreduction.

REPEATED OPTIMAL CYTOREDUCTIVE SURGERIES IN COMBINED MODALITY TREATMENT OF OVARIAN CANCER. CASE REPORT

To date, the algorithm for the treatment of recurrent ovarian cancer and the criteria for selecting patients for performing secondary cytoreductive surgeries have not been fully developed. Although the role of secondary surgery in recurrent ovarian cancer remains controversial, most retrospective studies showed better survival in patients for whom maximal cytoreduction was achieved. Several studies have developed prognostic models for the feasibility of performing complete secondary cytoreduction. We report a rare case of repeated cytoreductive surgeries in combination with chemotherapy for recurrent ovarian cancer. This clinical case indicates the feasibility of performing repeated cytoreductive surgeries in patients with localized recurrent ovarian cancer undergoing previous optimal cytoreductions and having no ascites.

Performance of AGO score for secondary cytoreduction in a high-volume U.S. center

ObjectivesDetermine the predictive value of the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) score, and prognostic factors for survival, in patients undergoing secondary cytoreductive surgery (SCS) for recurrent ovarian cancer in a high-volume U.S. center. MethodsMedical records of women undergoing SCS between 12/1/1998 and 12/31/2013 were reviewed. Women with no gross residual disease (RD0) at primary surgery, ECOG performance status (PS) ≤1 at recurrence, and no ascites on CT at recurrence were classified as AGO score positive. Women with incomplete information to determine the AGO score were excluded. Overall survival (OS) and progression-free survival (PFS) following SCS, respectively, were estimated from multivariable Cox proportional hazards models. Results192 women met inclusion criteria. Median disease-free interval (DFI) was 1.9years (IQR, 1.0–3.5). Of the 102 (53.1%) AGO score positive cases, 84.3% (95% CI, 77.3–91.4%) achieved RD0 at SCS. However, 64.4% of AGO score negative cases also reached RD0. Patients with RD0 after SCS survived longer (median OS, 5.4years) vs. RD ≤1cm (2.4years) vs. RD >1cm (1.3years) (p<0.001). Median PFS was also longer in patients with RD0 (1.5years) vs. RD ≤1cm (0.9years) vs. RD >1cm (1.0years) (p=0.001). Among those with RD0 at SCS, AGO score was not associated with survival benefit, however, number of disease sites at recurrence, ECOG PS at recurrence, and DFI were associated with OS and PFS. ConclusionsAGO score can identify patients with a high likelihood of complete secondary cytoreduction and improved survival. However, most AGO score negative cases were also completed resected at SCS. Additional refinement of the score is needed to exclude women from SCS.

A Risk Model for Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer: An Evidence-Based Proposal for Patient Selection

To develop a risk model for predicting complete secondary cytoreductive surgery (SCR) in patients with recurrent ovarian cancer. Individual data of 1075 patients with recurrent ovarian cancer undergoing SCR from 7 worldwide centers were pooled and analyzed. The risk model was developed based on the factors impacting on SCR surgical outcome. Additional data on 117 patients who were not included in the development of the model were used for external validation and to assess the discrimination of the model. Of the 1075 patients, 434 (40.4%) underwent complete resection. Complete secondary cytoreduction was associated with six variables: FIGO stage (odds ratio [OR] = 1.32, 95% confidence interval [95% CI]: 0.97-1.80), residual disease after primary cytoreduction (OR = 1.69, 95% CI: 1.26-2.27), progression-free interval (OR = 2.27, 95% CI: 1.71-3.01), Eastern Cooperative Oncology Group (ECOG) performance status (OR = 2.23, 95% CI: 1.45-3.44), CA125 (OR = 1.85, 95% CI: 1.41-2.44), and ascites at recurrence (OR = 2.79, 95% CI: 1.88-4.13). These variables were entered into the risk model and assigned scores ranging from 0 to 11.9. Patients with total scores of 0-4.7 were categorized as the low-risk group, in which the proportion of complete cytoreduction was 53.4% compared with 20.1% in the high-risk group (OR = 4.55, 95% CI: 3.43-6.04). In external validation, the sensitivity and specificity was 83.3% and 57.6%, respectively. Area under the curve of the receiver-operating characteristics for predicting complete SCR was 0.68 (95% CI: 0.60-0.79). This model and scoring system may well predict the outcome of SCR and could potentially be useful in future clinical trials to determine which patients with recurrent ovarian cancer should have SCR as part of their management.

Survival after secondary cytoreduction for recurrent ovarian cancer: Which are the prognostic factors?

Significant controversy exists concerning the factors affecting survival after secondary cytoreduction (SCR) in recurrent ovarian cancer. This study aims to identify factors independently associated with survival after SCR. We retrospectively retrieved 39 patients with recurrent ovarian cancer. All patients had been initially treated with primary cytoreduction in our institution and received platinum- and paclitaxel-based chemotherapy postoperatively. Disease-free interval (DFI) had to be longer than 6 months. A variety of clinicopathological factors were recorded. Multivariable Cox regression was performed to examine the associations of parameters with survival. Median survival was equal to 24 months, the median DFI was 22 months, and complete SCR had been achieved in 19/39 patients (48.7%, 95% CI: 32.4-65.2%). Higher number of recurrence sites, clear-cell histological type, and more advanced FIGO stage were independently associated with shorter survival; longer DFI was associated with longer survival. Noticeably, complete SCR lost its significance at the multivariable model, although it was associated with longer survival at the univariable analysis. Four factors seem capable of independently modifying survival after SCR: number of recurrence sites, DFI, FIGO stage, and clear cell histology. The two latter factors might reflect aggressive clinicopathological features of the tumor with long-term effect.

Surgery in recurrent epithelial ovarian cancer: Benefits on Survival for patients with residual disease of 0.1–1 cm after secondary cytoreduction

Recent retrospective trials stated that a benefit of surgery for recurrent ovarian cancer may be limited to patients in whom a complete cytoreduction (R0) could be achieved. Most of them pointed out there was no difference in survival between residual disease of 0.1-1 cm (R1) and >1 cm (R2). The aim of this study was to evaluate survival benefits from cytoreduction to R1. Between 2002 and 2006, 123 patients with recurrent epithelial ovarian cancer undergoing secondary cytoreduction were identified from tumor registry databases. The median age at recurrence was 51 years (range: 28-84). Fifty-one (41.5%) patients had R0, 46 (37.4%) patients had R1, and 26 (21.1%) patients had R2 resection. The median survival of the entire cohort was 31.7 months, with an estimated 5-year survival of 31.1%. The median survival and estimated 5-year survival for patients with R1 were 31.1 months and 23.9%, and there were significant differences in survival when compared to 15.6 months and 6.4% in R2 (chi(2) = 7.45, P = 0.006), 63.2 months (mean survival) and 54.4% in complete cytoreduction (chi(2) = 8.93, P = 0.0028). Complete secondary cytoreduction is the strongest survival determinant in recurrent epithelial ovarian cancer, whereas patients with residual disease of 0.1-1 cm may also benefit from secondary cytoreduction.

Combined PET/CT for detecting recurrent ovarian cancer limited to retroperitoneal lymph nodes

Objective. To evaluate the utility of combined positron emission tomography/computed tomography (PET/CT) for detecting recurrent epithelial ovarian cancer limited to retroperitoneal adenopathy. Methods. Fourteen patients (median age = 53 years) with rising serum CA125 levels, and negative or equivocal conventional CT imaging ≥ 6 months after primary therapy were retrospectively identified as having recurrent disease limited to retroperitoneal lymph nodes by combined PET/CT and underwent surgical reassessment of targeted nodal basins. Fisher's Exact Test was used to measure the ability of PET/CT to predict isolated retroperitoneal nodal disease. Results. The median increase in serum CA125 from baseline nadir was 14 U/ml (range = 2–76 U/ml). There were 29 target nodes in 15 nodal basins identified with increased metabolic uptake on combined PET/CT. Eleven patients (78.6%) had recurrent ovarian cancer in retroperitoneal lymph nodes targeted by PET/CT. Of 143 nodes retrieved, 59 contained recurrent ovarian cancer (median nodal diameter = 2.5 cm, range = 0.8–5.2 cm). For all target nodal basins, the sensitivity, specificity, positive and negative predictive values, and accuracy for recurrent ovarian cancer in dissected lymph nodes were: 40.7% (24/59), 94.0% (79/84), 82.8% (24/29), 69.3% (79/114), and 72.0% (103/143) ( P < 0.001). PET/CT failed to identify microscopic disease in 59.3% of pathologically positive nodes. Conclusion. Combined PET/CT demonstrates high positive predictive value in identifying recurrent ovarian cancer in retroperitoneal lymph nodes when conventional CT findings are negative or equivocal. The high incidence of occult disease within the target nodal basins suggests that regional lymphadenectomy may be necessary for complete secondary cytoreduction of recurrent disease.

Second-look and second surgery: second chance or second best?

About 40 years ago, second-look laparotomy (SLL) was introduced to evaluate, surgically and pathologically, primary treatment in case a clinical complete remission was obtained in ovarian cancer patients. But does SLL increase the disease-free or overall survival? Important technical aspects of the procedure as: how many biopsies should be taken, can laparoscopy be replaced by laparotomy and should complete lymphadnectomy be performed at SLL, are still not clarified. This and maybe even more important issues, are disputed in literature: for instance, should a SLL be done at all, or should a SLL be performed in order to do a secondary cytoreduction in case tumour is found at the operation. If clinical remission is reached in more than 50% of the patients with advanced disease, tumour still can be found at SLL. If no tumour is found at SLL, macroscopically or microscopically, the operation is redundant. Apart from this, the recurrence rate after such a "negative SLL" is about 35%. Whether tumour found at SLL should be removed will depend on the fact if the tumour still is responsive to chemotherapy. To minimise the chance of tumour resistance, secondary surgery should be done as early as possible during treatment. Therefore, an interval debulking will be the intervention of choice. So, as long as there is no evidence that SLL increases the survival in ovarian cancer patients, it should be done in a research setting only. Also, the usefulness of secondary surgery for recurrent disease mainly depends on the chemo-sensitivity of the tumour. After a complete remission, which lasts for more than a year, complete secondary cytoreduction, again followed by chemotherapy, improves survival.