Cytoreductive Surgery For Ovarian Cancer Research Articles

Abstract PR623

Background & Objectives: Massive fluid shifts occur during ovarian cancer (OC) cytoreductive surgery (CRS), which is associated with increased morbidity. Goal directed therapy (GDT) for intra-operative fluid (IOF) has not been widely studied in OC; Only 2 studies showed reduction in median length of stay (LOS) and postoperative morbidity. Objective: To analyse the current IOF management in OC CRS and develop a prospective study comparing GDT versus standard fluid management and measure impact on hospital stay, post-operative morbidity and cost-effectiveness. Materials & Methods: Retrospective observational study using data from electronic medical records between December 2014 and May 2015. Results: Results: Forty-one patients underwent primary debulking surgery (PDS, n=15) or interval debulking (IDS, n=26). Median total IOF administration using standard approach was 5000 ml (crystalloids 3000 ml, colloid 2000 ml). Intra-operative acidosis occurred in 25 % patients, 29 % patients required intraoperative albumin infusion, 56 % required vasopressors on postoperative day 1 (POD1). There was no difference in mean IOF administration between PDS (longer duration of surgery or DOS) (5304 ml, DOS=627 min) vs. IDS (5215 ml, DOS=504 min). Cumulative fluid balance on POD1 was 2435 ml. The median LOS for PDS was 11 days vs. 8 days in IDS. In a later cohort of 4 patients (PDS=3, IDS=1) where GDT was initiated using stroke-volume variability (SVV), median IOF requirement was 8000 ml and no intra- operative acidosis occurred. Conclusion: GDT might give better guidance to replace IOF loss and maintain tissue perfusion in OC CRS.

Diverting ileostomy during primary cytoreductive surgery for ovarian cancer: Associated factors and postoperative outcomes

Diverting ileostomy during primary cytoreductive surgery for ovarian cancer: Associated factors and postoperative outcomes

Improved Postoperative Pain Control for Cytoreductive Surgery in Women With Ovarian Cancer Using Patient-Controlled Epidural Analgesia.

ObjectiveMany studies have compared different methods of postoperative pain management in abdominal laparotomy patients; however, the conclusions have been inconsistent and controversial. This study aimed to compare the pain scores and complications of patients who underwent cytoreductive surgery for ovarian cancer and used either patient-controlled epidural analgesia (PCEA) or patient-controlled intravenous analgesia (PCA) for postoperative pain management. We hypothesized that PCEA would be superior to PCA for postoperative pain management in ovarian cancer surgery.Materials and MethodsThe medical records of women who underwent ovarian cancer surgery in 2014 were reviewed retrospectively. Pain scores for postoperative days (PODs) 0 to 5 days and the incidence of complications were examined and compared in patients who received PCEA and PCA. Means were compared using an independent sample t test or Wilcoxon rank sum test, and proportions were compared using Fisher exact test or a χ2 test at each time point. A mixed-effects model was applied to determine correlations among repeated measurements. A P value less than 0.05 was considered significant.ResultsOf the 105 study patients, 38 received PCEA and 67 received PCA. Pain scores were significantly lower in the PCEA group than the PCA group at POD 0 (2.47 ± 1.75 vs 4.39 ± 1.17; P < 0.001), 1 (2.65 ± 1.02 vs 3.32 ± 1.09; P < 0.001), and 3 (2.17 ± 1.13 vs 2.79 ± 1.08; P = 0.011), and tended to be lower in the PCEA group at PODs 2, 4, and 5. Patient-controlled epidural analgesia provided significantly better pain relief as analyzed by a mixed-effect model. Complications were not significantly different between both groups. There was no significant difference in pain relief between both groups at PODs 4 and 5.ConclusionsPatient-controlled epidural analgesia was more effective for postoperative pain management compared with PCA from POD 0 to POD 3 in patients with ovarian cancer who underwent cytoreductive surgery, without increasing the morbidity.

Outcomes of Splenectomy During Primary Cytoreductive Surgery in Ovarian Cancer

Banerjee, Dipti; Langstraat, Carrie MD, FACS; Janco, Jo Marie MD; Weaver, Amy L.; McGree, Michaela E.; Lemens, Maureen A. RN; Podratz, Karl C. MD, FACS; Bakkum-Gamez, Jamie N. MD Author Information

Effectiveness and Safety of Cytoreduction Surgery in Advanced Ovarian Cancer: Initial Experience at a University General Hospital

Background: The aim of the study was to evaluate the initial efficiency and security of maximal effort cytoreductive surgery in stages III and IV of ovarian cancer at a university hospital. Methods: Thirty-four patients with stage III and IV ovarian carcinoma underwent surgery between January 2013 and June 2014 in the University General Hospital of Castellon (Spain). Patients with primary and relapse ovarian cancer were included. The extent of disease, type of surgical technique, amount of tumor prior to surgery and amount of residual disease after surgery were recorded. To quantify the efficiency and the security of the procedure, the complete cytoreduction and the morbidity and the mortality rates were described. Results: Of the patients 26.4% received neoadjuvant chemotherapy. Complete cytoreductive surgery, without evident residual tumor at the end of the procedure, was obtained in 79% of patients and optimal cytoreductive surgery (CC0-CC1) in 91%. Surgical complications were found in 56% of patients and two deaths (6%) occurred attributable to surgery. The disease free interval was 15 months. Conclusions: This study confirms that with experienced multidisciplinary teams and in tertiary referral hospitals, 79% of complete cytoreduction surgery in advanced ovarian cancer can be achieved but they must be prepared to deal with a high rate of complications. J Clin Gynecol Obstet. 2015;4(3):251-257 doi: http://dx.doi.org/10.14740/jcgo345w

Randomized phase III trial of carboplatin/paclitaxel alone (CP) or in combination with bevacizumab followed by bevacizumab (CPB) and secondary cytoreduction surgery in platinum-sensitive recurrent ovarian cancer: GOG0213, an NRG Oncology/GOG Study—Analysis of patient reported outcomes (PRO) on chemotherapy randomization.

5525 Purpose: GOG 213 is a bifactorial, phase III, randomized trial studying the efficacy and tolerability of the incorporation of B and secondary cytoreduction in women with platinum sensitive rec...

Radical cytoreductive surgery for ovarian cancer in the United States: Trends and associated factors over the past twenty years

Radical cytoreductive surgery for ovarian cancer in the United States: Trends and associated factors over the past twenty years

Benefit of negative pressure drain within surgical wound after cytoreductive surgery for ovarian cancer.

The objective of this study was to investigate the efficacy of subcutaneous negative-pressure wound drains on wound healing after cytoreductive surgery for ovarian cancer. A retrospective study was performed on patients who underwent cytoreductive surgery for epithelial ovarian cancer, between 2012 and 2013. The patients were divided into 2 groups, according to using (n = 163) and not using (n = 37) of subcutaneous wound drains, and wound outcomes were analyzed. Patients' characteristics were not statistically different, except for the prolonged operative time in patients with wound drains (median, 395 vs 240 minutes; P = 0.001). A lower rate of wound infection (12.9% vs 27.0%; P = 0.032) was observed in the drain group. In the multivariate analysis, placement of subcutaneous wound drain was an independent prognostic factor for reducing wound complications: disruption (odds ratio [OR], 0.367; 95% confidence interval [CI], 0.145-0.929; P = 0.034) and wound infection (OR, 0.198; 95% CI, 0.068-0.582; P = 0.003). Bowel surgery at the time of cytoreductive surgery and prolonged operative time (≥360 minutes) were also associated with higher rates of disruption (OR, 2.845; 95% CI, 1.111-7.289; P = 0.029) and wound infection (OR, 4.212; 95% CI, 1.273-13.935; P = 0.019), respectively. Installation of subcutaneous negative-pressure wound drain is an effective method to achieve clearer wound healing and less wound complications after cytoreductive surgery for ovarian cancer.

Is Dexamethasone Associated with Recurrence of Ovarian Cancer?

Basic science studies suggest that perioperative immune impairment may augment the risk of cancer recurrence after otherwise potentially curative surgery. Despite its immunosuppressant properties, dexamethasone is commonly given to oncologic patients in an effort to reduce postoperative nausea and vomiting. We therefore tested the hypothesis that perioperative dexamethasone administration increases the risk of ovarian cancer recurrence. Women who had primary ovarian cytoreductive surgery between January 1997 and October 2007 were identified using a database maintained by the division of Gynecologic Oncology at Northwestern University. Tumor recurrence in women given perioperative systemic dexamethasone (4-10 mg) was compared with those who did not receive dexamethasone. The primary outcome was the propensity-matched time to cancer recurrence. Recurrence was defined by a carcinoantigen 125 >21 U/mL or computerized tomography evidence of the disease followed by tissue confirmation. Median difference and 95% confidence interval between the propensity-matched groups were calculated using a 10,000 sample bootstrap. Among 260 women having primary cytoreductive surgery for ovarian cancer that met our inclusion criteria, 102 subjects were given perioperative systemic dexamethasone. Cancer recurrence was observed in 178 subjects, and the overall unadjusted median (IQR) time to recurrence was 18 (7-50) months. Eighty-seven cases and 87 controls were propensity matched to adjust for confounding covariates. After propensity matching the groups for confounding covariates, the median (IQR) time to recurrence in the dexamethasone group was 23 (6-46) compared with 18 (8-53) months in the control group (P = 0.63) with a median (95% confidence interval) difference of time to recurrence between the dexamethasone and the control group of 5 (-8 to 17) months. We could not find evidence for an association between perioperative systemic dexamethasone administration and ovarian cancer recurrence after primary cytoreductive surgery. Our results do not support avoiding low-dose perioperative dexamethasone for prevention of postoperative nausea, vomiting, and pain in ovarian cancer patients.

Quaternary cytoreductive surgery in ovarian cancer. A literature review.

Quaternary cytoreductive surgery in ovarian cancer. A literature review.

Cytoreduction of para-aortic lymph nodes behind the inferior vena cava and the right renal vessels in a patient with fallopian tube cancer

Objective. The resection of bulky lymph nodes is occasionally required to achieve a complete cytoreductive surgery for ovarian cancer. The most common area in which bulky nodes are encountered is at the level of the renal veins [1]. The authors present a cytoreduction technique for bulkypara-aortic lymph nodes locatedbehindthe inferior vena cava (IVC) and the right renal vessels that involves the mobilization of the right kidney. Methods. A 68-year-old woman underwent a laparotomy for FIGO stage IIIC (pT2c N1 M0) fallopian tube cancer with up-front cytoreductive surgery. Para-aortic adenopathy behind the right renal vessels and right pelvic adenopathy was preoperatively demonstrated on an enhanced computed tomography examination. After performing a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and pelvic lymphadenectomy, cytoreduction of the para-aortic lymph nodes behind the inferior vena cava and the right renal vessels was performed as follows: first, an incision was made along the peritoneal reflection in the right lumbar gutter. The right

Gene Expression and Prediction of Complete Cytoreduction in Ovarian Cancer

INTRODUCTION: The objective of this study was to investigate the role of microarray gene expression analysis in predicting the feasibility of complete cytoreduction in ovarian cancer. METHODS: Microarray expression of 507 women with ovarian cancer from The Cancer Genome Atlas was initially analyzed and a gene expression signature created. Complete cytoreduction was defined as removal of all tumors with no macroscopic residual disease. The model was applied to the Australian Ovarian Cancer Study data set with 216 ovarian cancer samples. RESULTS: One hundred fifteen women had complete cytoreduction in The Cancer Genome Atlas data set with significantly higher 5-year overall survival as compared with the 392 women with macroscopic residual disease (P<.001). A total of 12,718 genes were analyzed; 142 predicted accuracy of complete cytoreduction 69% of the time (P=.02). The model was more precise in predicting incomplete cytoreduction with macroscopic residual tumor with a sensitivity of 82% and a positive predictive value of 78%. The performance, measured by the area under the receiver operating characteristic curve was 63%. When applied to the Australian Ovarian Cancer Study set, with 58 women with complete cytoreduction and 158 with macroscopic residual, the accuracy was 72% (P<.019) and it was still more sensitive predicting incomplete cytoreduction with a sensitivity of 83% and a positive predictive value of 79%, and the area under the receiver operating characteristic curve was 68%. CONCLUSIONS: This analysis stresses again on the importance of complete cytoreductive surgery in ovarian cancer to microscopic disease and shows that gene expression analysis might have a role in predicting patients who are not amenable to complete cytoreduction and thus would have shorter survival.

Application of a subcutaneous negative pressure drain without subcutaneous suture: impact on wound healing in gynecologic surgery

ObjectiveTo evaluate the surgical outcome of a subcutaneous negative pressure drain without subcutaneous suture on wound healing in women undergoing abdominal gynecologic surgery. Study designThe medical records of total 322 patients who underwent abdominal surgery, including cytoreductive surgery for ovarian cancer, between March 2010 and January 2013 were reviewed retrospectively. Patients were divided into two groups by the presence of subcutaneous negative pressure drains without subcutaneous suture, or suture without drainage. ResultsPatient's characteristics in the two groups were not statistically different. Among all patients, the 71 patients who had a subcutaneous wound drain achieved a higher rate of clear healing (97.2% vs. 88.8%; p=0.033): 100% vs. 98.0% (not significant) in 126 benign and 95.6% vs. 82.8% (p=0.032) in 196 malignant disease patients. In a multivariate analysis, wound drain placement was an independent prognostic factor affecting the surgical wound outcome; the disruption (OR, 0.100; 95% CI, 0.021–0.485; p=0.004) rate was significantly lower with subcutaneous negative pressure drain. Placement of a subcutaneous negative pressure drain without subcutaneous suture resulted in clinical benefit, such as shorter admission duration (median, 8 vs. 11 days; p=0.021). ConclusionsApplication of subcutaneous negative pressure drain is one of the effective and easy ways for clearer wound healing after major gynecologic surgery for malignant disease.

Postoperative outcomes among patients undergoing thoracostomy tube placement at time of diaphragm peritonectomy or resection during primary cytoreductive surgery for ovarian cancer

ObjectivePrimary cytoreductive surgery in patients with stage IIIC–IV epithelial ovarian cancer frequently includes diaphragm peritonectomy or resection, which can lead to symptomatic pleural effusions when the resection specimen is ≥10cm. Our objective was to evaluate whether the placement of an intraoperative thoracostomy tube decreased the incidence of symptomatic pleural effusions in these cases. MethodsWe identified 156 patients who underwent primary debulking surgery involving diaphragm peritonectomy or resection for stage III–IV ovarian cancer from 1/01–12/09. Using standard statistical tests, the incidence of symptomatic pleural effusions and other variables were compared between patients who did and did not have intraoperative chest tubes placed. ResultsForty-nine patients had a resected diaphragm specimen ≥10cm in largest dimension; 28 (57%) did not undergo chest tube placement (NCT group) while 21 (43%) did (CT group).Mediastinal lymph node dissection (0% vs 19%, P=0.028) and liver resections (11% vs 38%, P=0.037) were higher in the CT group.Postoperatively, 57% of the NCT group developed a moderate or large pleural effusion compared to 19% of the CT group (P=0.007). Thirteen patients (46%) in the NCT group developed respiratory symptoms requiring either placement of a postoperative chest tube or thoracentesis compared to 3 patients (14%) in the CT group (P=0.018). ConclusionsDiaphragm peritonectomy or resection can often lead to moderate or large pleural effusions that may become symptomatic. In these patients, intraoperative chest tube placement may be considered to decrease the incidence of symptomatic effusions and the need for postoperative chest tube placement or thoracentesis.

Management of Pancreatic Fistulas After a Splenectomy as Part of Cytoreductive Surgery for Ovarian Cancer

This study evaluated the incidence of postoperative morbidities, focusing specifically on pancreatic fistulas, after a splenectomy performed as part of cytoreductive surgery for the treatment of ovarian cancer. A retrospective chart review was performed for all the patients with ovarian, tubal, or peritoneal cancer who underwent splenectomy during a 5-year period. Patient-, disease-, and surgery-related data were collected. Pancreatic fistulas were identified when the drainage fluid obtained via a surgically placed drain had an amylase content greater than 3 times the normal serum value after postoperative day 3. A splenectomy was performed in 21 patients. Postoperative pancreatic fistulas developed in 6 patients (29%). Of these 6 patients, 2 had no symptoms and did not require specific treatment for their pancreatic fistulas. Therapeutic intervention was required in the remaining 4 patients. The durations of oral feeding prohibition and the use of a peripancreatic drain were longer in the patients with a pancreatic fistula than in those without a pancreatic fistula. Overall, the pancreatic fistulas were managed conservatively or using minimally invasive procedures. Staple-line reinforcement seemed to be an effective means of closing the transected stump during the splenectomy, compared with the standard stapling technique. Elevated amylase levels in the drainage fluid reflect the patient's actual condition better than serum amylase levels. We recommend the intraoperative placement of a peripancreatic drain and postoperative measurement of amylase concentrations in the drainage fluid to identify the development of pancreatic fistulas and to facilitate the management of this complication.

Quaternary Cytoreductive Surgery in Ovarian Cancer

To evaluate surgical outcome and survival benefit after quaternary cytoreduction (QC) in epithelial ovarian cancer (EOC) relapse. We systematically evaluated all consecutive patients undergoing QC in our institution over a 12-year period (October 2000–January 2012). All relevant surgical and clinical outcome parameters were systematically assessed. Forty-nine EOC patients (median age: 57; range: 28–76) underwent QC; in a median of 16 months (range:2–142) after previous chemotherapy. The majority of the patients had an initial FIGO stage III (67.3%), peritoneal carcinomatosis (77.6%) and no ascites (67.3%). At QC, patients presented following tumour pattern: lower abdomen 85.7%; middle abdomen 79.6% and upper abdomen 42.9%. Median duration of surgery was 292 min (range: a total macroscopic tumour clearance could be achieved. Rates of major operative morbidity and 30-day mortality were 28.6% and 2%, respectively. Mean follow-up from QC was 18.41 months (95% confidence interval (CI):12.64–24.18) and mean overall survival (OS) 23.05 months (95% CI: 15.5–30.6). Mean OS for patients without vs any tumour residuals was 43 months (95% CI: 26.4–59.5) vs 13.4 months (95% CI: 7.42–19.4); P=0.001. Mean OS for patients who received postoperative chemotherapy (n=18; 36.7%) vs those who did not was 40.5 months (95% CI: 27.4–53.6) vs 12.03 months (95% CI: 5.9–18.18); P<0.001. Multivariate analysis indentified multifocal tumour dissemination to be of predictive significance for incomplete tumour resection, higher operative morbidity and lower survival, while systemic chemotherapy subsequent to QC had a protective significant impact on OS. No prognostic impact had ascites, platinum resistance, high grading and advanced age. Even in this highly advanced setting of the third EOC relapse, maximal therapeutic effort combining optimal surgery and chemotherapy appear to significantly prolong survival in a selected patients ‘group’.

Postoperative outcomes among patients undergoing thoracostomy tube placement at time of diaphragm peritonectomy or resection during primary cytoreductive surgery for ovarian cancer

Objective: Primary cytoreductive surgery in patients with stage IIIC-IV epithelial ovarian cancer frequently includes diaphragm peritonectomy or resection, which can often lead to symptomatic pleural effusions with larger (≥10cm) specimens. Our objective was to evaluate if the placement of an intraoperative chest tube decreased the incidence of symptomatic pleural effusions when ≥10cm diaphragm peritonectomies/resections were performed.

Optimal (≤ 1 cm) but visible residual disease: Is extensive debulking warranted?

ObjectivesTo determine if extensive upper abdominal surgery (UAS) affected overall survival (OS) in patients left with ≤1cm but visible residual disease after undergoing primary cytoreductive surgery for ovarian cancer. Our secondary objective was to determine if leaving ≤1cm but visible residual throughout the small bowel (SB) conferred a worse prognosis. MethodsAll stage IIIB–IV ovarian cancer patients who had visible but ≤1cm residual disease at time of primary cytoreductive surgery from 2001 to 2010 were identified. Extensive UAS procedures and residual SB involvement were recorded. ResultsThe 219 patients identified with ≤1cm but visible residual disease had a median OS of 51months. In this cohort, 127 had extensive UAS performed, and 87 had residual disease involving the SB. Univariate OS analysis was performed. There was no significant difference in OS between patients who did or did not have extensive UAS (45 vs. 52months, P=0.56), or between patients with or without residual SB disease (45 vs. 51months, P=0.84). Factors that were significantly associated with OS were age, ASA score, family history, and stage. ConclusionsPatients cytoreduced to ≤1cm but visible residual disease who required UAS did not have a worse OS than those who did not require UAS. OS was similar if residual disease involved the SB or not. For ovarian cancer patients with disease not amenable to complete gross resection, extensive surgery should still be considered to achieve ≤1cm but visible residual disease status, including cases where the residual disease involves the SB.

Quaternary cytoreductive surgery in ovarian cancer: does surgical effort still matter?

Background:To evaluate surgical outcome and survival benefit after quaternary cytoreduction (QC) in epithelial ovarian cancer (EOC) relapse.Methods:We systematically evaluated all consecutive patients undergoing QC in our institution over a 12-year period (October 2000–January 2012). All relevant surgical and clinical outcome parameters were systematically assessed.Results:Forty-nine EOC patients (median age: 57; range: 28–76) underwent QC; in a median of 16 months (range:2–142) after previous chemotherapy. The majority of the patients had an initial FIGO stage III (67.3%), peritoneal carcinomatosis (77.6%) and no ascites (67.3%). At QC, patients presented following tumour pattern: lower abdomen 85.7% middle abdomen 79.6% and upper abdomen 42.9%. Median duration of surgery was 292 min (range: a total macroscopic tumour clearance could be achieved. Rates of major operative morbidity and 30-day mortality were 28.6% and 2%, respectively.Mean follow-up from QC was 18.41 months (95% confidence interval (CI):12.64–24.18) and mean overall survival (OS) 23.05 months (95% CI: 15.5–30.6). Mean OS for patients without vs any tumour residuals was 43 months (95% CI: 26.4–59.5) vs 13.4 months (95% CI: 7.42–19.4); P=0.001. Mean OS for patients who received postoperative chemotherapy (n=18; 36.7%) vs those who did not was 40.5 months (95% CI: 27.4–53.6) vs 12.03 months (95% CI: 5.9–18.18); P<0.001.Multivariate analysis indentified multifocal tumour dissemination to be of predictive significance for incomplete tumour resection, higher operative morbidity and lower survival, while systemic chemotherapy subsequent to QC had a protective significant impact on OS. No prognostic impact had ascites, platinum resistance, high grading and advanced age.Conclusion:Even in this highly advanced setting of the third EOC relapse, maximal therapeutic effort combining optimal surgery and chemotherapy appear to significantly prolong survival in a selected patients ‘group’.

Spontaneous Resolution of an Iatrogenic Ureterovaginal Fistula after Clinical Treatment of Hypothyroidism: A Case Study with a Review of the Literature

Spontaneous Resolution of an Iatrogenic Ureterovaginal Fistula after Clinical Treatment of Hypothyroidism: A Case Study with a Review of the Literature Association of hypothyroidism and disturbances of healing process is well known, but its exact effect on tissue integrity and mechanisms of dehiscence remain unclear. The relationship between hypothyroidism and iatrogenic ureterovaginal fistula is scarcely reported in the literature. We report the case of a 46-yearold woman who underwent cytoreductive surgery for ovarian cancer and developed an ureterovaginal fistula that was conservatively and successfully managed with thyroid hormone replacement after being diagnosed with myxedema.