Debulking Surgery For Ovarian Cancer Research Articles

The Cukurova score in the prediction of primary cytoreduction in ovarian cancer

ObjectivePrimary debulking surgery has been the preferred surgical route and is still considered a quality indicator for advanced ovarian cancer surgery. However, a significant number of patients are not amenable...

Predicting postoperative pain by using preoperative pain threshold in response to electrical stimulus in women undergoing gynaecological cancer surgery - Single-arm, prospective, observational study.

Individual variability leading to different pain experiences makes pain prediction challenging. This study aimed to evaluate whether preoperative electrical pain threshold testing is predictive of postoperative pain. Following ethics committee approval and registration of the trial, 40 consenting patients undergoing open laparotomy (interval debulking surgery) for ovarian cancer were included in the study. Electrical stimulus (maximum of 256 μA) was used preoperatively to determine the current perception threshold (CPT) and pain equivalent current (PEC). A numerical rating scale (NRS; 0-10, with 0 indicating no pain and 10 indicating severe pain) was used to assess pain. All patients received intravenous paracetamol in accordance to body weight, diclofenac (1 mg/kg, maximum 50 mg), and tramadol (1 mg/kg, maximum 50 mg) eight hourly for 24 hours. The preoperative PEC was compared with worst pain score (PS) at movement at the end of 24 hours. PEC was also compared with average PS at rest, at movement, and with opioid requirement (24 hours). The median values of CPT and PEC were 12.51 (45 [10.1-14.6]) μA and 94.75 (174 [48.8-94.7]) μA, respectively. A moderate correlation was observed between PEC and worst PS (P = 0.01, r = -0.402), with patients having PEC less than 60 μA being associated with moderate-to-severe PS. There was no correlation between PEC and average PS at rest (P = 0.16, r = 0.225), at movement (P = 0.46, r = 0.119), and the postoperative opioid consumption in the first 24 hours (P = 0.50, r = -0.110). There is a moderate association between preoperative pain threshold in response to electrical stimulus and worst PS in the postoperative period following interval debulking surgery for ovarian cancer.

Risk factors of major intraoperative blood loss at primary debulking surgery for ovarian cancer

ObjectiveThe goal of this study was to find the risk factors for major intraoperative blood loss (MBL) of primary debulking surgery (PDS) for ovarian cancer. MethodsPatients with ovarian cancer who underwent PDS in our hospital, from 2010 to 2017, were enrolled. The association between risk factors and MBL was modeled with the use of logistic regression. Receiver operating characteristic (ROC) curve analysis was used to determine the predictive value of the logistic regression model. ResultsA total of 346 patients met the inclusion criteria. There were 150 patients with MBL. Tumor stage 3/4 (P ​< ​0.001), American Society of Anesthesiologists (ASA) score ≥3 (P ​= ​0.044), ascites volume ≥500 ​ml ​(P ​= ​0.002), radical or ultra-radical surgery (P ​= ​0.002), and diabetes (P ​= ​0.035) were independent risk factors for MBL in patients with ovarian cancer. The logistic regression combined model of these five factors is more reliable in the prediction of MBL with an area under the ROC curve of 0.729 than the tumor stage (ROC curve ​= ​0.645) and surgical complexity (ROC curve ​= ​0.568). ConclusionIn patients with ovarian cancer, five risk factors for major intraoperative bleeding were identified. Planned surgical procedures and preoperative risk factors can be used to predict perioperative blood requirements.

Effects of Intravenous Infusion of Lidocaine on Short-Term Outcomes and Survival in Patients Undergoing Surgery for Ovarian Cancer: A Retrospective Propensity Score Matching Study.

BackgroundIntravenous lidocaine has been shown to reduce opioid consumption and is associated with favourable outcomes after surgery. In this study, we explored whether intraoperative lidocaine reduces intraoperative opioid use and length of stay (LOS) and improves long-term survival after primary debulking surgery for ovarian cancer and explored the correlation between SCN9A expression and ovarian cancer prognosis.MethodsThis retrospective study included patients who underwent primary debulking surgery(PDS) for ovarian cancer from January 2015 to December 2018. The patients were divided into non-lidocaine and lidocaine [bolus injection of 1.5 mg/kg lidocaine at the induction of anaesthesia followed by a continuous infusion of 2 mg/(kg∙h) intraoperatively] groups. Intraoperative opioid consumption, the verbal numeric rating scale (VNRS) at rest and LOS were recorded. Propensity score matching was used to minimize bias, and disease-free survival (DFS) and overall survival (OS) were compared between the two groups.ResultsAfter propensity score matching(PSM), the demographics were not significantly different between the groups. The intraoperative sufentanil consumption in the lidocaine group was significantly lower than that in the non-lidocaine group (Mean: 35.6 μg vs. 43.2 μg, P=0.035). LOS was similar between the groups (12.0 days vs. 12.4 days, P=0.386). There was a significant difference in DFS between the groups (32.3% vs. 21.6%, P=0.015), and OS rates were significantly higher in the lidocaine group than in the non-lidocaine group (35.2% vs. 25.6%, P=0.042). Multivariate analysis indicated that intraoperative lidocaine infusion was associated with prolonged OS and DFS.ConclusionIntraoperative intravenous lidocaine infusion appears to be associated with improved OS and DFS in patients undergoing primary debulking surgery for ovarian cancer. Our study has the limitations of a retrospective review. Hence, our results should be confirmed by a prospective randomized controlled trial.

Prediction of optimal debulking surgery in ovarian cancer.

The mainstay management of advanced ovarian cancer is maximal cytoreductive surgery followed by chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) are alternative treatments for patients with comorbidity, poor performance status, and predicted for suboptimal debulking surgery. It is the invariable principle in any situation that no residual disease after the completion of surgery is useful for patients with ovarian cancer. Therefore, the prediction of optimal debulking before the treatment of ovarian cancer is of utmost importance. Many studies have reported on the use of serum biomarkers, such as cancer antigen 125 (CA125) or human epididymis 4 (HE4), and imaging studies, such as computed tomography (CT), diffusion-weighted magnetic resonance imaging (DW-MRI), and positron emission tomography (PET)/CT, to identify adequate surgical candidates for primary debulking surgery (PDS). Laparoscopy has also been studied as a reliable tool for the prediction of optimal debulking. Here, we summarize a review of the related literature.

Extreme complications related to bevacizumab use in the treatment of ovarian cancer: a case series from a III level referral centre and review of the literature.

In patients undergoing debulking surgery for ovarian cancer (OC), bevacizumab-combined chemotherapy has been reported to be associated with an increased incidence of adverse events (AEs). Reports in the literature have noted the overall morbidity of bevacizumab to be between 3.7% and 9%. The aim of this study is to report uncommon and unusual manifestations of morbidity in surgical cases performed at our third level referral centers for gynecologic oncology. Additionally, we review the rare and severe bevacizumab-related complications that have been described in the literature. We defined as “extreme”, the particularly rare and/or severe complications up to determining a life-threatening condition or death, which are related to the use of bevacizumab. A case-series of extreme complications registered at our institutions were reported. In addition, a literature search of the PubMed, MEDLINE and EMBASE electronic databases was performed for this review. The studies collected included: 8 randomized controlled trials (RCT) and 5 prospective observational, 1 prospective phase-IV, 10 prospective phase-II, 2 prospective phase-I, and 20 retrospective studies, as well as 9 case reports. Bevacizumab was administered as primary treatment in adjuvant and neo-adjuvant setting in 16 and 5 studies respectively, as treatment for recurrence in 36 trials, and for secondary cytoreductive surgery (SCS) in 3 studies. The overall population administered with bevacizumab numbered 7,096 women. Extreme complications were observed in 591 patients, with a morbidity rate of the 8.3%. Overall, central nervous system (CNS), cardiovascular, gastrointestinal (GI) and primary infectious complications were seen in 22 patients (0.3%), 261 patients (3.7%), 159 patients (2.2%), and 8 patients (0.13%), respectively. Hemorrhagic and wound complications occurred in 18 women (0.25%), and 112 women (1.6%), respectively. Extreme complications related to the use of bevacizumab are rare, and often go unrecognized. The recognition and immediate management of such rare and life-threatening complications in patients treated at third level referral centers could significantly improve patient survival.

Racial disparities in surgical outcomes of patients undergoing debulking surgery for ovarian cancer

Objective: While racial disparities in ovarian cancer survival have been well documented, disparities in short-term outcomes are less studied. We aimed to identify racial differences in perioperative morbidity among white and black women following debulking surgery for ovarian cancer.

Study of upfront surgery versus neoadjuvant chemotherapy followed by interval debulking surgery for patients with stage IIIC and IV ovarian cancer, SGOG SUNNY (SOC-2) trial concept.

BackgroundTwo randomized phase III trials (EORTC55971 and CHORUS) showed similar progression-free and overall survival in primary or interval debulking surgery in ovarian cancer, however both studies had limitations with lower rate of complete resection and lack of surgical qualifications for participating centers. There is no consensus on whether neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) could be a preferred approach in the management of advanced epithelial ovarian cancer (EOC) in the clinical practice.MethodsThe Asian SUNNY study is an open-label, multicenter, randomized controlled, phase III trial to compare the effect of primary debulking surgery (PDS) to NACT-IDS in stages IIIC and IV EOC, fallopian tube cancer (FTC) or primary peritoneal carcinoma (PPC). The hypothesis is that PDS enhances the survivorship when compared with NACT-IDS in advanced ovarian cancer. The primary objective is to clarify the role of PDS and NACT-IDS in the treatment of advanced ovarian cancer. Surgical quality assures include at least 50% of no gross residual (NGR) in PDS group in all centers and participating centers should be national cancer centers or designed ovarian cancer section or those with the experience participating surgical trials of ovarian cancer. Any participating center should be monitored evaluating the proportions of NGR by a training set. The aim of the surgery in both arms is maximal cytoreduction. Tumor burden of the disease is evaluated by diagnostic laparoscopy or positron emission tomography/computed tomography scan. Patients assigned to PDS group will undergo upfront maximal cytoreductive surgery within 3 weeks after biopsy, followed by 6 cycles of standard adjuvant chemotherapy. Patients assigned to NACT group will undergo 3 cycles of NACT-IDS, and subsequently 3 cycles of adjuvant chemotherapy. The maximal time interval between IDS and the initiation of adjuvant chemotherapy is 8 weeks. Major inclusion criteria are pathologic confirmed stage IIIC and IV EOC, FTC or PPC; ECOG performance status of 0 to 2; ASA score of 1 to 2. Major exclusion criteria are non-epithelial tumors as well as borderline tumors; low-grade carcinoma; mucinous ovarian cancer. The sample size is 456 subjects. Primary endpoint is overall survival.Trial RegistrationClinicalTrials.gov Identifier: NCT02859038

Complications and Survivorship Trends After Primary Debulking Surgery for Ovarian Cancer

BackgroundWe examined factors associated with postoperative complications, 1-year overall and cancer-specific survival after epithelial ovarian cancer (EOC) diagnosis. MethodsPatients who underwent surgery for EOC between 2004 and 2013 were included. Multivariable models analyzed postoperative complications, overall survival, and cancer-specific survival. ResultsAmong 5223 patients, surgical complications were common. Postoperative complications correlated with increased odds of overall and disease-specific survival at 1 y. Receipt of chemotherapy was similar among women with and without postoperative complications and was independently associated with a reduction in the hazard of overall and disease-specific death at 1-year. Extensive pelvic and upper abdomen surgery resulted in 2.26 times the odds of postoperative complication, but was associated with longer 1-year overall 0.53 (0.35, 0.82) and disease-specific survival 0.54 (0.34, 0.85). ConclusionsAlthough extent of surgery was associated with complications, the survival benefit from comprehensive surgery offset the risk. Tailored surgical treatment for women with EOC may improve outcomes.

Efficacy and safety results from GEICO 1205, a randomized phase II trial of neoadjuvant chemotherapy with or without bevacizumab for advanced epithelial ovarian cancer

BackgroundBevacizumab is an approved treatment after primary debulking surgery for ovarian cancer. However, there is limited information on bevacizumab added to neoadjuvant chemotherapy before interval debulking surgery.ObjectiveTo evaluate neoadjuvant bevacizumab...

Patients treated with primary debulking surgery for ovarian cancer require a unique set of reportable complications to accurately capture postoperative events

Patients treated with primary debulking surgery for ovarian cancer require a unique set of reportable complications to accurately capture postoperative events

Beyond prophylaxis: Extended risk of venous thromboembolism following primary debulking surgery for ovarian cancer

ObjectiveTo determine the incidence and risk factors for venous thromboembolism (VTE) within six months after primary debulking surgery (PDS) for epithelial ovarian cancer (EOC). MethodsIn a historical cohort, we estimated the cumulative incidence of clinically diagnosed VTE within 6 months among consecutive women who underwent PDS for EOC at a single institution from 1/1/2003 to 12/31/2011. We evaluated perioperative variables as potential risk factors of VTE within 6 months during the postoperative period using univariate and multivariable Cox proportional hazards models. ResultsAmong 860 women without an immediate history (past 30 days) of a VTE, the cumulative incidence of VTE was 7.5% (95% CI, 5.7–9.3) by 30 days and 13.8% (95% CI, 11.4–16.2) by 6 months following surgery. Macroscopic residual disease (adjusted HR 1.99 [95% CI 1.35–2.94] vs microscopic), increasing estimated blood loss (1.25 [1.05–1.49] per doubling), longer hospital length of stay (3.00 [1.57–5.75]), and experiencing a cardiac event within 30 postoperative days (2.72 [1.55–4.80]) were independently associated with subsequent VTE within 6 months. In-hospital VTE prophylaxis included heterogeneous approaches; dual prophylaxis did not impact 30-day or 6-month VTE rates. ConclusionsVTE occurred in 1 in 7 women with EOC within 6 months of PDS—a substantial risk of VTE that extends into the adjuvant chemotherapy period. Novel prophylactic measures should be explored in these women at high risk for VTE.

Epidural anesthesia is associated with improved overall survival in patients undergoing primary debulking surgery for ovarian cancer

Objective: Epidural anesthesia has been associated with improved oncologic outcomes in other solid tumors, presumably because of its effect on surgical stress response. Our objective was to investigate the impact of epidural anesthesia on outcomes of patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer.

Correlation of chemotherapy response score to residual tumor at interval debulking surgery in ovarian cancer

Correlation of chemotherapy response score to residual tumor at interval debulking surgery in ovarian cancer

Ovarialkarzinom: Wie wirkt sich verzögerte Chemotherapie nach Operation aus?

Seagle BL et al. Chemotherapy delay after primary debulking surgery for ovarian cancer. Gynecol Oncol 2017; 144: 260 – 265

Chemotherapy delay after primary debulking surgery for ovarian cancer

ObjectiveTo determine the association of chemotherapy delay with overall survival (OS) and investigate predictors of delay among a population-representative American ovarian cancer cohort. MethodsAn observational retrospective cohort analysis of women with ovarian cancer who received National Comprehensive Cancer Network guideline-consistent care was performed with the 1998–2011 National Cancer Data Base. Chemotherapy delay was defined as initiation of multiagent chemotherapy >28days from primary debulking surgery. Associations of patient and disease characteristics with chemotherapy delay were tested with multivariate logistic regression. Survival analyses for women diagnosed from 2003 to 2006 approximated a 21-daycycle intravenous platinum-taxane chemotherapy cohort. Overall survival was estimated by Kaplan-Meier analyses and Cox proportional-hazards regressions, with sensitivity analyses using matched cohorts. Results58.1% (26,149/45,001) of women experienced chemotherapy delay. Race, insurance status, cancer center type, and community median income were significantly associated with chemotherapy delay (P<0.001). Odds for chemotherapy delay were higher for older or sicker women, women with endometrioid or mucinous histology, lower stage or grade disease, and uninsured or low-income women (P<0.05). Chemotherapy delay >35days from surgery was associated with a 7% (95% confidence interval, 2–13%) increased hazard of death (P=0.01). Relative hazard of death was lowest between 25 and 29days after surgery but was not significantly different within the longer two-week interval from 21 to 35days. ConclusionA survival benefit may be achieved by consistently starting chemotherapy between 21 and 35days from primary debulking surgery. Women at higher risk for chemotherapy delay may be targeted for close follow-up.

Use of PlasmaJet for Peritoneal Carcinomatosis in Ovarian Cancer.

This study aimed to assess the role and complications of extensive cytoreduction with PlasmaJet (Plasma Surgical, Roswell, Ga) in ovarian cancer with peritoneal carcinomatosis. All patients undergoing primary, secondary, or interval debulking surgery for ovarian cancer and treated with PlasmaJet between October 2013 and February 2015 were analyzed. Nineteen patients were enrolled. The median operative time was 270 minutes, median blood loss was 700 mL, and median length of stay was 9 days. In all patients, complete resection of all macroscopic disease was achieved.We used PlasmaJet to remove peritoneal carcinomatosis on the abdominal peritoneum, intestinal mesentery, bowel serosa, and diaphragmatic region. Overall, we treated 66 organs with PlasmaJet in our series. No bowel or urological fistulas were observed. According to the Clavien-Dindo classification, 13 adverse events were recorded at grade 2 or lesser. We observed only 1 grade 3 adverse event. No postoperative mortality was recorded. In our series, the PlasmaJet seems to be an efficient device for tumor ablation or dissection to obtain complete resection of all macroscopic disease in patients with peritoneal carcinomatosis.

Preoperative predictors of delay in initiation of adjuvant chemotherapy in patients undergoing primary debulking surgery for ovarian cancer

ObjectiveThe objective of this study was to identify preoperative characteristics of patients that experience a delay in initiation of adjuvant chemotherapy after primary debulking surgery for ovarian cancer. Materials/methodsWe performed a retrospective review of patients with Stage II to IV high-grade epithelial ovarian, tubal, and peritoneal carcinoma who underwent primary debulking surgery followed by adjuvant chemotherapy from 2005 to 2013. Patients were divided into 2 groups: Control (those who received their first cycle of chemotherapy within 6weeks of debulking surgery) vs. chemotherapy delay (those who received their first cycle of chemotherapy at an interval >6weeks from primary debulking surgery). Relevant clinical variables and survival outcomes were compared between the 2 groups using standard statistical methods. ResultsA total of 221 patients were included in the analyses – 169 (76.5%) were in the control group and 52 (23.5%) were in the chemo delay group. On multi-variate analysis, risk factors that were significantly associated with a delay in initiation in chemotherapy included: age >65, albumin <3.5, and high age-adjusted Charlson Comorbidity Index score. Delay in chemotherapy initiation was associated with a shorter progression-free (p=0.014) but not overall survival (p=0.19). ConclusionsDelay in initiation of chemotherapy affected 23.5% of patients in our study population. Easily identifiable risk factors for chemotherapy delay exist that can help us pre-operatively identify patients for which neoadjuvant chemotherapy may be a better treatment option. Further study into prospective modeling with these identified risk factors is warranted.

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

ObjectiveTo examine the use, as well as postoperative and long-term oncologic outcomes of diverting loop ileostomy (DI) during primary debulking surgery (PDS) for ovarian cancer. MethodsPatients with stage II-IV ovarian, fallopian tube, or primary peritoneal carcinoma who underwent colon resection during PDS from 1/2005–1/2014 were identified. Demographic and clinical data were analyzed. ResultsOf 331 patients, 320 (97%) had stage III/IV disease and 278 (84%) had disease of high-grade serous histology. Forty-four (13%) underwent a DI. There were no significant differences in age, comorbidity index, smoking status, serum albumin, or attending surgeon between the DI and non-DI groups. Operative time (OR=1.21; 95% CI, 1.03–1.42; p=0.02) and length of rectosigmoid resection (OR=1.04; 95% CI, 1.01–1.08; p=0.02) were predictors of DI on multivariable analysis. The overall anastomotic leak rate was 6%. A comparison of groups (DI vs non-DI) showed no significant differences in major complications (30% vs 23%; p=0.41), anastomotic leak rate (5% vs 7%; p=0.60), hospital length of stay (10 vs 9days; p=0.25), readmission rate (23% vs 17%; p=0.33), or interval to postoperative chemotherapy (41 vs 40days; p=0.20), respectively. Ileostomy reversal was successful in 89% of patients. Median follow-up was 52.6months. There were no differences in median progression-free (17.9 vs 18.6months; p=0.88) and overall survival (48.7 vs 63.8months; p=0.25) between the groups. ConclusionsIn patients undergoing PDS, those with longer operative time and greater length of rectosigmoid resection more commonly underwent DI. DI does not appear to compromise postoperative outcomes or long-term survival.

A laparoscopic risk-adjusted model to predict major complications after primary debulking surgery in ovarian cancer: A single-institution assessment

ObjectiveTo develop and validate a simple adjusted laparoscopic score to predict major postoperative complications after primary debulking surgery (PDS) in advanced epithelial ovarian cancer (AEOC). MethodsFrom January 2006 to June 2015, preoperative, intraoperative, and post-operative outcome data from patients undergoing staging laparoscopy (S-LPS) before receiving PDS (n=555) were prospectively collected in an electronic database and retrospectively analyzed. Major complications were defined as levels 3 to 5 of MSKCC classification. On the basis of a multivariate regression model, the score was developed using a random two-thirds of the population (n=370) and was validated on the remaining one-third patients (n=185). ResultsMajor complication rate was 18.3% (102/555). Significant predictors included in the scoring system were: poor performance status, presence of ascites (>500cm3), CA125 serum level (>1000U/ml), and high laparoscopic tumor load (predictive index value, PIV ≥8). The mean risk of developing major postoperative complications was 3.7% in patients with score 0 to 2, 13.2% in patients with score 3 to 5, 37.1% in patients with score 6 to 8. In the validation population, the predicted risk of major complications was 17.8% (33/185) versus a 16.7% (31/185) observed risk (C-statistic index=0.790). ConclusionThis new score may accurately predict a patient's postoperative outcome. Early identification of high-risk patients could help the surgeon to adopt tailored strategies on individual basis.