Optimal Cytoreductive Surgery Research Articles

Robotic Lymph Node Resection Off the Aortic Bifurcation for Presumed Recurrence Management of Advanced Ovarian Cancer

Study Objective To demonstrate a surgical video where-in lymph node resection was performed robotically in a patient with presumed ovarian cancer recurrence. Design Case report and a step-by-step video demonstration of robotic lymph node resection off of the aortic bifurcation (Canadian Task Force classification III). Setting Tertiary referral center. Patients or Participants 42-year-old female with stage IIIA1 high-grade serous ovarian adenocarcinoma. Interventions 42-year-old female was diagnosed with stage IIIA1 high-grade serous ovarian adenocarcinoma in 2018 when she underwent upfront optimal cytoreductive surgery, inclusive of extensive debulking of aortocaval lymphadenopathy. The patient remained disease free until February 2020, when surveillance imaging showed a single hypermetabolic lymph node, anterior to the left common iliac artery. She was taken to the operating room for robotic debulking. Robotic trocars were placed on a horizontal line along the umbilical fold. Exploration of the peritoneal cavity revealed no evidence of disease. There was some adhesive disease over right pelvic sidewall and distal small bowel mesentery was overlying the aortic bifurcation. These adhesions were taken down by paying meticulous attention in order not to injure the small bowel mesentery. The retroperitoneum was explored to the level of the third part of the duodenum. Aortocaval lymph node basins were explored. The IMA was skeletonized and left ureterolysis was performed; allowing safe access to the left para-aortic as well as to the presacral area. The suspicious lymph nodes, including the one which correlated with the hypermetabolic left common iliac lymph node were resected without any complications. Measurements and Main Results Successful robotic secondary debulking was performed. The patient was discharged home on postoperative day 0. Pathology of the suspicious lymph nodes were negative for malignancy. Therefore, the patient was deemed free of disease and has been scheduled for surveillance imaging in three months. Conclusion Robotic secondary debulking of presumed ovarian cancer recurrence is feasible and should be considered in selected patients.

S1676 A Case of Rectal Primary Krukenberg Tumor

INTRODUCTION: Krukenberg Tumors (KTs) are secondary ovarian tumors defined as mucinous signet-ring cell carcinomas. Nearly 30% of ovarian tumors are metastatic in origin, with KTs accounting for 1–2% of all ovarian tumors. Worldwide, stomach is the primary site in most KT cases (70%), followed by colorectal and breast. However, in Europe and the USA, colorectal and breast cancers are the most common primary tumors metastasizing to the ovaries. KTs occur in 3–14% of women with colorectal cancer (CRC), with 20% arising from the rectum. The prognosis for KTs is poor, although CRC primary KTs appear to benefit from more aggressive treatment with cytoreductive surgery and post-adjuvant chemotherapy. We present a case of rectal primary KT to improve awareness of CRC KTs in the western population, as well the implications of histological type on management. CASE DESCRIPTION/METHODS: Our patient is a 48 year old African American female who underwent surgical resection of a 6.6cm complex right ovarian mass seen on MRI after having reported one year of abdominal pain, nausea, and progressive constipation. Ascites was noted prior to surgery. Final surgical pathology specimens demonstrated mucinous carcinoma with signet ring features. Immunohistochemical (IHC) evaluation was CK20+/CDX2+ and CK7-, suggestive of colorectal primary. Laboratory values were notable for CEA 1.0ng/mL, CA-125 44 U/mL, and the absence of iron deficiency anemia. An upper endoscopy was performed, ruling out gastric malignancy. A colonoscopy revealed a non-traversable malignant appearing stricture 15 cm from the anal verge with biopsies demonstrating poorly differentiated adenocarcinoma with signet cell features. Our patient was lost to follow up for several months as she explored alternative natural therapies before ultimately transitioning to hospice care with palliative FOLFOXIRI. DISCUSSION: CRCs are a relatively common primary source for KTs in the western population. While the median survival of patients with KTs is 14 months, there is a small but promising body of evidence that select patients with CRC primary KTs may have a survival benefit with optimal cytoreductive surgery and post-adjuvant chemotherapy. IHC markers may help identify the primary tumor, as the pattern of CK20+/CDX2+ and CK7- is classic for a colorectal primary. Our case serves to improve awareness of CRC primary KTs, and the unique treatment survival benefits for these patients.Figure 1.: MRI image of a 6.6cm complex right ovarian mass.Figure 2.: Invasive signet ring cells forming cords and nests within ovarian stroma (x40 hematoxylin and eosin stain).Figure 3.: Non-traversable rectal stricture 15cm from the anal verge.

How far should we go in optimal cytoreductive surgery for ovarian cancer?

The treatment of ovarian cancer should be appropriate, since clinical and surgical decisions may affect the prognosis; the surgery must be performed by an expert oncological surgeon or gynecological oncologist, it's fundamental roles are cancer staging and cytoreduction. The concept of staging surgery in early stages has its justification in the fact that up to 11% of "early ovarian cancers" will have metastasis in different sites of the peritoneal cavity at the time of diagnosis. In advanced stages of epithelial ovarian cancer, the goal is the complete cytoreduction of all visible macroscopic disease, since this variable is the most strongly associated with increased overall survival and disease-free period. The ideal time for cytoreductive surgery in relation to chemotherapy (before or after) is still under debate. In 2010 a randomized trial (EORTC) was published, comparing 310 patients initially operated (followed by adjuvant chemotherapy) versus 322 patients initially treated with neoadjuvant chemotherapy (followed by cytoreductive surgery); no significant differences in overall survival between groups were found. Another important factor playing a role in survival and in the probability of surgical cytoreductive success is tumor biology; there has been described a clear difference between serous and mucinous tumors, but some groups advocate that maximal surgical effort in mucinous tumors may compensate morbidity with an increase in survival. The extension of resection in cytoreduction is still controversial; some authors have confirmed that the most important factor is the residual disease and that radical surgery is superior to non-radical surgery in terms of overall survival. The need and extent of lymphadenectomy in advanced cancer will be treated in another chapter of this issue. Undoubtedly, an important factor is to perform procedures in specialized centers.

The interval between the primary cytoreductive surgery and adjuvant chemotherapy in patients with advanced ovarian cancer

Aim of the study was to establish the effect of the time interval between the initial optimal cytoreductive surgery and the initiation of adjuvant chemotherapeutic treatment (ACT) on the overall survival (OS) of patients with advanced ovarian adenocarcinoma. Materials and methods. Clinical cases of 60 patients with advanced ovarian adenocarcinoma (FIGO IIIC-IV), with the average age of 61 years, who underwent primary cytoreductive surgery (PDS) with the completeness of cytoreduction (CC) — 0 score according to Shugarbaker and adjuvant chemotherapeutic treatment according to the standard first-line regimen were examined. Patients were categorized depending on the time between surgery and chemotherapeutic treatment into two groups: I — delay of chemotherapy for no more than one month (30 patients), II — from two to six months (30 patients). The OS data of the patients obtained from the national cancer registry were analyzed. Results. The results demonstrate an increase in OS of patients who underwent CC-0 PDS at the early initiation of ACT. Conclusions. Delaying the onset of ACT is an independent predictor of the worse OS after performing PDS. According to the data obtained, patients should start ACT within 1 month after the surgery. However, the findings are proved if CC-0 is achieved during the operation.

Combined and expanded operations in patients with relapsed ovarian cancer and affected retroperitoneal lymph nodes

Objective: to analyze short-term and long-term outcomes of expanded surgeries in patients with recurrent ovarian cancer and to identify factors affecting their overall survival (OS) and progression-free survival (PFS). Materials and methods. This retrospective study included patients with recurrent ovarian cancer stage I–IV less than 80 years of age who was treated in the Department of Gynecologic Oncology, N. N. Blokhin National Medical Research Center of Oncology, between 2015 and 2017. Other inclusion criteria were as follows: time to relapse more than 12 months and no chemotherapy during the last 6 months or more. We analyzed the main perioperative parameters, OS, PFS, and prognostic factors affecting OS and PFS. Results. This study included 55 patients. Of them, 44 (80 %) women have undergone complete cytoreductive surgery, whereas 11 (20 %) women have undergone optimal cytoreductive surgery. The median duration of surgery was 210 minutes (range: 60–390 minutes), median blood loss was 400 mL (range: 30–4500 mL). Postoperative complications were observed in 23 (41.2 %) patients; 5 (9.1 %) patients developed grade IIIB complications. Median follow-up time was 30.3 months (range: 7.5–67.1 months). Three-year OS was 73.7 % and three-year PFS was 30.7 %. More than one line of chemotherapy before repeated cytoreductive surgery was found to be a negative factor affecting OS (hazard ratio 2.749; 95 % confidence interval 1.059–7.138; p = 0.038). The primary ECOG performance status had a significant impact on PFS (hazard ratio 0.543; 95 % confidence interval 0.347–0.851; p = 0.008). Conclusions. Poor ECOG status and more than one line of chemotherapy before repeated cytoreductive surgery for ovarian cancer relapse were demonstrated to have a negative impact on survival in this group of patients. However, in some patients, repeated cytoreductive surgeries ensured long-term remission.

Phase II Trial on the Feasibility of Single-Dose Intraoperative Intraperitoneal Carboplatin in Advanced Epithelial Ovarian Cancer Following Optimal Cytoreductive Surgery.

To evaluate the feasibility administering single-dose intraoperative intraperitoneal carboplatin (IP) in advanced epithelial ovarian cancer (EOC) after optimal primary or interval debulking surgery. A phase II non-randomized prospective study conducted at a regional cancer institute from January 2015 to December 2019. The advanced high-grade epithelial ovarian cancer FIGO stage IIIB-IVA was included. A total of 86 consented patients with optimal primary and interval cytoreductive surgeries received single-dose intraoperative IP carboplatin. The immediate (< 6h), early (6-48h), and late (48h-21days) perioperative complications were recorded and analyzed. The severity of adverse events was graded on the basis of National Cancer Institute Common Terminology Criteria for Adverse Events (version 3.0). A total of 86 patients received single-dose intra-operative IP carboplatin during the study period. The 12 (14%) patients underwent primary debulking surgery and 74(86%) interval debulking surgery (IDS). The 13 (15.1%) patients underwent laparoscopic/robotic IDS. All the patients tolerated the intraperitoneal carboplatin well with no or minimal adverse events. Three cases (3.5%) needed resuturing for the burst abdomen, three cases (3.5%) had paralytic ileus for 3-4days, one case (1.2%) underwent re-explorative laparotomy for hemorrhage, and one case (1.2%) mortality due to due late sepsis. The 84 (97.7%) of 86 cases received scheduled IV chemotherapy on time. Single-dose intraoperative IP carboplatin is a feasible procedure with no or minimal manageable morbidity. The procedure is user friendly combining the prognostic benefits of IP chemotherapy with assurance of earliest timely administration of chemotherapy in advanced EOC. Our study is a hypothesis generating for the future clinical trials comparing single-dose NIPEC versus HIPEC in advanced EOC.

Technical essentials and safety analysis of "rolling carpet" cytoreduction surgery in stage Ⅲc epithelial ovarian cancer

Objective: To introduce the technical essentials of cytoreduction surgery (CRS) with extensive peritonectomy （"rolling carpet" surgery） in stage Ⅲc epithelial ovarian cancer (EOC) and evaluate the feasibility and safety of the operation by analyzing the incidence of surgical complications and perioperative mortality. Methods: From December 2017 to December 2019, 30 patients with stage IIIc EOC who underwent "rolled carpet" CRS and 30 patients who underwent traditional CRS at the same period in Sichuan Cancer Hospital were collected. To summarize the key points of "rolled carpet" CRS operation technology, i.e. the extraperitoneal space was the cut path of ovarian cancer operation, and the tumor in the pelvic cavity was dissociated from the extraperitoneal space of the pelvic cavity. The tumor in the pelvic cavity and all the implants or potential metastases on the parietal peritoneum were removed completely. The clinical and pathological characteristics between the two groups were analyzed retrospectively, and the feasibility and safety of "rolling carpet" CRS were evaluated by comparing the operation related indexes and the occurrence of surgical complications between the two groups. Results: (1) Clinicopathological features: the age of patients in "rolling carpet" CRS group and traditional CRS group were respectively (55.4±9.6) and (54.6±9.5) years, and the median peritoneal cancer index (PCI) was 12 (range, 4-24) and 10 (range, 5-18), respectively. There were no statistical significance between the two groups (all P>0.05). (2) Operation related indexes: in the "rolled carpet" CRS group, all patients （100%, 30/30） were performed optimal CRS, reaching completeness of cytoreduction score （CC score）, named CC-0 score, and there was no visible residual lesion after operation. While, in the traditional CRS group, 23 patients （77%, 23/30） reached CC-0 score, 5 cases （17%, 6/30） reached CC-1 score, 2 cases （7%, 2/30） reached CC-2 score, and there were statistical significance between the two groups (P=0.011). The median surgical time was 315 minutes (range, 252-446 minutes) vs 268 minutes (range, 215-372 minutes), the median intraoperative blood loss was 589 ml (range, 300-900 ml) vs 450 ml (range, 250-800 ml), the median ICU hospital stay time was 2 days (range, 1-7 days) vs 1 day (range, 0-5 days), the median total hospital stay time was 14 days (range, 9-17 days) vs 12 days (range, 7-15 days). There were no statistical significance between the two groups (all P>0.05). (3) Surgical complications: there were respectively 5 cases (17%, 5/30) and 3 cases (10%, 3/30) complications with Clavien-Dindo grading Ⅰ-Ⅱ, which was significant no difference between the "rolled carpet" CRS group and the traditional CRS groups (P>0.05). No re-operations were needed and the operative mortality was 0. Conclusion: It is safe and feasible to perform "rolled carpet" CRS in patients with advanced stage Ⅲc EOC with peritoneum implantation and metastasis, which could achieve optimal CRS, and has an acceptable incidence of perioperative complications, no perioperative death.

Abstract 5305: Characterization of the ovarian tumor transcriptome and microenvironment in pre and post-chemotherapy treated patients

Abstract Purpose: Ovarian cancer has one of the highest deaths to incidence ratios across all cancers. Initial chemotherapy is typically effective, but most patients will experience recurrence and enter a cycle of response and recurrence, ultimately developing resistant disease. Importantly, the understanding of mechanisms contributing to clinical chemoresistance in ovarian cancer is limited. Achieving optimal cytoreduction improves survival. Gynecologic oncologists therefore perform laparoscopy to evaluate resectability and collect tumor biopsies. Patients identified with un-resectable tumor receive three cycles of neoadjuvant platinum/taxane-based chemotherapy (NACT) to improve the likelihood of optimal cytoreductive surgery. NACT offers a previously unavailable window for identifying therapy-induced remodeling of the tumor, potentially providing insight into drivers of chemo-resistance. Experimental Design: We accessed formalin fixed (FFPE) tumor tissue from high-grade serous ovarian cancer NACT patients (n=6) pre- and post-chemotherapy. RNA was extracted and the mRNA transcript levels were examined for 791 genes via the Immunoncology 360 NanoString panel. Further, using the pre-treated ascites fluid we examined the cytokine environment through MesoScale Discovery multiplex ELISA. Transcriptional and cytokine profiles were correlated to clinical outcomes, such as days to recurrence. Results: Component analysis found that transcriptional profiles separated based on pre- and post-chemotherapy status. Comparing the pre- (n=6) and post-chemotherapy (n=6), the most upregulated gene following therapy was IL6 (4.1 log2 fold change, adj. p = 0.045) and the most downregulated gene was UBE2C (-3.9 log2 fold change, adj. p = 0.001). Elevated IL-6 within ascites correlated to a shorter time to recurrence. On the patient-by-patient basis we compared transcriptional changes between pre- and post therapy. We correlated these changes to IL6 expression and time to recurrence uncovered that an increase in Immediate Early Response 3 (IER3) is a poor prognostic indicator. IER3/IEX-1 is a NF-κB target gene involved in apoptosis and potentiates MAPK activation. Conclusion: Using ovarian cancer tumors from NACT patients provides a unique insight into chemo-induced transcriptional changes. To-date little is known of IER3's function in ovarian cancer thus future work will focus on a potential novel IL-6/IER3 signaling axis that protects tumors from chemotherapy-induced apoptosis. Also, computer modeling and integration of transcriptional and cytokine date could also provide an approach to predict recurrence. Citation Format: Kimberly R. Jordan, Jill Slansky, Angela Minic, Jennifer K. Richer, James C. Costello, Aaron J. Clauset, Rajendra T. Kumar, Kian Behbakht, Matthew J. Sikora, Benjamin G. Bitler. Characterization of the ovarian tumor transcriptome and microenvironment in pre and post-chemotherapy treated patients [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 5305.

Tumor Microenvironment in Ovarian Cancer: Function and Therapeutic Strategy.

Ovarian cancer is one of the leading causes of death in patients with gynecological malignancy. Despite optimal cytoreductive surgery and platinum-based chemotherapy, ovarian cancer disseminates and relapses frequently, with poor prognosis. Hence, it is urgent to find new targeted therapies for ovarian cancer. Recently, the tumor microenvironment has been reported to play a vital role in the tumorigenesis of ovarian cancer, especially with discoveries from genome-, transcriptome- and proteome-wide studies; thus tumor microenvironment may present potential therapeutic target for ovarian cancer. Here, we review the interactions between the tumor microenvironment and ovarian cancer and various therapies targeting the tumor environment.

Association of Molecular Genetic Markers of TP53, MDM2, and CDKN1A Genes with Progression-Free Survival of Patients with Ovarian Cancer after Platinum-Based Chemotherapy.

We studied the association of polymorphic markers of cell cycle control genes (Arg72Pro of the TP53 gene, T(-410)G of the MDM2 gene, and Ser31Arg of the CDKN1A gene) in ovarian cancer and progression-free survival following platinum-based chemotherapy. Tumor tissue samples obtained from 49 patients who had undergone chemotherapy were examined. Patients received standard platinum-based chemotherapy and were observed until disease progression. Polymorphic markers of genes were evaluated by PCR-RFLP and real-time PCR. In patients carrying the G allele of the T(-410)G marker of the MDM2 gene, a decreasing trend was observed in median progression-free survival. An increase in the median progression-free survival was observed in carriers of the Pro allele of the TP53 gene (p=0.045). Furthermore, a stronger association was noted with carriers of the minor Pro/Pro homozygous genotype relative to the Arg/Arg genotype (p=0.007). In the subgroup of patients who underwent optimal or complete cytoreductive surgery, carriage of the minor Arg allele of the Ser31Arg marker (CDN1A gene) was associated with a decrease in the median progression-free survival time (p=0.004).

Dose-intensive regimen treatment for small-cell carcinoma of the ovary of hypercalcemic type (SCCOHT)

PurposeSmall cell carcinoma of the ovary of hypercalcemic type (SCCOHT) is a rare and rapidly lethal disease affecting young women. Cytoreductive surgery associated with chemotherapy followed by a high dose chemotherapy regimen (HDC) demonstrated improved outcomes in a unique prospective and several retrospective studies, and this report aimed to confirm these results in an independent and larger cohort. MethodsBetween 2006 and 2018, we conducted a multicentric prospective study on 44 women diagnosed with SCCOHT. Patients were treated homogeneously with optimal cytoreductive surgery and chemotherapy protocol for four to six cycles (PAVEP). In case of complete response, patients received HDC with stem-cell support, followed by pelvic radiotherapy. The primary endpoint was the event-free survival (EFS) in the per-protocol cohort. Secondary analysis explored the effect of HDC with outcomes. ResultsMean age at diagnosis was 33 years old (range 13.8–75.8). 14 patients presented with stage FIGO I, 21 with stage III and 9 with stage IV. Median follow-up was 53.4 months. 38 patients underwent optimal surgery with up to 6 cycles of PAVEP. 30 received HDC, and 21 pelvic radiotherapy. 21 relapses were reported leading to death for 18 patients. Median EFS in the per-protocol cohort was 18.2 months, and 2-year EFS rate was 40%. HDC was significantly associated with better overall survival (p < .001). Grades 3/4 adverse events were frequent but, in most cases, manageable, although one grade-5 adverse-event occurred during HDC. ConclusionIntensive regimen containing multidrug chemotherapy, HDC and pelvic radiotherapy, for the management of SCCOHT, demonstrated encouraging survival and should be proposed for all patients. However, the significant toxicity cost associated is of concern and it should be restricted to expert centers.

Adherence and adverse events of intraperitoneal chemotherapy in optimally debulked ovarian cancer patients: Real-life study.

Intraperitoneal with intravenous chemotherapy (IP/IV) is the recommended option for patients with stage III cancer with optimally debulked (<1 cm residual) disease based on randomized controlled trials and showing important improvements in overall survival and progression free survival. However, its application has not been largely adopted due to its difficult administration that requires a trained nurse staff. The aim of this work was to study the completion and the toxicity of an IP outpatient chemotherapy regimen in optimally debulked stage III ovarian cancer patients. A single-center, retrospective observational study in women with stage III ovarian cancer following optimal cytoreductive surgery (<1 cm) followed by IP/IV chemotherapy from 2009 to 2017. The IP/IV regimen was as it follows: IV paclitaxel 175 mg/m2 in 3 h, day 1; IP cisplatin (100 mg/m2-until December 2013-or 75 mg/m2), day 2; IP paclitaxel 60 mg/m2, day 8, each 21 days for six cycles. A total of 60 patients received IP/IV regimen. Of these, 41 patients (68.3%) completed the six IP chemotherapy cycles and 51 (84.9%) completed four or more cycles. Most of the adverse events reported were non-hematological and G1-2. There was no difference neither in adherence nor in the frequency of adverse events between both cisplatin groups. Despite a high rate of adverse events, IP chemotherapy can be delivered with a high completion rate and manageable toxicity to patients with optimally debulked ovarian cancer.

Neoadjuvant Versus Adjuvant Chemotherapy in Advanced Ovarian Carcinoma

Aim: Aim of this retrospective study was to assess whether there is an advantage of treating women with advanced ovarian cancer with chemotherapy before cytoreductive surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows maximal cytoreductive surgery. Patients and Methods: Include patients with advanced epithelial ovarian cancer (stage III and IV) who underwent surgery from 2009–2015 with optimal cyto-reductive surgery (R0). Results: The study included 60 patients the mean age for all patients was 53.7 years, a total of 60 patients diagnosed and treated in NCI and Agouza Police hospital in the specified period (2009-2015), with locally advanced epithelial ovarian carcinoma were divided into 2 groups according to the pattern of treatment where 30 patients seemed resectable and primary cytoreductive surgery was carried out (conventional group), and 30 patients seemed unresectable and neoadjuvant chemotherapy (NACT) was given to them followed by interval debulking surgery (IDS). On assessment of the survival we compared the whole number of both groups. The median overall survival time was 45.77 months in the conventional group and 49.06 months in the NACT group. Conclusion: Primary chemotherapy followed by IDS in a selected group of patients doesn't appear to worsen the prognosis, but it permits a less aggressive surgery to be performed. NACT is not inferior to primary surgery.

Robotic debulking of confluent pelvic lymph nodes

In patients with uterine carcinoma, optimal cytoreductive surgery (maximum residual tumor <1 cm) as well as pelvic lymphadenectomy are associated with improvements in survival.[1][1] Furthermore, complete cytoreduction to no gross...

Robotic Colostomy Takedown in a Patient with Extensive Ventral Hernias and Adhesive Disease

To demonstrate a surgical video wherein a robot-assisted colostomy takedown was performed with anastomosis of the descending colon to the rectum after reduction of ventral hernias and extensive lysis of adhesions. Case report and a step-by-step video demonstration of a robot-assisted colostomy takedown and end-to-side anastomosis. Tertiary referral center in New Haven, Connecticut. A 64-year-old female was diagnosed with stage IIIA endometrioid endometrial adenocarcinoma in 2015 when she underwent an optimal cytoreductive surgery. In addition, she required resection of the sigmoid colon and a descending end colostomy with Hartmann's pouch, mainly secondary to extensive diverticulitis. After adjuvant chemoradiation, she remained disease free and desired colostomy reversal. Body mass index at the time was 32 kg/m2. Computed tomography of her abdomen and pelvis did not show any evidence of recurrence but was notable for a large ventral hernia and a parastomal hernia. She then underwent a colonoscopy, which was negative for any pathologic condition, except for some narrowing of the distal rectum above the level of the levator ani. Enterolysis was extensive and took approximately 2 hours. The splenic flexure of the colon had to be mobilized to provide an adequate proximal limb to the anastomosis site. An anvil was then introduced into the distal descending colon through the colostomy site. A robotic stapler was used to seal the colostomy site and detach it from the anterior abdominal wall. Unfortunately, the 28-mm EEA sizer (Covidien, Dublin, Ireland) perforated through the distal rectum, caudal to the stricture site. A substantial length of the distal rectum had to be sacrificed secondary to the perforation, which mandated further mobilization of the splenic flexure. The rectum was then reapproximated with a 3-0 barbed suture in 2 layers. This provided us with approximately 6- to 8-cm distal rectum. An end-to-side anastomosis of the descending colon to the distal rectum was performed. Anastomotic integrity was confirmed using the bubble test. Because of the lower colorectal anastomosis, a protective diverting loop ileostomy was performed. The patient had an uneventful postoperative course. A hypaque enema performed 3 months after the colostomy takedown showed no evidence of anastomotic leak or stricture. The ileostomy was then reversed without any complications. Robot-assisted colostomy takedown and anastomosis of the descending colon to rectum were successfully performed. Although there is a paucity of literature examining this technique within gynecologic surgery, the literature on general surgery has supported laparoscopic Hartmann's reversal and has demonstrated improved rates of postoperative complications and incisional hernia and reduced duration of hospitalization [1]. Minimally invasive technique is a feasible alternative to laparotomy for gynecologic oncology patients who undergo colostomy, as long as the patients are recurrence free.

Comparative\xa0transcriptome analysis of matched primary and distant metastatic ovarian carcinoma

BackgroundHigh grade serous ovarian carcinoma (HGSOC) is the most common subtype of epithelial ovarian cancers (EOC) with poor prognosis. In most cases EOC is widely disseminated at the time of diagnosis. Despite the optimal cytoreductive surgery and chemotherapy most patients develop chemoresistance, and the 5-year overall survival being only 25–35%.MethodsHere we analyzed the gene expression profiles of 10 primary HGSOC tumors and 10 related omental metastases using RNA sequencing and identified 100 differentially expressed genes.ResultsThe differentially expressed genes were associated with decreased embryogenesis and vasculogenesis and increased cellular proliferation and organismal death. Top upstream regulators responsible for this gene signature were NR5A1, GATA4, FOXL2, TP53 and BMP7. A subset of these genes were highly expressed in the ovarian cancer among the cancer transcriptomes of The Cancer Genome Atlas. Importantly, the metastatic gene signature was suggestive of poor survival in TCGA data based on gene enrichment analysis.ConclusionBy comparing the gene expression profiles of primary HGSOC tumors and their matched metastasis, we provide evidence that a signature of 100 genes is able to separate these two sample types and potentially predict patient survival. Our study identifies functional categories of genes and transcription factors that could play important roles in promoting metastases and serve as markers for cancer prognosis.

A retrospective study comparing the efficacy of dose-dense chemotherapy, intraperitoneal chemotherapy and dose-dense chemotherapy with hyperthermic intraperitoneal chemotherapy in the treatment of advanced stage ovarian carcinoma

ObjectivesHyperthermic intraperitoneal chemotherapy (HIPEC), intraperitoneal chemotherapy (IP) and dose-dense (DD) chemotherapy have been employed with varying success in the treatment of advanced stage ovarian carcinoma. Despite the clinical benefits associated with these specific forms of chemotherapy administration, they have not been comparatively analyzed, vis-à-vis their efficacy. Study designAdvanced stage ovarian cancer patients who were treated with platinum/taxane chemotherapy via a DD regimen (n = 100), IP approach (n = 81) or a DD regimen in conjunction with HIPEC (n = 64) were retrospectively evaluated. The clinical variables of interest were patient age, body mass index, surgery and pathology data, chemotherapy regimen, inclusion of maintenance therapy, and progression free/overall survival. ResultsProgression free survival (PFS) was significantly more pronounced in the HIPEC (34.9 months) and IP (34.0 months) patients, compared to the DD group (27.6 months) (P = 0.005). A cox-proportional hazards regression model indicated that there was a decreased risk of disease progression accorded to the patients who were treated with IP chemo or HIPEC and DD chemotherapy (HR, 0.43; 95 % CI: 0.21–0.88; P = 0.022) and the subjects who underwent optimal cytoreductive surgery (HR, 2.42; 95 % CI: 1.22–4.80; P = 0.011). Positive BRCA status (HR, 0.434; 95 % CI: 1.59–3.44; P = 0.001) and number of chemotherapy regimens (HR, 1.36; 95 % CI: 1.159–1.61; P = 0.001) were significantly correlated with improved OS although we did not discern a survival benefit associated with any of the chemotherapy treatments (P = 0.136). ConclusionWe observed PFS advantages conferred to the ovarian cancer patients treated with HIPEC and IP chemotherapy compared to DD chemotherapy. However, an overall survival advantage related to the chemotherapy regimens was not borne out, possibly due to the retrospective nature of the study or differing time periods wherein the specific patient cohorts underwent treatment.

Impact of extent of parietal peritonectomy on oncological outcome after cytoreductive surgery and HIPEC.

BackgroundIn peritoneal surface malignancy (PSM), in spite of optimal cytoreductive surgery (CRS), majority of recurrences that occur are intraperitoneal. In patients with PSM, studies employing fluorescent imaging and microscopic examination have shown normal looking peritoneum may harbor active disease. This study was done to assess the recurrence pattern, oncological outcomes, and morbidity and mortality of the extent of peritonectomy in patients who underwent total parietal peritonectomy (TPP) or involved field peritonectomy (IFP) as a part of the procedure during CRS and hyperthermic intraperitoneal chemotherapy (HIPEC).MethodsThis was a retrospective analysis of prospectively collected data, from February 2013 to December 2017. A total of 163 patients with PSM underwent TPP or IFP with CRS plus HIPEC. Their oncological outcomes, recurrence pattern, postoperative morbidity and mortality were analyzed.ResultsOf the 163 cases, the primary organs of origin were ovary, colorectal, appendicular pseudomyxoma, stomach, mesothelioma and others (67.4%, 16.5%, 6.1%, 4.9%, 2% and 2%), respectively. TPP was performed in 70 patients and IFP in 93 patients. TPP group had higher mean PCI (16 vs. 14), longer duration of surgery (11 vs. 9 h), and more blood loss (1,243 vs. 675 mL). Overall G3–G4 morbidity was comparable in both groups (42.8% vs. 33.3%) as was mortality (5.7% vs. 4.4%). Kaplan–Meier analysis showed that with a median follow-up of 45 months, TPP group had a recurrence-free survival (RFS) of 26 months and overall survival (OS) was yet to be achieved, whereas the IFP group had a RFS and OS of 21 and 43 months, respectively.ConclusionsPerforming TPP reduces the chance of missing the microscopic disease, therefore can minimize local recurrence, and better oncological outcomes. TPP can be performed with acceptable morbidity and mortality, at the cost of increased duration of surgery and higher blood loss.

238P - Laparoscopic cytoreduction in low disease burden, advanced-stage ovarian cancers: Experience from a tertiary cancer center

BackgroundSurgery remains the cornerstone of treatment in ovarian cancers with the aim to achieve a complete cytoreduction with no macroscopic residual disease. The present study tries to assess the feasibility of laparoscopic optimal cytoreduction surgery (LOCS) in patients with advanced ovarian cancer (AOC) with low burden disease. MethodsA retrospective study of advanced ovarian cancer that underwent LOCS between 2010 and 2014 was done. Histologically confirmed epithelial or germ cell ovarian cancer who underwent either interval or primary cytoreduction surgery were included. ResultsIn all 40 patients with stage 3 ovarian cancers were included in the analysis. The median age was 50 years and the median BMI was 23 kg/m2. 39 patients had epithelial ovarian cancer (38 – serous, 1- endometrioid) and 1 patient had germ cell tumor. 23 were grade 3 and 17 were grade 2, with no patient in grade 1. Stage wise majority were stage IIIC (26 patients) followed by 3 in stage IIIA and 1 patient was stage IIIB.3 patients underwent primary cytoreduction (1- IIIA, 2- IIIB) and 37 patients received neoadjuvant chemotherapy (NACT) before surgery. 3 to 8 cycles of chemotherapy was given. On the final histopathological examination, complete response was seen in 7 patients. There was no intraoperative complication and one postoperative complication (2.5%). The median time to discharge was 5 days and the median time to start chemotherapy was 23 days. After a median follow up of 70 months 7 patients (17.5%) were lost to follow up. The overall survival was 48.3% and the recurrence-free survival was 27.2 %.19 patients recurred in the peritoneum and 5 patients had a nodal recurrence. ConclusionsLaparoscopic cytoreduction is feasible in patients with advanced-stage ovarian cancers, provided the disease burden permits optimal debulking, especially so if done in centers with experience in complex laparoscopic procedures. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Role of diagnostic laparoscopy in patients with large cell neuroendocrine carcinoma of the ovary with cancerous peritonitis: case report and review of the literature

BackgroundLarge cell neuroendocrine carcinoma is a very rare ovarian neoplasm that has a poor clinical outcome even in the early stage, and there is as yet no established treatment. Diagnostic laparoscopy has been used to determine the possibility of primary optimal cytoreductive surgery or neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer. However, the role of diagnostic laparoscopy is still unclear in large cell neuroendocrine carcinoma due to its rarity.Case presentationA 31-year-old woman with abdominal distention was referred to our hospital. She was strongly suspected of having advanced ovarian cancer because of a huge pelvic mass, massive ascites, and their appearance on medical imaging. However, cytological examinations from ascitic fluid by abdominal paracentesis did not show any malignant cells. She underwent diagnostic laparoscopy to evaluate the possibility of primary optimal cytoreductive surgery, and only tissue sampling was performed for pathological diagnosis because of the countless disseminated lesions of various sizes in the intraperitoneal organs. The patient had no postoperative complications, leading to the early start of postoperative chemotherapy.ConclusionsTo date, there have been no systematic reviews that focused on determining the treatment strategy using laparoscopy. Diagnostic laparoscopy can be helpful to determine the optimal treatment, including primary debulking surgery, neoadjuvant chemotherapy, or best supportive care, assisting in decision-making particularly for patients with advanced large cell neuroendocrine carcinoma with carcinomatous peritonitis.