Cytoreductive Surgery For Ovarian Cancer Research Articles

Cost-effectiveness of laparoscopy as diagnostic tool before primary cytoreductive surgery in ovarian cancer

ObjectiveTo evaluate the cost-effectiveness of a diagnostic laparoscopy prior to primary cytoreductive surgery to prevent futile primary cytoreductive surgery (i.e. leaving >1cm residual disease) in patients suspected of advanced stage ovarian cancer. MethodsAn economic analysis was conducted alongside a randomized controlled trial in which patients suspected of advanced stage ovarian cancer who qualified for primary cytoreductive surgery were randomized to either laparoscopy or primary cytoreductive surgery. Direct medical costs from a health care perspective over a 6-month time horizon were analyzed. Health outcomes were expressed in quality-adjusted life-years (QALYs) and utility was based on patient's response to the EQ-5D questionnaires. We primarily focused on direct medical costs based on Dutch standard prices. ResultsWe studied 201 patients, of whom 102 were randomized to laparoscopy and 99 to primary cytoreductive surgery. No significant difference in QALYs (utility=0.01; 95% CI 0.006 to 0.02) was observed. Laparoscopy reduced the number of futile laparotomies from 39% to 10%, while its costs were € 1400 per intervention, making the overall costs of both strategies comparable (difference € −80 per patient (95% CI −470 to 300)). Findings were consistent across various sensitivity analyses. ConclusionIn patients with suspected advanced stage ovarian cancer, a diagnostic laparoscopy reduced the number of futile laparotomies, without increasing total direct medical health care costs, or adversely affecting complications or quality of life.

The Effect of Para Aortic Lymph Node Dissection in Staging and Complete Cytoreductive Surgery of Ovarian Cancer

Objective: Lymphatic spread is a common feature of ovarian cancer both in early and advanced stages of the disease. There is also a controversial problem of the impact of para-aortic lymph node dissection between gynecologist oncologist experts. The aim of this study is evaluating the effect of Para aortic Lymph node dissection in ovarian cancer patients. Methods: This descriptive cross-sectional study was performed on 100 ovarian cancer patients admitted in department of gynecology oncology of Ghaem hospital, Mashhad University of Medical Sciences, Iran, from November 2013 - 2014. All patients underwent surgical staging surgery and optimal debulking surgery as possible. In addition, concurrent systematic pelvic and para-aortic lymphadenectomy up to the level of inferior mesenteric artery was performed. Results: A total of 100 patients were studied. The mean age was 47 years (SD = 13). In 73 patients optimal cytoreductive surgery was done with para aortic lymphadenectomy. 53 cases (72.6%) were in primary cytoreductive surgery and 20 cases (27.3%) in interval debulking surgery groups. Positive paraaortic lymph node in the first group was 6 cases (11.3) and in the second group was 2 cases (10%). 27 patients were in apparent stage I and 46 patients were in stage II-III-IV of disease. We found positive paraaortic lymph node in 11% of total patients. We found positive paraaortic lymph node without positive pelvic lymph node in two patients. Conclusions: Lymph node dissection will produce a significant benefit in accurate and complete surgical staging; it will reduce residual disease and then progression-free survival.

A comparative analysis of prediction models for complete gross resection in secondary cytoreductive surgery for ovarian cancer

ObjectiveWe sought to examine compliance and outcomes using Memorial Sloan Kettering “(MSK) criteria” to predict complete gross resection (CGR) and compare them with the validated Tian and AGO models. MethodsPatients who underwent SCS for recurrent platinum-sensitive ovarian cancer from 5/2001–6/2014 were identified. The AGO and Tian models were applied to the study population; appropriate statistical tests were used to determine ability to predict CGR. Results214 SCS cases were identified. Since the implementation of MSK criteria, the CGR rate has been 86%. The AGO model had a 49% accuracy rate in predicting CGR, and predicted gross residual disease (RD) in 51%; however, CGR was achieved in 86%. The Tian model had an 88% accuracy rate. Of the 4% scored as Tian high risk for gross RD, 33% achieved a CGR. Comparing models, McNemar's p-value was 0.366 between the Tian and MSK models and <0.001 between AGO and MSK criteria. Median PFS was 21.3 (95%CI, 18.2–24.5), 22.5 (95%CI, 19.4–25.3), and 14.1months (95%CI, 9.7–22.1) for the entire cohort, for those achieving CGR, and for those left with RD, respectively (p=0.013). OS was 82.2 (95%CI, 60.2–123.3), 95.6 (95%CI, 63.6–NE), and 57.5months (95%CI, 27.5–113.9), respectively (p=0.014). ConclusionCGR during SCS is associated with extended PFS and OS. We report a high rate of CGR using MSK criteria. There was good concordance between the Tian and MSK models; however, the latter has fewer variables and is more user-friendly. Tian criteria may be applied to intermediate MSK cases for further stratification.

The Impact of Extensive Cytoreductive Surgery for Ovarian Cancer on the Histopathology Laboratory Workload

Objectives: Cytoreductive surgery is the principal management for ovarian cancer. Recently there has been progressive change to more extensive cytoreductive surgery (ECS) as evidence shows this improves patient prognosis. The aim of this study is to investigate the change in histopathology work load with change in surgical practice for the treatment of ovarian cancer patients at Hammersmith Hospital, UK. Materials and methods: Specimens for patients with ovarian cancer (n=116) were selected and classified into three groups: (i) standard debulking surgery; (ii) a mix of standard debulking and ECS and (iii) ECS only. The types of specimens and numbers of blocks in each group were studied. Results: Post-hoc analysis demonstrates a statistically significant increase in the number of specimens per case from standard debulking to the mixed group (p<0.0001) and to the ECS group (p<0.0001). There is also a statistically significant increase in the number of blocks from standard debulking to the mixed (p<0.0001) and to the ECS groups (p<0.0001). Conclusion: The study shows there is a significant increase in the histopathology workload with the shift from standard to extensive cytoreductive surgery, as well as increase in the complexity and range of specimens sent for histopathological examination. It is essential that centres opting for a shift to ECS ensure that adequate provisions and resources are in place to accommodate these changes.

Trends in Mortality After Primary Cytoreductive Surgery for Ovarian Cancer: A Systematic Review and Metaregression of Randomized Clinical Trials and Observational Studies.

Primary cytoreductive surgery (PDS) followed by platinum-based chemotherapy is the cornerstone of treatment and the absence of residual tumor after PDS is universally considered the most important prognostic factor. The aim of the present analysis was to evaluate trend and predictors of 30-day mortality in patients undergoing primary cytoreduction for ovarian cancer. Literature was searched for records reporting 30-day mortality after PDS. All cohorts were rated for quality. Simple and multiple Poisson regression models were used to quantify the association between 30-day mortality and the following: overall or severe complications, proportion of patients with stage IV disease, median age, year of publication, and weighted surgical complexity index. Using the multiple regression model, we calculated the risk of perioperative mortality at different levels for statistically significant covariates of interest. Simple regression identified median age and proportion of patients with stage IV disease as statistically significant predictors of 30-day mortality. When included in the multiple Poisson regression model, both remained statistically significant, with an incidence rate ratio of 1.087 for median ageand 1.017 for stage IV disease. Disease stage was a strong predictor, with the risk estimated to increase from 2.8% (95% confidence interval 2.02-3.66) for stage III to 16.1% (95% confidence interval 6.18-25.93) for stage IV, for a cohort with a median age of 65 years. Metaregression demonstrated that increased age and advanced clinical stage were independently associated with an increased risk of mortality, and the combined effects of both factors greatly increased the risk.

The impact of perioperative β blocker use on patient outcomes after primary cytoreductive surgery in high-grade epithelial ovarian carcinoma

ObjectiveTo quantify the impact of perioperative β blocker use on survival after primary cytoreductive surgery for epithelial ovarian cancer. MethodsWe conducted a multi-center retrospective study of all women who underwent primary cytoreductive surgery for ovarian cancer (2000−2010). One institution had routinely used perioperative β blockers for patients “at risk” for coronary events. The other institution did not routinely use perioperative β blockers. Demographic, operative, and follow up data were collected. Cox proportional hazards models were used to assess the effect of β blockers on progression-free interval (PFI) as well as overall survival (OS). ResultsOut of 185 eligible patients, 70 received β blockers and 115 underwent cytoreductive surgery without perioperative β blockers. Both groups were similar in demographics. A history of hypertension was present more often in the β blocker group compared to the group that did not receive β blockers (22% and 6%, p=0.002). PFI in β blocker group was greater at 18.2 vs. 15.8months (p=0.66). The OS in the β blocker group was significantly higher at 44.2 vs. 39.3months (p=0.01). In multivariate analysis, perioperative β blocker use was associated with significant improvement in OS (HR 0.68 (0.46–0.99); p=0.046). ConclusionOur study showed an association between perioperative β blocker use and longer overall survival in patients undergoing primary ovarian cancer cytoreductive surgery. A prospective randomized clinical trial in this population would further validate these results.

Impact of a Surgical Site Infection Prevention Bundle in Women Undergoing Cytoreductive Surgery for Ovarian Cancer

Impact of a Surgical Site Infection Prevention Bundle in Women Undergoing Cytoreductive Surgery for Ovarian Cancer

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.