Primary Cytoreduction Research Articles

Traditional Systemic Treatment Options in Advanced Low-Grade Serous Ovarian Cancer after Successful Cytoreduction: A Systematic Review and Meta-Analysis.

Simple SummaryLow-Grade Serous Ovarian cancer (LGSOC) is considered less sensitive to traditional chemotherapy than its high-grade counterpart. Guidelines are still inconsistent around the use and value of cytotoxic and antihormonal agents in the adjuvant setting. Traditional cytotoxic or antihormonal systemic treatment option is not associated with a significant OS or PFS benefit in this Meta-analysis.Objective: We performed a systematic literature review and a subsequent meta-analysis to compare traditional treatment options, i.e., antihormonal and cytotoxic, in LGSOC. Methods: We conducted a systematic literature review in MEDBASE and MEDLINE between September 2000 and June 2021 for women who received cytotoxic chemotherapy and/or antihormonal treatment after primary cytoreduction due to stage II–IV LGSOC and also at relapse. PFS and OS were calculated depending on the type of their adjuvant treatment. For each endpoint in the meta-analysis, pooled HR was calculated using the random effect model with the inverse variance weighted method. Only primary patients were included in the subsequent meta-analysis due to the small number of studies in the relapsed setting. Results: Five eligible first-line studies were included. Systemic chemotherapy failed to provide a significant OS benefit when compared to no systemic treatment (pooled HR = 1.01, 95% CI [0.79, 1.29]) after successful cytoreduction. Moreover, systemic chemotherapy followed by antihormonal treatment also did not result to a significant PFS or OS benefit when compared to systemic chemotherapy alone (for PSF: pooled HR = 0.59, 95% CI [0.33, 1.04]; for OS: pooled HR = 0.83, 95% CI [0.50, 1.39]). There were insufficient data from studies in the recurrent setting to allow their inclusion in the meta-analysis. Conclusions: In this meta-analysis, we failed to identify a traditional cytotoxic or antihormonal systemic treatment option that was associated with a significant OS or PFS benefit when administered following successful cytoreduction for advanced LGSOC. Prospective randomized studies are urgently warranted to define optimal adjuvant options in this challenging disease.

Prehospital care for ovarian cancer in Catalonia: could we do better in primary care? Retrospective cohort study

ObjectiveTo assess the impact of prehospital factors (diagnostic pathways, first presentation to healthcare services, intervals, participation in primary care) on 1-year and 5-year survival in people with epithelial ovarian cancer...

Abstract 2248: Environmental factors associated with residual disease after ovarian cancer primary cytoreduction surgery

Abstract Background: Ovarian cancer is the deadliest gynecologic cancer. Standard treatments for advanced stage high-grade serous ovarian cancer, the most common type, include (1) primary cytoreductive surgery (PCS) followed by adjuvant chemotherapy or (2) neoadjuvant chemotherapy (NACT) with interval debulking surgery. Patients in whom PCS is unlikely to yield optimal cytoreduction to no visible residual disease (R0) or who have medical contraindications to PCS are recommended to undergo NACT. Previous studies on associations between environmental factors and risk of any macroscopic residual disease have yielded inconsistent results. We aimed to (1) comprehensively examine the associations between demographic, lifestyle and reproductive factors and risk of residual disease after PCS; and (2) develop and internally validate a risk prediction model based on these factors. Methods: We used pooled data on 3,492 women who had PCS following a diagnosis with advanced stage high-grade serous ovarian, fallopian tube or primary peritoneal cancers from the Ovarian Cancer Association Consortium. Fifteen exposures of interest included age at diagnosis, menopausal status, race/ethnicity, education level, first-degree family history of ovarian cancer, endometriosis, smoking, body mass index, parity, incomplete pregnancy, tubal ligation, use of combined oral contraceptives, depot-medroxyprogesterone acetate, estrogen (ET), and combined estrogen-progestin therapy. We fit logistic regression models to examine each exposure-residual disease association in 80% of the data (n=2,794; random selection of participants). We developed a risk prediction model including the factors with p-values ≤0.2. Area under the receiver operating characteristic curve (AUC) was used to assess the model’s discrimination in the remaining 20% of the data (n=698). Results: Of the 3,492 participants, 2,003 (57%) had residual disease following PCS. Older age at diagnosis was associated with an increased risk of residual disease (OR=1.07 per five years, 95% CI 1.03-1.11). In contrast, a family history of ovarian cancer (OR=0.63, 95% CI 0.42-0.95) or ET use for 5+ years (OR=0.61, 95% CI 0.39-0.96) were associated with achieving R0. These above factors were included in the risk prediction model as were race/ethnicity, personal history of endometriosis, and smoking, whose p-values ≤0.2. The model showed modest performance in the validation set (AUC=0.64). Conclusions: Younger age at diagnosis, family history of ovarian cancer, and long-term ET use were associated with achieving R0 following PCS. Future studies incorporating genetic and clinical factors to improve the risk prediction for residual disease following PCS are warranted. Citation Format: Minh Tung Phung, Andrew Berchuck, Ellen L. Goode, Marc T. Goodman, Gillian E. Hanley, Jean Richardson, Bronwyn Grout, Anne Chase, Cindy McKinnon Deurloo, Beth Y. Karlan, Toon Van Gorp, Keitaro Matsuo, Karen McLean, Malcolm C. Pike, Joellen M. Schildkraut, Kathryn L. Terry, Anna DeFazio, Penelope M. Webb, Paul D. P. Pharoah, Susan J. Ramus, Celeste Leigh Pearce. Environmental factors associated with residual disease after ovarian cancer primary cytoreduction surgery [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 2248.

Cost-effectiveness of hyperthermic intraperitoneal chemotherapy at primary cytoreduction of epithelial ovarian cancer based on residual disease status

Hyperthermic intraperitoneal chemotherapy (HIPEC) with cisplatin when used at the time of interval cytoreductive surgery (ICS) after neoadjuvant chemotherapy (NACT) has been shown to provide a survival advantage compared to interval cytoreduction alone for patients with advanced epithelial ovarian cancer in a cost-effective manner. A recent large multi-center retrospective cohort study showed a survival advantage with HIPEC given during primary debulking surgery compared to surgery alone. While there is an ongoing randomized controlled trial examining HIPEC at the time of primary cytoreductive surgery (PCS) before chemotherapy (OVHIPEC-2), there is currently no study of this practice in the United States or cost data to inform incorporation of this practice. To help guide the use of HIPEC in the upfront setting until the results of the OVHIPEC-2 are available in 2026, a decision-analytic cost-effectiveness model of the US healthcare sector was developed for patients undergoing PCS with or without HIPEC. Effectiveness inputs were extracted from a Chinese retrospective cohort study of 425 patients who underwent PCS with HIPEC and 159 patients who underwent PCS alone. We found incremental cost effectiveness ratios (ICER) of $9,789 per life year saved (LYS) for optimal PCS, $18,164/LYS for suboptimal PCS, and $7,854/LYS for all patients. Our findings provide preliminary data to support that HIPEC at the time of primary cytoreductive surgery can be considered cost-effective regardless of residual disease status when using a standard willingness to pay threshold.

Surgical Implications of Advanced Low-Grade Serous Ovarian Cancer: Analysis of the Database of the Tumeurs Malignes Rares Gynécologiques Network.

Simple SummaryLow-grade serous carcinoma is a recent entity. The surgical management of advanced stages is modeled on that of high-grade tumors, with the use of neoadjuvant chemotherapy in the case of carcinosis not amenable to complete primary resection. We retrospectively analyzed data from the French national network dedicated to rare gynecologic tumors. We compared disease extension, surgical characteristics, postoperative course and survival after primary surgery vs. interval debulking. Carcinosis was more extended in the case of neoadjuvant chemotherapy. However, chemotherapy did not reduce surgical complexity, nor late postoperative morbidity. Surprisingly, progression-free and overall survival were similar after complete macroscopic or minimal resection (residuals < 2.5 mm). Survival was similar in the case of residuals ≥2.5 mm or more and nonoperated patients. Neoadjuvant chemotherapy does not improve the resectability of advanced low-grade serous cancers. Primary cytoreduction with complete or with minimal residuals should be preferred when feasible.The surgical specificities of advanced low-grade serous ovarian carcinoma (LGSOC) have been little investigated. Our objective was to describe surgical procedures/complications in primary (PDS) compared to interval debulking surgery (neoadjuvant chemotherapy and interval debulking surgery, NACT-IDS) and to assess the survival (progression-free (PFS) and overall survival (OS)) in patients with advanced LGSOC. We retrospectively analyzed advanced LGSOC from a nationwide registry (January 2000 to July 2017). A total of 127 patients were included (48% PDS and 35% NACT-IDS). Peritoneal carcinomatosis was more severe (p = 0.01 to 0.0001, according to sites), surgery more complex (p = 0.03) and late postoperative morbidity more frequent (p = 0.03) and more severe in the NACT-IDS group. PFS and OS were similar in patients with CC0 and CC1 residual disease after PDS or IDS. Prognosis was poorest for NACT-IDS patients with CC2/CC3 resection (PFS: HR = 2.31, IC95% (1.3–4.58); p = 0.005; OS: HR = 4.98, IC95% (1.59–15.61); p = 0.006). NACT has no benefit in terms of surgical outputs in patients with advanced LGSOC. Patients with complete resection or minimal residual disease (CC0 and CC1) have similar prognoses. On the other hand, patients with CC2 and more residual disease have similar survival rates compared to nonoperated patients. Primary cytoreduction with complete or with minimal residuals should be preferred when feasible.

Primary versus interval debulking surgery in the management of ovarian cancer patients, current data summary

Objective: Optimal management of ovarian cancer patients have been investigated by several centers and have been discussed in a great number of published articles. Aim of this article is the review of current data regarding this lethal malignancy treatment. Moreover, we discuss the ongoing trials regarding primary or interval cytoreductive surgery after neoadjuvant chemotherapy. Mechanism: We reviewed the relevant literature regarding ovarian cancer treatment via primary debulking surgery (PDS) as well as neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS). Findings in Brief: Our findings suggest that Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) are alternative treatments for advanced-stage ovarian cancer patients where optimal debulking surgery is considered unfeasible, while some studies indicate that NACT/IDS offer similar oncological outcomes with fewer postoperative complications. The prediction of optimal debulking probability can be evaluated by CA-125 level ≥500 U/mL, performance status ≥2, suprarenal paraaortic or supradiaphragmatic nodes &gt;1 cm, Porta hepatis disease, diffuse serosal bowel carcinomatosis, bowel mesenteric involvement or a PIV score ≥8 if a laparoscopy is performed. Conclusions: Regarding the management of advanced ovarian cancer patientswho receive neoadjuvant interval debulking surgery seems to be as efficacient as primary cytoreduction. The patients that are more eligible and could benefit from this treatment strategy should be specified through larger, double-blind randomized control trials.

Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction.

Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials—CHORUS, JCOG0602, and SCORPION—have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.

When we open and close: Postoperative outcomes after aborted primary cytoreduction for ovarian cancer

ObjectiveLittle data exists to adequately counsel patients on the postsurgical morbidity and outcomes of an aborted primary debulking (AD) for advance stage epithelial ovarian cancer. Our objectives were to examine the 30-day morbidity of AD, percentage of patients who subsequently undergo neoadjuvant chemotherapy (NACT) and interval cytoreductive surgery (ICS), residual disease at ICS, and predictors for complications after AD. MethodsThis was a single-institution retrospective analysis of patients who underwent AD for ovarian cancer from 01/2008 to 12/2020 using ICD-10 diagnoses and procedure codes. Patient demographics, perioperative metrics, and residual disease at ICS were collected. Thirty-day postoperative complications were graded by the Common Terminology Criteria for Adverse Events. Fisher’s exact tests compared categorical and Wilcoxon rank-sum tests compared continuous variables. Logistic regression provided unadjusted odds ratios to identify predictors for post-AD complications. ResultsForty-eight patients underwent AD, and 43 were included for analysis. All had at least stage IIIC high grade serous ovarian cancer. All patients subsequently underwent ICS, with 21 (48.8%) achieving no residual macroscopic disease and 21 (48.8%) to ≤ 1 cm of macroscopic disease. After AD, 16 (37.2%) experienced at least one G ≥ 3 event within the first 30 days. The most common complication was gastrointestinal complications. Preoperative albumin was the only significant predictor for G ≥ 3 complication after AD. ConclusionsApproximately one-third of patients will experience at least one G ≥ 3 complications after AD. Complications may be anticipated by low preoperative albumin. Patients can be counseled that, after AD, proceeding to subsequent NACT and ICS and achieving optimal debulking is common.

Improved survival after implementation of ultra-radical surgery in advanced epithelial ovarian cancer: Results from a tertiary referral center

ObjectiveTo compare survival rates of surgically treated advanced epithelial ovarian cancer patients before and after a programmatic change in surgical approach from standard surgery towards ultra-radical surgery. Methods247 patients with FIGO stage IIIB-IV ovarian, tubal, and primary peritoneal carcinoma were operated during 2013–2019 either by primary or interval cytoreduction in Tampere University Hospital, Finland. Group 1 (n = 122) patients were operated during 2013 and February 2016. Group 2 patients (n = 125) were operated between March 2016 and March 2019, when a systematic change in surgical approach towards more extensive surgery was implemented. ResultsThe complete resection (R0) rate increased significantly from 17.2% (21/122) to 52.0% (65/125) within the study period (p < 0.001). The median progression-free survival (PFS) was 15.6 months vs 19.3 months (p = 0.037), and the median overall survival (OS) was 33.5 months vs 54.5 months in Groups 1 and 2, respectively (p = 0.028). Median OS for stage III patients in Group 1 was 36.1 months (95% CI 27.4–44.8) but could not be reached in Group 2 (p = 0.009). In Stage IV patients, OS was 32.0 months (16.4–47.7) and 39.3 months (24.8–53.8) in Group 1 and 2, respectively (p = 0.691). Multivariable Cox regression analysis revealed that OS was independently affected by the amount of residual tumor and complication grade. ConclusionsThe change of surgical approach towards maximal surgical effort improved both progression-free and overall survival. The survival benefit was unquestionable for stage III patients but did not reach statistical significance in stage IV patients.

DNA Repair Protein HELQ and XAB2 as Chemoresponse and Prognosis Biomarkers in Ascites Tumor Cells of High-Grade Serous Ovarian Cancer.

Nucleotide excision repair (NER) is an important mediator for responsiveness of platinum-based chemotherapy. Our study is aimed at investigating the NER-related genes expression in ascites tumor cells and its application in the prediction of chemoresponse in high-grade serous ovarian cancer (HGSC) patients. The relationship between 16 NER-related genes and the prognosis of ovarian cancer was analyzed in the TCGA database. NER-related genes including HELQ and XAB2 expressions were determined via immunocytochemistry in ascites cell samples from 92 ovarian cancer patients prior to primary cytoreduction surgery. Kaplan-Meier analysis and Cox model were used to investigate the association between NER-related gene expression and prognosis/chemotherapeutic response. Predicting models were constructed using a training cohort of 60 patients and validated in a validation cohort of 32 patients. We found that high expression of HELQ and XAB2 in the training cohort was associated with poor prognosis (for HELQ, P = 0.001, HR = 2.83, 95% CI: 1.46-5.49; for XAB2, P = 0.008, HR = 2.38, 95% CI: 1.23-4.63) and platinum resistance (for HELQ, P < 0.001; for XAB2, P = 0.006). In the validation cohort, the combination of HELQ and XAB2 (AUC = 0.863) showed the highest AUC. The expression levels of HELQ (RR 5.7, 95% CI 1.7-19.2) and XAB2 (RR 3.2, 95% CI 0.9-10.8) in ascites tumor cells were positively correlated to the risk of platinum resistance. In summary, we revealed that the expression levels of HELQ and XAB2 are candidate predictors for primary chemotherapy responsiveness and prognosis in HGSC. Ascites cytology is applicable as a promising method for chemosensitivity prediction in HGSC.

CHRONO: randomized trial of the CHROnology of surgery after Neoadjuvant chemotherapy for Ovarian cancer

BackgroundIn patients treated for advanced ovarian cancer not suitable for complete primary surgery, interval surgery after three courses of neoadjuvant chemotherapy has been considered standard management since the EORTC randomized...

Fertility-sparing treatment for serous borderline ovarian tumors with extra-ovarian invasive implants: Analysis from the MITO14 study database

ObjectiveOnly 10–15% of serous borderline ovarian tumors (BOTs) with extra-ovarian disease have invasive implants, and conservative treatments have been rarely reported. The MITO14 is a multi-institutional retrospective study conducted with the aim of systematically collecting data from consecutive BOT patients. The present analysis reports the oncological and reproductive outcomes of women with serous BOT and invasive implants registered into the MITO14 database and conservatively treated between August 2002 and May 2019. MethodsThirteen patients (FIGO2014 stage II–III serous BOT with invasive implants) were recruited. Primary and secondary endpoints were, respectively, recurrence and death rates, and pregnancy and live birth rates. Only patients undergoing fertility-sparing surgery (FSS) were included, while patients were excluded in case of: age > 45 years; second tumor(s) requiring therapy interfering with the treatment of BOT. ResultsMedian follow-up time from primary cytoreduction was 146 months (range 27–213 months). Eleven patients (84.6%) experienced at least one recurrence (median time to first relapse 17 months, range 4–190 months), all of these undergoing secondary surgery (FSS in 7). Five patients attempted to conceive: 3 achieved at least one pregnancy and 2 gave birth at least to a healthy child. At the end of the observation period, all patients were alive with no evidence of disease. ConclusionsFertility-sparing treatment should be considered in a context of serous BOT with invasive implants. Despite the high rate of recurrence, FSS provides good chances of reproductive success without a negative impact on overall survival.

Primary peritoneal carcinoma and ovarian carcinoma - a ten-year comparative analysis.

Primary peritoneal carcinoma (PPC) at presentation often masquerades as epithelial ovarian carcinoma (OC) but behaves different with respect to treatment response, recurrence patterns and has inferior outcomes. The objective of this study is to compare the clinicopathological features and survival outcomes of PPC and OC. Prospectively maintained database of patients presenting to the gynecologic oncology department at a tertiary hospital was reviewed between 1st January 2010 and 31st December 2020. A comparative analysis of high-grade serous stage III/IV PPC and OC was done. Demographics, treatment details, complications and survival outcomes were collected from electronic medical records. 151 OC and 69 PPC patients were included. A higher proportion of women with PPC had reduced performance status prior to hysterectomy with salpingo-oophorectomy, a shorter symptom to treatment interval, and large volume ascites. A significantly lower number of women with PPC (4.3 vs. 46.1%; P &lt; 0.001) underwent primary cytoreduction, had a lower median surgical complexity score (3 vs. 4; P &lt; 0.001) but higher recurrence rates (66.7 vs. 47.0%; P = 0.041) as compared to the patients with OC. The median progression-free survival (PFS) was 18 (15-20) months in PPC and 23 (17-28) months in OC patients (log-rank P = 0.034), while the median overall survival (OS) was similar (44 vs. 48 months; log-rank P = 0.696). The presence of extraperitoneal disease and interval cytoreduction was associated with shorter PFS. Suboptimal cytoreduction and delay in adjuvant chemotherapy beyond 6 weeks post-surgery was associated with reduced OS. PPC is an aggressive disease with lower PFS compared to OC. Commonly presenting with large volume carcinomatosis, it is not amenable for primary cytoreduction, making the usage of neoadjuvant chemotherapy a common practice and pragmatic approach.

Cost-effectiveness of Iterative Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for the Treatment of Peritoneal Carcinomatosis.

Iterative cytoreduction (iCRS) and hyperthermic intraperitoneal chemotherapy is a treatment for recurrence of peritoneal carcinomatosis. There are considerable upfront costs for this approach for which the cost-effectiveness has not been evaluated. We used a prospectively maintained database of patients having undergone primary and iterative cytoreduction at St. George Hospital between January 1, 2014, and December 31, 2017, which was linked with financial data. Cost effectiveness and survival outcomes were used to compare primary cytoreduction (pCRS) and iterative cytoreduction (iCRS) in addition to comparison with other treatment modalities. The average cost per patient in Australian dollars was $69,295 ($14,691-$696,002) and the average cost per life-year was $15,842. There was no difference in cost-effectiveness between those who had undergone pCRS and those who had undergone iCRS. The overall survival was 52.5 months (95% confidence interval=49.7-55.2 months) with no difference in survival between pCRS and iCRS groups. The median length of hospital stay was significantly longer for patients in the pCRS treatment group (25.51 days) when compared to the iCRS treatment group (21.15 days, p=0.034). iCRS is a cost-effective treatment in the management of recurrent peritoneal carcinomatosis.

New therapeutic opportunities for women with low-grade serous ovarian cancer.

Low-grade serous ovarian cancer (LGSC) is a morphologically and molecularly distinct subtype of ovarian cancer, accounting for ~10% of serous carcinomas. Women typically present at a younger age and have a protracted clinical course compared with the more common, high-grade serous ovarian cancer. Currently, the primary treatment of LGSC is the same as other epithelial ovarian cancer subtypes, with treatment for most patients comprised of debulking surgery and platinum/taxane chemotherapy. Primary surgical cytoreduction to no visible residual disease remains a key prognostic factor; however, the use of platinum-based chemotherapy in both upfront and relapsed setting is being questioned due to low response rates in LGSC. Most LGSC expresses steroid hormone receptors, and selected patients may benefit from endocrine maintenance therapy following chemotherapy, in particular, those with evidence of residual disease at completion of surgery. In the recurrent setting, while hormonal therapies may offer disease stabilisation with relatively low toxicity, objective response rates remain low. Strategies to increase response rates, including combining with CDK4/6 inhibitors, are being investigated. LGSC has a high prevalence of activating somatic mutations in mitogen-activated protein kinase pathway genes, most commonly in KRAS, BRAF and NRAS. Trametinib, a MEK inhibitor, has shown efficacy over chemotherapy and endocrine therapy. The use of combination targeted therapies, immunotherapy and anti-angiogenic agents, remain active areas of investigation for the treatment of LGSC.

The fundamental role of the exploration of the upper abdomen in ovarian cancer surgery

Purpose: Several studies have shown the benefit of cytoreductive surgery in advanced disease, that is why the residual tumor has prognostic value. Our primary objective was to determine the frequency of involvement of the upper abdomen, defined as the extension of the disease above the transverse colon (diaphragm, spleen, gallbladder, stomach, hepatic parenchyma, hepatic capsule, minor omentum, hepatic ilium, pancreas). Our secondary objective was to analyze the possibilities of complete cytoreduction in these patients, their complications and results. Materials and methods: We retrospectively include patients undergoing primary and secondary cytoreduction due to ovarian carcinoma between January 2008 and December 2012, in the gynecology department of the German Hospital. Results: One hundred and thirty nine patients with ovarian carcinoma were analyzed. An average age of 60 years (28-90). 91 of them with attempted primary cytoreduction and 48 secondary cytoreduction. In the group of primary cytoreductions we excluded 17 patients that were stages I and II, 20 (22%) of the 74 stages III-IV had upper abdomen involvement, 17 stages III and 3 stages IV. Those stage IV patients were only limited to hepatic intraparenchymal involvement. Of the 48 secondary cytoreductions, 21 (43%) presented upper abdominal involvement. Including both groups we have 30% of upper abdomen compromise. Complete or optimal cytoreduction was achieved in 56% of them. Conclusion: The exploration of the superior abdomen in ovarian cancer surgery is key, and the approach of this patients by a team of properly trained gynecologists is mandatory if we want to obtain better complete cytoreduction rates.

Multiquadrant Robotic Assisted Primary Cytoreduction for Stage III C Ovarian Cancer Part II Modified Posterior Exenteration

<h3>Study Objective</h3> To demonstrate Part II of multi-quadrant robotic assisted pelvic primary cytoreductive surgery for Stage IIIC epithelial ovarian cancer. <h3>Design</h3> A prospective single patient underwent robotic assisted cytoreductive surgery. Docking time for pelvic and abdominal dissection was recorded. The multiple procedures that patient underwent was recorded for operative time along with intraoperative complications and postoperative complication, estimated blood loss, and length of hospitalization. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> Patient is a 56-year-old female presents with abdominal pain. CT scan showed no ascites soft tissue mass in the right hepatic gutter omental mass with minimal pelvic fluid and pelvic mass. CA 125 was 533. <h3>Interventions</h3> Robotic Xi. <h3>Measurements and Main Results</h3> The abdominal docking time was 2 minutes and 30 seconds. The pelvic docking time which was the time from de-docking after completion of abdominal dissection to rotating the boom to re-docking for pelvic dissection was 5 minutes and 30 seconds. Total operative time for both pelvic and abdominal dissection was 246 minutes. The operative time for right diaphragm peritonectomy 30 minutes and resection of omental caking with complete omentectomy was 68 minutes. The pelvic dissection which consisted of en bloc modified posterior exenteration procedure with total intracorporal sigmoid rectal anastomosis was 126 minutes. A complete cytoreductive surgery with no gross residual was achieved. EBL 200 cc and length of hospitalization was 4 days. There was no intraoperative or postoperative complication. <h3>Conclusion</h3> Robotic assisted multi-quadrant surgery is feasible to achieve upper abdominal, abdominal and pelvic procedures to achieve an optimal cytoreductive surgery for stage IIIc ovarian cancer.

Multiquadrant Robotic Assisted Primary Cytoreduction for Stage III C Ovarian Cancer Part I Complete Omentectomy Right Diaphragm Stripping

<h3>Study Objective</h3> To demonstrate Part I of multi-quadrant robotic assisted abdominal primary cytoreductive surgery for Stage IIIC epithelial ovarian cancer. <h3>Design</h3> A prospective single patient underwent robotic assisted cytoreductive surgery. Docking time for pelvic and abdominal dissection was recorded. The multiple procedures that patient underwent was recorded for operative time along with intraoperative complications and postoperative complication, estimated blood loss, and length of hospitalization. <h3>Setting</h3> Tertiary hospital. <h3>Patients or Participants</h3> Patient is a 56-year-old female presents with abdominal pain. CT scan showed no ascites soft tissue mass in the right hepatic gutter omental mass with minimal pelvic fluid and pelvic mass. CA 125 was 533. <h3>Interventions</h3> Robotic Xi. <h3>Measurements and Main Results</h3> The abdominal docking time was 2 minutes and 30 seconds. The pelvic docking time which was the time from de-docking after completion of abdominal dissection to rotating the boom to re-docking for pelvic dissection was 5 minutes and 30 seconds. Total operative time for both pelvic and abdominal dissection was 246 minutes. The operative time for right diaphragm peritonectomy 30 minutes and resection of omental caking with complete omentectomy was 68 minutes. The pelvic dissection which consisted of en bloc modified posterior exenteration procedure with total intracorporal sigmoid rectal anastomosis was 126 minutes. A complete cytoreductive surgery with no gross residual was achieved. EBL 200 cc and length of hospitalization was 4 days. There was no intraoperative or postoperative complication. <h3>Conclusion</h3> Robotic assisted multi-quadrant surgery is feasible to achieve upper abdominal, abdominal and pelvic procedures to achieve an optimal cytoreductive surgery for stage IIIc ovarian cancer.

A New Paradigm in Managing Advanced Ovarian Cancer: Differentiating Patients Requiring Neoadjuvant Treatment from Primary Cytoreduction.

Simple SummaryThis study evaluates the comparability of patients treated with primary cytoreduction and patients undergoing neoadjuvant chemotherapy for advanced stages high grade serous ovarian carcinoma by comparing the preoperative and postoperative characteristics after a propensity score matching analysis during ten years in a tertiary cancer center.Our study aims to evaluate the comparability of primary debulking surgery (PDS) and neoadjuvant chemotherapy (NACT) patients. This single-center retrospective study includes all patients treated for advanced stages high-grade serous ovarian carcinomas (HGSOC) between 2007 and 2017. Preoperative characteristics and postoperative outcomes were compared after a propensity score matching analysis. Of the 221 patients included, 38% underwent PDS, and 62% received NACT. There was no age difference at diagnosis; however, CA125 levels, PCI score levels, and rates of stage IV were higher in the NACT group. There were no differences concerning the rate and the severity of complications (p = 0.29). The propensity score distribution showed a broad distinction between PDS patients and NACT patients with no significant overlap. Survival analyses demonstrate, after a median follow-up of 66.5 months, an overall survival (OS) of 105.9 and progression-free survival (PFS) of 29.2 months in the PDS group, compared to OS of 52.8 and PFS of 18.9 months in the NACT group. Advanced HGSOC is a heterogeneous population, in which inoperable patients should be differentiated from PDS patients based on many factors, primarily tumor burden.

The correlation between BRCA status and surgical cytoreduction in high-grade serous ovarian carcinoma

<h3>Objectives:</h3> BRCA-associated ovarian cancers are biologically unique, as evident by differential molecular and clinical behaviour of these tumor as compared to sporadic ovarian cancers. It is unclear if these biological differences translate to favorable outcomes at the time of primary cytoreduction. The aim of this study is to compare the amount of residual disease after primary cytoreduction in <i>BRCA</i> mutated and wildtype populations, and to assess whether <i>BRCA</i> status is an independent predictor of optimal cytoreduction. <h3>Methods:</h3> We conducted a retrospective analysis of patients with high-grade serous (HGSC) ovarian cancers with known germline and somatic <i>BRCA</i> mutation status, treated with primary cytoreductive surgery from 2000 to 2017. Post-operative <i>BRCA</i> germline and somatic testing was conducted in all cases. We compared the complete, optimal and suboptimal cytoreduction rates between the <i>BRCA</i> positive and the <i>BRCA</i> negative cohorts and built a predictive model to assess whether the <i>BRCA</i> status was associated with the amount of residual disease after controlling for confounding variables. <h3>Results:</h3> Of 355 women with HGSC ovarian cancers treated with primary cytoreduction, 144 harbored germline or somatic <i>BRCA</i> mutations (41%) and 211 were <i>BRCA</i> wildtype (59%). <i>BRCA</i> positive women tended to be younger (54 vs 59; p<0.001), but there were no differences between the two groups in preoperative CA-125 levels, disease burden (measured by disease score), surgical complexity score, stage distributions, length of surgery, intraoperative or postoperative complications. Comparing residual disease burden at the end of primary cytoreduction, the <i>BRCA</i> positive group had a higher rate of complete cytoreduction to no residual disease (0mm) [75% vs 54%], and a lower rate of optimal cytoreduction (1-9mm) [16% vs 34%] or suboptimal cytoreduction (≥10mm) [9% vs. 12%] (p<0.001). In our predictive model, after accounting for length of surgery, CA-125 level, stage distributions, disease scores and surgical complexity scores, <i>BRCA</i> positive status was predictive of complete cytoreduction to 0mm residual disease with odds ratio (OR) of 4.78 (95% CI 2.32-9.85; p<0.001). Subgroup analysis restricted to patients with stage III/IV HGSC showed similar results, with <i>BRCA</i> positive status having OR of 5.2 (95% CI 2.44-11.09; p<0.001) for complete primary cytoreduction. <h3>Conclusions:</h3> <i>BRCA</i> status is predictive of complete and optimal cytoreduction at the time of primary surgical cytoreduction in patients presenting with newly diagnosed ovarian cancer. This positive correlation should be taken into consideration when deciding between primary cytoreductive surgery or neoadjuvant chemotherapy in women with this disease.