Primary Cytoreductive Surgery Group Research Articles

Does neoadjuvant chemotherapy reduce surgical complexity in patients with advanced-stage epithelial ovarian cancer?

BackgroundThis study aimed to determine the effect of neoadjuvant chemotherapy (NACT) on the complex surgical procedures required in addition to staging surgery for the need to achieve a residual tumor 1 cm or less in a population of stage IIIC–IV epithelial ovarian cancer patients.MethodsPatients were referred for NACT if preoperative imaging and/or intraoperative evaluation confirmed that it was not possible to achieve a residual tumor size of 1 cm or less with cytoreductive surgery or if the patient had a poor performance status and a high American Society of Anesthesiologists (ASA) score. Surgical complexity was defined as complex or non-complex.ResultsOne hundred and twenty-six patients with stage IIIC–IV ovarian cancer were included in the study. Primary cytoreductive surgery was performed in 67 patients, and interval cytoreductive surgery was performed in 59 patients after NACT. At least one complex surgery was performed in 74.6% of the patients in the primary cytoreductive surgery group and in 61% of the patients in the NACT group, with no statistically significant difference between the groups. However, the NACT group showed significantly decreased rates of low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy.ConclusionsThe analyses showed no reduction in the requirement for at least one complex surgical procedure in the group of patients who underwent NACT. Nevertheless, this group exhibited a significant decrease in low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy due to their effectiveness in reducing peritoneal disease.

Short- and long-term morbidity of total parietal peritonectomy for advanced ovarian cancer

ObjectiveTotal parietal peritonectomy is gradually being recognized as a surgical option for advanced ovarian cancer; however, evidence regarding its efficacy and safety remains insufficient. Herein, we aimed to assess the...

Role of Computed Tomography in the Diagnosis of Ovarian Cancer

Introduction. Malignant formations in the ovaries remain a pressing issue in the field of oncology today. Ovarian cancer occupies one of the leading positions in terms of frequency (7th place) and mortality (4th place). The lack of symptoms during the course of the disease is explained by the fact that cancer cells primarily spread through the abdominal cavity, often leading to late-stage disease diagnosis. The prognosis of the disease depends on the stage of the disease, the level of tumor differentiation, the period of recurrence-free survival, and the size of the residual tumor after surgical treatment. Considering these factors, this disease remains of interest to researchers in terms of identifying new prognostic factors for the course of the disease and the possibility of influencing them. Methods. The study is based on the results of observing 139 patients with stage III-IV ovarian cancer. The study and evaluation included the peritoneal cancer index and overall survival. Results. An analysis of two groups of patients who received neoadjuvant chemotherapy/intraperitoneal chemotherapy and primary cytoreductive surgery was conducted. Peritoneal carcinomatosis was evaluated in the primary patients in the neoadjuvant chemotherapy/intraperitoneal chemotherapy group and the primary cytoreductive surgery group. The average peritoneal cancer index in the neoadjuvant chemotherapy/intraperitoneal chemotherapy group was 21.5 points, and in the primary cytoreductive surgery group, it was 14.3 points. Overall patient survival was calculated, according to the Kaplan-Meier curve, the median overall survival in the neoadjuvant chemotherapy/intraperitoneal chemotherapy group was 24 months, and in the primary cytoreductive surgery group, it was 25 months. Conclusions. The use of contrast-enhanced CT in patients with ovarian cancer is an informative method for diagnosing peritoneal carcinomatosis and allows for the correct diagnosis and planning of treatment tactics. Although interval cytoreductive surgery does not affect the overall survival of patients, it allows for optimal cytoreductive surgery in patients with advanced carcinomatosis.

Beyond post-operative readmissions: analysis of the impact of unplanned readmissions during primary treatment of advanced-stage epithelial ovarian cancer on long-term oncology outcome

BackgroundMultiple studies have assessed post-operative readmissions in advanced ovarian cancer.ObjectiveTo evaluate all unplanned readmissions during the primary treatment period of advanced epithelial ovarian cancer, and the impact of readmission on...

Factors influencing treatment delays in a safety net hospital: teachable moments?

<h3>Objectives:</h3> Delays in diagnosis and treatment of ovarian cancer contribute to decreased overall survival. A post-hoc analysis of a GOG study demonstrated that initiation of chemotherapy more than 25 days after surgery adversely affected survival. Furthermore, previous studies have shown that socio-demographic factors also play a role in treatment delays. We sought to determine factors contributing to delays in treatment initiation and reasons for delay in chemotherapy administration in patients receiving primary treatment of epithelial ovarian cancer at our safety net hospital. <h3>Methods:</h3> All patients with epithelial ovarian cancer seen between 1/1/2009 and 12/1/2019 were identified. Only patients who had primary chemotherapy at our safety net hospital were included. Demographic variables included race, ethnicity, median household income (MHI), and age for patients undergoing both primary cytoreductive surgery (PCRS) and neoadjuvant chemotherapy (NACT). A delay in initiation of chemotherapy was defined as > 25 days post surgery (whether undergoing PCRS or interval cytoreduction after NACT). Time to treatment initiation (TTI) was defined as date of gynecologic oncology consult to surgery (for PCRS) or first cycle of chemotherapy (for NACT). Delays between cycles of chemotherapy were noted through chart review. Linear regression analyses were performed using demographic variables as predictors for treatment duration (with p value set at 0.05). <h3>Results:</h3> 101 patients were identified that met inclusion criteria. The median age in this cohort was 61 years (range 25-82). 18 (17.8%) were Black and 75 (74.3%) were Hispanic. 81 (80.2%) patients had a MHI less than $60,000. 63 (62.4%) patients underwent PCRS and 38 (37.6%) patients underwent NACT. 77.2% of patients did not initiate adjuvant chemotherapy until > 25 days post surgery. The median TTI in the PCRS group was 15 days; however, 53 (84.1%) patients undergoing PCRS received their first cycle of chemotherapy > 25 days post surgery. The median TTI in the NACT group was 19 days, and 25 (65.8%) patients who completed NACT received their first cycle of adjuvant chemotherapy > 25 days after surgery. Black patients undergoing PCRS experienced a 30 day longer TTI than White patients (p=0.013). TTI for patients undergoing PCRS and living in an area with a median household income < $30,000 was 42 days versus 14 days in patients living in an area with median household income >$60,000 (p=0.033). In patients greater than 65 years old undergoing NACT, the time from interval cytoreductive surgery to adjuvant chemotherapy start was longer: 27 days for patients age < 65 years versus 39 days for patients ≥65 years (p=0.005). There were 76 total delays in chemotherapy administration identified. 39 (60.9%) of these were due to medical reasons and 37 (48.6%) were due to non-medical reasons. Specifically, 5 (6.5%) were due to regimen intolerance; 11 (14.5%) were due to hospitalizations or surgeries; 15 (19.7%) were due to patient factors such as transportation; 22 (28.9%) were due to scheduling barriers; and 23 (30.1%) were due to lab abnormalities. <h3>Conclusions:</h3> Significant delays exist in initiation of treatment and completion of treatment in patients receiving first line therapy for epithelial ovarian cancer. Race, income, and age were predictors of delays in treatment. Both medical as well as non-medical factors precluded timely delivery of treatment. Future quality studies at our institution will investigate whether these changes decrease delays in cancer care.

Use and outcomes of neoadjuvant chemotherapy for metastatic uterine cancer

ObjectiveNeoadjuvant chemotherapy (NACT) has emerged as an alternative to primary cytoreductive surgery (PCS) for stage IV uterine cancer. We examined utilization, perioperative outcomes and survival for NACT and PCS for stage IV uterine cancer. MethodsThe Surveillance, Epidemiology, End Results-Medicare database was used to identify women with stage IV uterine cancer treated from 2000 to 2015. Women were classified as NACT or PCS. Interval cytoreductive surgery (after NACT) or chemotherapy (after PCS) were recorded. The extent of surgery and perioperative outcomes were estimated for the groups. Multivariable proportional hazards models and Kaplan-Meier analyses were used to examine survival. ResultsAmong 3037 women, 1629 (53.6%) were treated with primary cytoreductive surgery, 554 (18.2%) with NACT, and 854 (28.1%) received no treatment. Use of NACT increased from 9.5% to 29.2%. After NACT, interval hysterectomy was performed in 159 (28.6%), while within the PCS group, 1052 (64.6%) received chemotherapy. Extended cytoreductive procedures were performed in 71.7% of women who received NACT vs. 79.1% after PCS (P = 0.03). The complication rate was 52.8% for NACT versus 56.2% for PCS (P = 0.42); medical complications were more frequently seen in the PCS group (39.4% versus 28.9%; P = 0.01). There was no difference in cancer specific (P = 0.48) or overall survival (P = 0.25) in women who received both chemotherapy and surgery regardless of whether the initial treatment was NACT or PCS. ConclusionUse of NACT is increasing for advanced stage uterine cancer. There was no difference in survival between NACT and primary cytoreductive surgery and NACT was associated with fewer perioperative medical complications.

Evaluation of Cytoreductive Surgery With or Without Hyperthermic Intraperitoneal Chemotherapy for Stage III Epithelial Ovarian Cancer

Interval cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) showed promising oncologic outcomes for patients with advanced ovarian cancer, but a large-scale, multicenter study to evaluate the efficacy of HIPEC combined with primary cytoreductive surgery (PCS) has yet to be conducted. To compare survival outcomes between PCS with HIPEC vs PCS alone for patients with stage III epithelial ovarian cancer. This cohort study was conducted from January 2010 to May 2017 at 5 high-volume institutions in China. A total of 584 patients with stage III primary epithelial ovarian cancer were treated with either PCS alone or PCS with HIPEC. The median (interquartile range) follow-up period was 42.2 (33.3-51.0) months. Data analysis was conducted from August to December 2019. PCS with HIPEC vs PCS alone. Primary outcomes were median survival time and 3-year overall survival. The inverse probability of treatment weighting (IPTW) method, based on propensity score, was used to control for confounding factors. From a total of 789 patients with stage III epithelial ovarian cancer, 584 patients (74.0%; mean [SD] age, 55.0 [10.5] years) were ultimately included for IPTW in this study. Of the 584 patients, 425 (72.8%) underwent PCS with HIPEC and 159 (27.2%) underwent PCS alone. After IPTW adjustment, the median survival time was 49.8 (95% CI, 45.2-60.2) months for patients undergoing PCS with HIPEC and 34.0 (95% CI, 28.9-41.5) months for patients undergoing PCS alone, and the 3-year overall survival rate was 60.3% (95% CI, 55.3%-65.0%) for patients undergoing PCS with HIPEC and 49.5% (95% CI, 41.0%-57.4%) for patients undergoing PCS alone (weighted hazard ratio, 0.64; 95% CI, 0.50-0.82; P < .001). Further stratified into complete and incomplete surgery subgroups, patients in the PCS with HIPEC group had significantly better survival than those in the PCS group, except for the 3-year overall survival rate in the incomplete subgroup. Among those who underwent complete surgical procedures and comparing those who received PCS with HIPEC vs those who received PCS alone, the median survival time was 53.9 (95% CI, 46.6-63.7) months vs 42.3 (95% CI, 31.1-59.3) months (P = .02), and the 3-year overall survival rate was 65.9% (95% CI, 60.1%-71.2%) vs 55.4% (95% CI, 44.7%-64.8%) (P = .04); meanwhile, among patients who underwent incomplete surgical procedures and comparing those who received PCS with HIPEC vs those who received PCS alone, the median survival time was 29.2 (95% CI, 22.3-45.5) months vs 19.9 (95% CI, 11.6-39.1) months (P = .03), and the 3-year OS rate was 44.3% (95% CI, 34.6%-53.4%) vs 36.7% (95% CI, 23.4%-50.1%) (P = .19). The treatment was well tolerated in both groups. In this study, the PCS with HIPEC treatment approach was associated with better long-term survival. When complete PCS is possible, this approach could be a valuable therapy for patients with stage III epithelial ovarian cancer.

Comparison of patient reported symptom burden on an enhanced recovery after surgery (ERAS) care pathway in patients with ovarian cancer undergoing primary vs. interval tumor reductive surgery

ObjectiveTo compare symptom burden and functional recovery in women undergoing primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy (NACT) and interval cytoreductive surgery (ICS) within an enhanced recovery after surgery program (ERAS). MethodsSymptom burden was measured using the MD Anderson Symptom Inventory-Ovarian Cancer, a 27-item validated tool that was administered preoperatively, daily while hospitalized, and weekly for 8 weeks after hospital discharge. Mixed-effect modeling was performed. Results196 patients (71 PCS, 125 ICS) participated. Patients in the PCS group were younger, median age of 59 vs. 63 in ICS group. Median length of stay was 4 days for PCS and 3 days for ICS group. PCS pts had a significantly higher median surgical complexity score (4 vs. 2, p = 0.002), and longer median surgical time (257 min vs. 220 min, p = 0.03). While patients undergoing PCS had significantly different symptom burden profiles prior to surgery compared to those undergoing ICS, there were no significant differences in symptoms in the immediate in-hospital and extended post-hospital discharge period. Irrespective of the timing of surgery in relation to chemotherapy, patients undergoing intermediate or high complexity surgery had more nausea, fatigue, and higher total interference scores compared to patients undergoing low complexity surgery. ConclusionWithin a center with a standardized, systematic method for patient selection for PCS and a standardized ERAS care pathway, there were not significant differences in surgery-related symptoms related to recovery between patients undergoing PCS or ICS. However, patient-reported symptom burden and symptom interference did meaningfully differentiate based on surgical complexity score.

Comparison of patient reported symptom burden in patients with ovarian cancer undergoing primary vs. interval tumor reductive surgery.

5557 Background: Patient-reported outcomes (PROs) are important in comparative effectiveness research. We compared symptom burden and functional recovery in pts undergoing primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy (NACT) and interval cytoreductive surgery (ICS) within an enhanced recovery after surgery program (ERAS). Methods: Perioperative PROs were measured for women with ovarian cancer undergoing PCS or ICS using the MD Anderson Symptom Inventory- Ovarian Cancer, a 27-item validated tool which was administered preoperatively, daily in hospital, and at least weekly for 8 weeks post-op. Mixed-effect modeling was performed. Results: 108 pts (45 PCS, 63 ICS) participated. There was no difference in median age, Charlson comorbidity index, ASA status, history of chronic opioid use, length of stay or readmission rate. At pre-op baseline assessment, the mean pain score was higher in the PCS group (3.8 vs. 1.8, p = .0005). ICS pts had a lower median surgical complexity score (4.0 vs. 2.0, p = .03), and shorter median surgical time (260 min vs. 223 min, p = .05). During hospitalization, pts undergoing PCS reported significantly more bloating, urinary urgency, distress, sadness and mood disturbance. Women who received NACT had a significantly higher symptom burden of neuropathy, leg cramps and memory disturbances. There was no difference in pain, fatigue, drowsiness, nausea, or emesis within the first 5 days postoperatively. While there was no significant differences in the physical interference composite score, (walking, work, activity), those who underwent ICS had improved affective interference scores (mood, relations, enjoyment of life). Conclusions: Within an ERAS program, there were few significant differences in surgery related symptoms related to physical recovery between pts undergoing PCS or ICS. The differences in overall symptom burden suggest that disease related symptoms (pain, bloating, urinary urgency) and emotional symptoms may be related to recent diagnosis and higher tumor burden in pts undergoing PCS while the increased numbness, leg cramps and memory issues reflect chemo-related effects in the ICS cohort.

Overall Survival Following Neoadjuvant Chemotherapy vs Primary Cytoreductive Surgery in Women With Epithelial Ovarian Cancer

Uncertainty remains about the relative benefits of primary cytoreductive surgery (PCS) vs neoadjuvant chemotherapy (NACT) for advanced-stage epithelial ovarian cancer (EOC). To compare overall survival of PCS vs NACT in a large national population of women with advanced-stage EOC. Retrospective cohort study of women with stage IIIC and IV EOC diagnosed between 2003 and 2011 treated at hospitals across the United States reporting to the National Cancer Data Base. We focused on patients 70 years or younger with a Charlson comorbidity index of 0 who were likely candidates for either treatment. Initial treatment approach of PCS vs NACT, examined using an intent-to-treat analysis. Overall survival, defined as months from cancer diagnosis to death or date of the last contact. We used propensity score matching to compare similar women who underwent PCS and NACT. The association of treatment approach with overall survival was assessed using the Kaplan-Meier method and the log-rank test. We assessed whether the findings were influenced by differences in the prevalence of an unobserved confounder, such as limited performance status (Eastern Cooperative Oncology Group 1-2), preoperative disease burden, and BRCA status. Among 22 962 patients (mean [SD] age, 56.12 [9.38] years), 19 836 (86.4%) received PCS and 3126 (13.6%) underwent NACT. We matched 2935 patients treated with NACT with similar patients who received PCS. The median follow-up was 56.5 (95% CI, 54.5-59.2) months in the PCS group and 56.3 (95% CI, 54.5-59.8) months in the NACT group in the propensity-matched cohort. Among propensity score-matched groups, the median overall survival was 37.3 (95% CI, 35.2-38.7) months in the PCS group and 32.1 (95% CI, 30.8-34.1) months in the NACT group (P < .001). However, if the NACT group had a higher proportion of women with performance statuses of 1 to 2 compared with those who underwent PCS (60% vs 50%), the association of PCS and improved survival would not be statistically significant. Primary cytoreductive surgery was associated with improved survival compared with NACT in otherwise healthy women with advanced-stage epithelial ovarian cancer aged 70 years or younger. The lower survival in women who received NACT could be explained by a higher prevalence of limited performance status in women undergoing NACT.

Personalized surgical therapy for advanced ovarian cancer: R0 resection after neoadjuvant chemotherapy is associated with decreased event-free survival compared with primary cytoreductive surgery

Objectives: To determine differences in survival among patients who undergo complete gross resection (R0) after primary cytoreductive surgery (PDS) compared with interval cytoreductive surgery (IDS).Methods: Standard practice at our institution is to have all patients with advanced ovarian cancer (OC) undergo a triage algorithm to determine those who should receive PDS versus neoadjuvant chemotherapy (NACT) followed by IDS. Using a previously described algorithm, preoperatively defined parameters are analyzed using laparoscopy (LS) to determine who should be offered PDS. Patient outcomes were tracked prospectively. The Fisher exact test and Wilcoxon rank sum test were used to compare medians among patients with PDS versus IDS. Event-free survival (EFS) was defined as months from the date of diagnosis to the date of first recurrence, progressive disease, or death. Prognostic factors associated with EFS were evaluated with Cox proportional hazards regression.Results: Between April 2013 and September 2015, 206 patients with suspected advanced OC presented to our center. Of these, 119 were offered LS; 88% had serous histology; 132 (64%) patients had stage III disease; and 74 (36%) had stage IV disease, with more patients in the NACT group having stage IV disease (10% vs 51%, P < .001). Rates of R0 resection were similar between the PDS and IDS groups (87% [n = 65] vs 83% [n = 85], P = .521). Compared with patients who underwent PDS, those who had IDS had higher pretreatment CA-125 levels (675 vs 247, P < .001) and platelet counts (379 vs 303 × 109/L, P < .001). EFS was longer in the PDS group (20.8 months) compared with the IDS group (13.8 months, P = .002). Factors associated with decreased EFS on multivariate analysis include Charlson Comorbidity Index >3 (HR 2.20, 95% CI 1.30–3.72, P = .003), pretreatment CA-125 higher than 73 (HR 3.02, 95% CI 1.16–7.85, P = .032), pretreatment platelet counts greater than 306 × 109/L (HR 1.70, 95% CI 1.02–2.82, P = .041), and administration of NACT (HR 1.84, 95% CI 1.11–3.04, P = .019). Stage as a surrogate marker for tumor burden was not associated with EFS.Conclusions: Despite high rates of R0 cytoreduction at the time of IDS, patients undergoing NACT have decreased EFS than those undergoing PDS. Predicting those patients likely to achieve R0 resection in the upfront setting is important for maximizing patient outcomes. Objectives: To determine differences in survival among patients who undergo complete gross resection (R0) after primary cytoreductive surgery (PDS) compared with interval cytoreductive surgery (IDS). Methods: Standard practice at our institution is to have all patients with advanced ovarian cancer (OC) undergo a triage algorithm to determine those who should receive PDS versus neoadjuvant chemotherapy (NACT) followed by IDS. Using a previously described algorithm, preoperatively defined parameters are analyzed using laparoscopy (LS) to determine who should be offered PDS. Patient outcomes were tracked prospectively. The Fisher exact test and Wilcoxon rank sum test were used to compare medians among patients with PDS versus IDS. Event-free survival (EFS) was defined as months from the date of diagnosis to the date of first recurrence, progressive disease, or death. Prognostic factors associated with EFS were evaluated with Cox proportional hazards regression. Results: Between April 2013 and September 2015, 206 patients with suspected advanced OC presented to our center. Of these, 119 were offered LS; 88% had serous histology; 132 (64%) patients had stage III disease; and 74 (36%) had stage IV disease, with more patients in the NACT group having stage IV disease (10% vs 51%, P < .001). Rates of R0 resection were similar between the PDS and IDS groups (87% [n = 65] vs 83% [n = 85], P = .521). Compared with patients who underwent PDS, those who had IDS had higher pretreatment CA-125 levels (675 vs 247, P < .001) and platelet counts (379 vs 303 × 109/L, P < .001). EFS was longer in the PDS group (20.8 months) compared with the IDS group (13.8 months, P = .002). Factors associated with decreased EFS on multivariate analysis include Charlson Comorbidity Index >3 (HR 2.20, 95% CI 1.30–3.72, P = .003), pretreatment CA-125 higher than 73 (HR 3.02, 95% CI 1.16–7.85, P = .032), pretreatment platelet counts greater than 306 × 109/L (HR 1.70, 95% CI 1.02–2.82, P = .041), and administration of NACT (HR 1.84, 95% CI 1.11–3.04, P = .019). Stage as a surrogate marker for tumor burden was not associated with EFS. Conclusions: Despite high rates of R0 cytoreduction at the time of IDS, patients undergoing NACT have decreased EFS than those undergoing PDS. Predicting those patients likely to achieve R0 resection in the upfront setting is important for maximizing patient outcomes.

Comparison of Morbidity and Survival Between Primary and Interval Cytoreductive Surgery in Patients After Modified Posterior Pelvic Exenteration for Advanced Ovarian Cancer

Surgical management of advanced ovarian cancer often requires low modified posterior pelvic exenteration (MPE) to achieved complete resection. The aim of this study was to evaluate the morbidity of MPE at the time of primary cytoreductive surgery (PCS) and interval cytoreductive surgery (ICS) after neoadjuvant chemotherapy. From 2001 to 2009, 63 patients underwent MPE for advanced ovarian cancer. We analyzed and compared surgical characteristics and postoperative courses between PCS and ICS. Modified posterior pelvic exenteration was performed during PCS for 50 patients (79%) and during ICS for 13 patients (21%). Complete cytoreduction was achieved in 80% of patients (84% in the PCS group and 69% in the ICS group; ns). There was no significant difference between the PCS and ICS groups in the type and the rate of standards or radical surgical procedures. Patients with ICS had a shorter length of stay in the intensive care unit (0.9 vs 2.7 days; P = 0.009), but there was no difference in the total length of hospitalization (P = 0.94). The global rate of postoperative complications was 76%. No differences were found between the 2 groups in digestive or extradigestive complications, iterative surgery, or interventional radiology procedures. The median overall survival was 49.4 months in the PCS group and 27.1 months in the ICS group (P = 0.27), and the median progression-free survival time in both groups was 20 months. There was no difference in the occurrence of postoperative complications between PCS and ICS, especially in morbidity related to MPE. The specific morbidity of this surgical procedure remained low compared with the overall morbidity in cases of extensive surgery.