Role Of Surgical Cytoreduction Research Articles

The natural history and role of surgical cytoreduction and systemic chemotherapy in high-grade mucinous adenocarcinomas of the appendix.

199 Background: The natural history, clinical presentation, and impact of cytoreductive surgery (CRS) or systemic chemotherapy for high grade MAA has been poorly studied. Methods: A retrospective chart review of patients (pts) with moderate or poorly differentiated AA was completed from 1994-2010. Radiographic response was assessed semi-quantitatively form physician records and complete cytoreductive surgery (CRS) was defined as a completeness of cytoreduction score of 0 or 1. For CRS and chemotherapy subgroups efficacy endpoints were calculated from date of CRS or first chemotherapy dose, respectively. Results: 288 (136 moderate and 152 poor grade) pts were identified with a median age of 52 years (range: 25-82). Mucinous histology was present in 110 pts (38%) and differed by grade: 55% of moderate and 23% of poor. Stage IV presentation (n=163) occurred in 76% of poor grade but only 35% of moderate grade. Both median OS (4.5 vs. 2.7 yrs, P=0.04) and median OS for the stage IV subgroup (3 vs 1.9yrs, P=0.005) were improved for MAA vs. non-MAA. Moderate compared to poor grade had improved median OS (3.7 vs 1.9 yrs, P=0.002) for Stage IV disease, but this differed by mucinous histology (moderate mucinous 6.2yr vs. poor mucinous 1.6yr, P=0.001; moderate nonmucinous 1.4yr, poor nonmucinous 2yr). 39 MAA pts underwent a complete CRS (30 moderate and 9 poor) with a median time to recurrence of 1.5yrs and median OS of 9.2yrs. Improved OS was seen for pts with a complete CRS compared to pts with an incomplete CRS, P<0.001. 55 MAA pts received systemic chemotherapy (fluoropyrimidine/oxaliplatin in 30, irinotecan-based in 8, fluoropyrimidine-based in 16, and other in 1): median OS of 2.1yr, median TTP of 7.2 months, and radiographic response of 36%. No statistical differences were seen between chemotherapy groups. Conclusions: High-grade MAA represents a heterogenous disease with a statistically worse OS for poor as opposed to moderate histological differentiation. This data does not support the AJCC 7th edition use of a single mucinous high-grade category. The use of systemic chemotherapy appears to be a viable treatment option for these pts and a complete CRS is associated with improved OS.

The role of surgical cytoreduction before imatinib therapy in patients with advanced GIST.

10093 Background: Despite dramatic improvement of survival with introduction of imatinib mesylate, resistance to imatinib eventually develops in most of patients with advanced gastrointestinal stromal tumor (GIST). It is well known that baseline tumor size is an important factor related to imatinib resistance. We hypothesize that decreasing tumor size by surgery before starting imatinib may delay the emergence of resistance and improve prognosis in patients with advanced GIST. Methods: From 2001 to 2010, 102 patients with initially metastatic GIST and 147 patients with recurrent GIST were enrolled in this analysis. Patients with local relapse only were excluded because they were potentially curable by surgery alone. Patients were categorized into two groups according to the extent of cytoreduction; i.e., patients whose initial tumor bulk reduced >75% surgically before starting imatinib (group A) and the others (group B). Results: Among total 249 patients, 62 patients received initial surgery. 35 (14%) patients whose tumor bulk reduced > 75% were categorized into group A, and the remaining 214 (86%) were in group B. In group A, the median age was younger; more patients were initially metastatic; peritoneal metastases were more frequent; but liver metastases were less. The total tumor size was significantly reduced from median 122 mm before cytoreduction to 0 mm after on CT scans in group A. With a median follow-up of 42.7 months, progression-free survival (PFS) tended to be better in group A than in group B in univariate analysis (HR=0.60; 95% CI, 0.36-1.02; p=0.061), but PFS was not statistically different between the two groups in multivariate analysis (p=0.488). Meanwhile, absence of KIT exon 11 mutation (p=0.007), baseline total tumor size > 150mm (p=0.043), and granulocyte count > 5000/mm3 (p=0.009) remained independent poor prognostic factors. Conclusions: Despite marked decrease of total tumor size, the outcomes were not significantly improved in patients receiving initial cytoreduction more than 75% of baseline tumor bulk before starting imatinib. These results suggest that initial cytoreduction does not have beneficial role in advanced GIST, so imatinib should be still the first treatment of choice in this population.

Tertiary cytoreduction in patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer: An updated series

Objective Surgical cytoreduction is an integral therapeutic modality for patients with epithelial ovarian (EOC), fallopian tube (FTC), or primary peritoneal (PPC) cancer in the primary setting. The role of surgical cytoreduction in the recurrent setting is not clearly defined and remains controversial. The objective of this study was to assess this potential survival benefit in a large cohort of patients with a long follow-up period. Methods We performed a retrospective chart review of all patients with recurrent EOC, FTC, or PPC who underwent tertiary cytoreduction at our institution from 2/98 to 2/08. Disease-specific survival (DSS) was calculated from the time of tertiary cytoreduction to death or last follow-up. Univariate and multivariate analyses were used to analyze outcomes and to identify potential prognostic factors. Results A total of 77 patients were identified, of which 38 (49%) have died of disease. The median time from secondary to tertiary cytoreduction was 25.7 months (range, 4.1–99.4 months). The median follow-up after tertiary cytoreduction was 28.9 months (range, 0.7–123.7 months), with a median DSS for the entire cohort of 47.7 months (95% CI, 25.5–69.9 months). On univariate analysis, residual disease after tertiary cytoreduction and TFI were found to be significant prognostic factors. On multivariate analysis, only residual disease after tertiary cytoreduction retained prognostic significance ( P < 0.001). Conclusion Tertiary surgical cytoreduction may offer a survival benefit in a highly select group of patients with recurrent EOC, FTC, or PPC. This benefit appears to be greatest in patients in whom a complete gross resection can be achieved.

The Role of Surgical Cytoreduction in Stage IV Endometrial Carcinoma

Objective.To evaluate the impact of surgical cytoreduction in patients (pts) with Stage IV endometrial adenocarcinoma.Methods.We performed a retrospective chart review of all pts with Stage IV endometrial carcinoma treated at our institution from January, 1977, to February, 1995.Results.Fifty-five patients who underwent surgery as part of their primary treatment for Stage IV endometrial carcinoma were identified. They were divided into three groups: Group I consisted of 24 pts (44%) who underwent optimal surgical cytoreduction (diameter of largest residual tumor nodule ≤2 cm); Group II contained 21 pts (38%) who underwent suboptimal surgical cytoreduction (>2 cm residual disease); Group III consisted of 10 pts (18%) who had unresectable carcinomatosis and had no cytoreduction at all. There were no statistically significant differences between the three groups with respect to median age at diagnosis, tumor grade, histologic subtype, or the presence of extra-abdominal metastases. The median survival rates for the three groups were I, 31 months; II, 12 months; and III, 3 months (P< 0.01). Within Group I, there was no statistically significant difference in survival between the 8 pts who were found at laparotomy to have metastatic disease ≤2 cm and the 16 pts who initially had metastatic disease >2 cm and were subsequently cytoreduced to optimal status. On multivariate analysis only the extent of surgical cytoreduction had prognostic significance on survival.Conclusion.The prognosis of Stage IV endometrial carcinoma is poor. However, the data in this series suggest that aggressive tumor cytoreduction may improve survival in these patients.

Malignant mixed müllerian tumors of the ovary. Experience with surgical cytoreduction and combination chemotherapy

The role of surgical cytoreduction and combination chemotherapy for malignant mixed müllerian tumors (MMMT) of the ovary was evaluated. A retrospective review of 27 women with ovarian MMMT treated from 1980 to 1990 was performed. The International Federation of Gynecology and Obstetrics stages for the 27 women were 1 Stage I, 3 Stage II, 17 Stage III, and 6 Stage IV. Only 10 of the 23 patients with Stage III or IV disease were cytoreduced optimally. With respect to postoperative therapy, 3 women received no treatment, 6 were treated with whole abdomen radiotherapy, 1 received melphalan, and 17 received chemotherapy incorporating a platinum agent (3), doxorubicin (4), or both (10). The significant prognostic factors were stage (P < 0.001) and, for women with Stage III or IV disease, the feasibility of cytoreductive surgery (P = 0.03). The four patients in Stages I or II remained disease free after an interval of at least 5 years. The median and 5-year survival rates for patients with Stages III or IV disease was 18 months and 8%, respectively. Patients in Stage III or IV for whom optimal cytoreduction was not possible had a 2-year survival of 14%, whereas optimal cytoreduction was associated with a 52% 2-year survival. Median survival for the 14 women with Stage III or IV ovarian MMMT treated with combination chemotherapy was 25 months and nine women achieved progression free intervals of greater than 18 months. Aggressive surgical cytoreduction followed by combination chemotherapy may result in improved progression free intervals for women with advanced ovarian MMMT. However, a major improvement in prognosis for this rare malignancy has not yet been achieved.