Stage IIIC Epithelial Ovarian Cancer Research Articles

Impact of Sepsis on the Oncologic Outcomes of Advanced Epithelial Ovarian Cancer Patients: A Multicenter Observational Study.

The sepsis-induced inflammatory response may potentially affect malignant cells. Recently, a case of spontaneous regression of a histologically confirmed International Federation of Gynecology and Obstetrics (FIGO) stage IIIC epithelial ovarian cancer (EOC) following sepsis was reported. The aim of our study was to assess the impact of sepsis on the oncologic outcomes of advanced-stage EOC patients. Gynecologic oncologic patients admitted to the Intensive Care Unit of three oncologic centers between 2006 and 2019 were identified and patients who experienced sepsis following advanced-stage EOC diagnosis were selected. Survival outcomes were compared with advanced-stage EOC patients from the Netherlands Cancer Registry (NCR). To correct for case-mix differences, propensity score matching using 1:3 nearest neighbor matching was conducted after which survival analyses were repeated. A total of 18 of 215 patients with advanced-stage EOC experienced sepsis. Sepsis patients had similar distributions of patient, tumor, and treatment characteristics to 3988 patients from the NCR cohort. A total of 3 of 18 patients died from the complications of sepsis. While the remaining patients initially responded to treatment, 14/15 patients relapsed. The median (IQR) overall survival was 31 (24-44) and 35 (20-60) months for the sepsis and unmatched NCR cohort (p = 0.56), respectively. The median (IQR) progression-free survival was 16 (11-21) and 16 (11-27) months (p = 0.90), respectively. Survival outcomes did not differ following propensity matching (overall survival of 31 (24-44) vs. 36 (20-56) months, p = 0.40; progression-free survival of 16 (11-21) and 16 (12-21) months, p = 0.72). In this observational study, the occurrence of sepsis did not affect the oncologic and survival outcomes of advanced-stage EOC patients.

HIPEC after neoadjuvant chemotherapy is associated with acceptable toxicity and favorable quality of life in newly diagnosed advanced ovarian cancer patients

ObjectiveTo evaluate toxicity, quality of life and PFS in patients with advanced ovarian cancer who underwent neoadjuvant chemotherapy (NAC) followed by CRS and HIPEC with carboplatin. MethodsPatients with stage IIIC or IVA epithelial ovarian cancer, who were not candidates for primary CRS, were enrolled in this phase two trial. Patients received 3–6 cycles of NAC with an IV carboplatin doublet followed by CRS with HIPEC (carboplatin 800 mg/m2 for 90 min). They were followed for at least 12 months to assess for adverse events, quality of life (QOL) and disease progression. QOL was measured using the Functional Assessment of Cancer Therapy-Ovarian (FACT-O) questionnaires prior to CRS and post-operatively at 6 weeks, 3 months, and 6 months after CRS. ResultsTwenty patients were enrolled. HIPEC was completed successfully in all twenty patients, and there was no peri-operative mortality. Twelve (70.6%) patients experienced a grade 3 or 4 toxicity; most commonly anemia (59%), thrombocytopenia (29%), and hypokalemia (24%). There was no significant change between the pre-operative and postoperative 6 weeks, 3 month, and 6 month FACT-O, NTX, and AD scores. Nine (45%) patients have experienced disease recurrence to date. The median progression free survival in this cohort is 11.2 months (2.5–23.7 months). ConclusionThe addition of HIPEC with carboplatin to interval CRS was well tolerated in patient population. Myelosuppression was the most common adverse event. CRS with HIPEC did not adversely impact these patients' QOL indices. The efficacy of this regimen should be further evaluated in a larger clinical trial.

HIPEC after neoadjuvant chemotherapy is associated with acceptable toxicity and favorable quality of life in newly diagnosed advanced ovarian cancer patients (509)

HIPEC after neoadjuvant chemotherapy is associated with acceptable toxicity and favorable quality of life in newly diagnosed advanced ovarian cancer patients (509)

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.

Disease Distribution at Presentation Impacts Benefit of IP Chemotherapy Among Patients with Advanced-Stage Ovarian Cancer.

Ovarian cancer with miliary disease spread is an aggressive phenotype lacking targeted management strategies. We sought to determine whether adjuvant intravenous/intraperitoneal (IV/IP) chemotherapy is beneficial in this disease setting. Patient/tumor characteristics and survival data of patients with stage IIIC epithelial ovarian cancer who underwent optimal primary debulking surgery from 01/2010 to 11/2014 were abstracted from records. Chi-square and Mann-Whitney U tests were used to compare categorical and continuous variables. The Kaplan-Meier method was used to estimate survival curves, and outcomes were compared using log-rank tests. Factors significant on univariate analysis were combined into multivariate logistic regression survival models. Among 90 patients with miliary disease spread, 41 (46%) received IV/IP chemotherapy and 49 (54%) received IV chemotherapy. IV/IP chemotherapy, compared with IV chemotherapy, resulted in improved progression-free survival (PFS; 23.0 versus 12.0 months; p = 0.0002) and overall survival (OS; 52 versus 36 months; p = 0.002) in patients with miliary disease. Among 78 patients with nonmiliary disease spread, 23 (29%) underwent IV/IP chemotherapy and 55 (71%) underwent IV chemotherapy. There was no PFS or OS benefit associated with IV/IP chemotherapy over IV chemotherapy in these patients. On multivariate analysis, IV/IP chemotherapy was associated with improved PFS (HR, 0.28; 95% CI 0.15-0.53) and OS (HR, 0.33; 95% CI 0.18-0.61) in patients with miliary disease compared with those with nonmiliary disease (PFS [HR, 1.53; 95% CI 0.74-3.19]; OS [HR, 1.47; 95% CI 0.70-3.09]). Adjuvant IV/IP chemotherapy was associated with oncologic benefit in miliary disease spread. This survival benefit was not observed in nonmiliary disease.

Critical Analysis of Stage IV Epithelial Ovarian Cancer Patients after Treatment with Neoadjuvant Chemotherapy followed by Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC).

Background Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) after neoadjuvant chemotherapy (NACT) showed promise as initial treatment for stage IIIC (SIII) epithelial ovarian cancer (EOC); however, stage IV (SIV) outcomes are rarely reported. We assessed our experience and outcomes treating newly diagnosed SIV EOC with NACT plus CRS/HIPEC compared to SIII patients. Methods Advanced EOC from 2015–2018 managed with NACT (carboplatin/paclitaxel) due to unresectable disease or poor performance status followed by interval CRS/HIPEC were reviewed. Perioperative factors were assessed. Overall survival (OS) and progression-free survival (PFS) were analyzed by stage. Results Twenty-seven FIGO stage IIIC (n = 12) and IV (n = 15) patients were reviewed. Median NACT cycles were 3 and 4, respectively. Post-NACT omental caking, ascites, and pleural effusions decreased/resolved in 91%, 91%, and 100% of SIII and 85%, 92%, and 71% of SIV. SIII/SIV median PCI was 21 and 20 obtaining 92% and 100% complete cytoreduction (≤0.25 cm), respectively. Median organ resections were 6 and 7, respectively. Grade III/IV surgical complications were 0% SIII and 23% SIV, without hospital mortality. Median time to adjuvant chemotherapy was 53 and 74 days, respectively (p=0.007). SIII OS at 1 and 2 years was 100% and 83% and 87% and 76% in SIV (p=0.269). SIII 1-year PFS was 54%; median PFS: 12 months. SIV 1- and 2- year PFS was 47% and 23%; median PFS: 12 months (p=0.944). Conclusion Outcomes in select initially diagnosed and unresectable SIV EOC are similar to SIII after NACT plus CRS/HIPEC. SIV EOC may benefit from CRS/HIPEC, and further studies should explore this treatment approach.

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

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

Impact of the timing and extent of debulking surgery on progression-free survival (PFS) and overall survival (OS) in advanced epithelial ovarian cancer (EOC): Single-center experience.

e18060 Background: To evaluate the impact of timing and extent of cytoreduction on the survival of patients with EOC before (2002-2008) and after (2009-2018) the introduction of aggressive debulking. Methods: A retrospective review of 195 patients with Stages IIIC and IV EOC who underwent debulking between 2002-2018 (Group#1: G1:(2002-2008), and Group#2: G2:(2009-2018). Medical and surgical variables related to PFS and OS were analyzed. Results: Compared to patients in G1, more patients in G2 had neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) [56%(39/70 Vs. 76%(95/125) Vs), p = 0.003], had complete debulking (CD) [44%(31/71) Vs. 79%(103/131), P-value &lt; 0.001]including [diaphragmatic resection [6%(4/72) Vs. 48%(63/131) p &lt; 0.001], bowel ressection [15%(11/72) Vs. 37%(48/131), p = 0.001], peritnoectomy [11%(8/72) Vs. 62%(81/131) p &lt; 0.001], and lymph node dissection [8%(6/72) Vs. 26%(34/131) p = 0.003] .More patients in G2 received Bevacizumab than in G1 [59%(38/65) Vs. 14%(4/29), p &lt; 0.001]. More patients who had ACT and IDS had CD than optimal debulking (OD) than patients who had (PDS) (adjusted odds ratio (aOR) = 1.89, 95% CI: 0.98,3.6). After 2008, there was an increase in the number of patients with high tumor load and lower performance status who were referred for NACT and IDS. In patients with stage IIIC and IV, median PFS was longer in patients who had CD Vs. OD [in stage IIIC: 24 months, 95% CI: 21,27 Vs. 19 months, 95% CI: 17, 21, HR = 0.4, p = 0.006 respectively] [in stage IV: 18 months, 95% CI: 16,20 Vs. 14 months, 95% CI: 9,18, HR = 0.4, p = 0.1 respectively].Patients with stage IIIC who had PDS Vs. NACT and IDS had a non-statistically significant longer PFS [24 months, 95% CI; 20,27 Vs. 19 months, 95% CI: 17,21, HR = 0.8, p = 0.3]. Moreover, in stage IV, there was no difference in PFS in NACT and IDS Vs. PDS [16 months, 95% CI: 12,20 Vs. 17 months, 95% CI: 15,19 HR = 0.8, p = 0.7 respectively]. However, the timing and extent of the cytoreductive surgery did not significantly affect OS in both stages IIIC and IV. Conclusions: In Stage IIIC EOC, the extent but not timing of debulking surgery has the greatest impact on PFS. Longer follow-up is needed to assess the impact on OS.

CRS + HIPEC in stage IIIc epithelial ovarian cancer and comparison of oncological outcome only with CRS and IV chemotherapy and CRS + IP chemotherapy.

e18054 Background: Our study aims to describe role of CRS &amp; HIPEC in stage IIIC epithelial ovarian malignancy &amp; compare the oncological outcome (DFS &amp; OS) of extensive CRS+ HIPEC in comparison with CRS &amp; IV chemotherapy &amp; CRS + IP chemotherapy. Methods: Patients diagnosed of stage IIIc EOC underwent extensive CRS + HIPEC. All data prospectively entered in the HIPEC registry was analysed. Outcome of CRS &amp; IV group (n = 50), CRS + IP group (n = 60) operated around same period was compared with the CRS &amp; HIPEC group. Results: Out of 135 patients, upfront, interval and secondary cytoreduction plus HIPEC was done in 29.6%, 44.4% &amp; 25.9% &amp; mean PCI was 14.1, 9.6 &amp; 13.0 respectively. Multi-visceral resection, diaphragmatic resection &amp; bowel resection was required in 12.7%, 50% &amp; 41.8% respectively. Overall G3- G5 morbidity was seen in 25.4% with major being electrolyte imbalance 16.3%, hematological 12.7% &amp; surgical 11.8%. Mean ICU &amp; hospital stay 1.5 &amp; 11 days respectively. Overall 30 day mortality was 4.5%. With a median follow up of 42 months DFS was 30, 33 &amp; 16 months and OS was 70%, 67% &amp; 51% at 4 year for upfront, interval and the recurrent settings respectively. Detailed description presented in Table. Most of the recurrences in CRS &amp; IV group were in peritoneum whereas the other two groups had lesser peritoneal &amp; systemic recurrence. Conclusions: Optimal cytoreduction &amp; some form of IP therapy is needed to improve outcomes. CRS+ HIPEC is feasible in all groups of ovarian cancer with acceptable morbidity &amp; mortality. However the role of single HIPEC in comparison to 6 cycles of IP chemotherapy needs to be evaluated with a well-designed multi-institutional randomised study. [Table: see text]

Role of Laparotomy-based Parameters in Assessment of Optimal Primary Debulking Surgery and Long-term Outcomes in Patients with Stage IIIC Epithelial Ovarian Cancer.

We evaluated the ability of our two laparotomy-based models to predict optimal primary debulking surgery (PDS) and long-term outcomes of stage IIIC epithelial ovarian cancer (EOC). Data of 400 IIIC EOC patients who underwent laparotomy were retrospectively analyzed. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy were calculated for 10 parameters. The parameters with a specificity ≥75%, PPV ≥50%, and NPV ≥50% were included in the final predictive index value (PIV) model. Peritoneal cancer index (PCI) was calculated summarizing lesion size scores (LSSs) of 13 regions. Receiver operating characteristic (ROC) curve was used to assessed the predictive value of PIV and PCI for optimal PDS. Univariate and multivariate analyses were performed to assess the prognostic value of PIV and PCI. After PDS, 223 (55.8%) patients with RD ≤1 cm had longer progression-free survival (PFS) and overall survival (OS) than patients with RD >1 cm (PFS: 22.4 vs. 15.4 months, respectively; P < 0.001 and OS: 48.6 vs. 35.6 months; P < 0.001). PCI better predicted optimal PDS than PIV (The area under the curve of ROC: PCI 0.79 vs. PIV 0.75). The predictive value of PIV and PCI models was verified using another cohort of 77 patients. And PIV and PCI models were demonstrated to be more powerful than the published laparoscopy-based predictive index (LPS-PI) model. Patients with a PIV ≥14 were more likely to undergo suboptimal PDS with a specificity of 100%. The median PFS and OS of patients with PIV < 3 were significantly longer than patients with PIV > 3 (PFS: 19.5 vs. 16.3 months, P = 0.007; OS: 46.1 vs. 37.0 months, P = 0.009). The median PFS and OS of patients with the PCI < 17.5 were significantly longer than patients with the PCI > 17.5 (PFS: 22.9 vs. 14.5 months, P < 0.001; OS: 54.3 vs. 31.5 months, P < 0.001). PCI could better predict optimal PDS compared with PIV. PCI was an independent prognostic factor for long-term outcome of IIIC EOC patients.

Potential survival benefits from optimized chemotherapy implementation in advanced ovarian cancer: Projections from a microsimulation model.

BackgroundOvarian cancer is often diagnosed in advanced stages, when survival is poor. Treatment advances have been made, but are inconsistently implemented. Our purpose was to project the maximum life expectancy gains that could be achieved in women with stage IIIC epithelial ovarian cancer if the implementation of available chemotherapy regimens could be optimized.MethodsWe used a microsimulation model to estimate life expectancy benefits associated with “optimized” implementation of four post-operative chemotherapy options: standard intravenous chemotherapy; intraperitoneal + intravenous chemotherapy; bevacizumab + intravenous chemotherapy; and hyperthermic intraperitoneal chemotherapy + intravenous chemotherapy. Optimized implementation was defined as follows. Patients triaged to primary cytoreductive surgery received intraperitoneal + intravenous chemotherapy if optimally or completely cytoreduced, and bevacizumab + intravenous chemotherapy if suboptimally cytoreduced. Patients triaged to neoadjuvant chemotherapy received hyperthermic intraperitoneal chemotherapy at interval cytoreductive surgery if optimally or completely cytoreduced, and standard IV chemotherapy if suboptimally cytoreduced. Life expectancy associated with optimized implementation was compared with that of current utilization practices, estimated using published literature and the National Cancer Database. Effects of model uncertainty were evaluated in sensitivity analyses.ResultsLife expectancy associated with optimized implementation vs. current practice was 76.7 vs. 64.5 months (life expectancy gain = 12.2 months). Providing intraperitoneal + intravenous chemotherapy to all eligible patients was the largest driver of life expectancy gains, due to both the potential benefit conferred by intraperitoneal + intravenous chemotherapy and the proportion of eligible women who do not receive intraperitoneal + intravenous chemotherapy in current practice.ConclusionPopulation-level life expectancy in stage IIIC epithelial ovarian cancer could be substantially improved through greater uptake of available chemotherapy regimens.

Intraperitoneal chemotherapy improves oncologic outcome in stage IIIC epithelial ovarian cancer patients with miliary subtype

Objective: To examine the effects of intraperitoneal (IV/IP) chemotherapy on oncologic outcomes in patients undergoing primary debulking surgery (PDS) for stage IIIC epithelial ovarian/fallopian tube/primary peritoneal carcinoma (EOC) with miliary subtype.

Impact of Laparoscopy to Assess Resectability in Stage IIIC Epithelial Ovarian, Tubal and Peritoneal Cancer Patients

Aims: To evaluate overall survival (OS) and progression-free survival (PFS) in patients with stage IIIC epithelial ovarian, tubal and peritoneal cancer (EOC) who underwent a laparoscopy to assess surgical resectability prior to Primary Debulking Surgery (PDS) or Interval Debulking Surgery (IDS). Methods: Retrospective cohort study that included all women with stage IIIC EOC treated at our center between 2000 and 2010. Patients were classified in groups: PDS, neoadjuvant chemotherapy (NACT) with IDS, NACT without IDS; and then sub-classified based on residual tumor (RT). A laparoscopy to assess resectability was performed before PDS and IDS. Results: Among 111 patients included, 66 underwent PDS, and 45 were treated with NACT, 80% of them receiving subsequent IDS. OS was 75.6 months in the PDS group, and 52.8 months for IDS group (p = 0.100); the PFS was 30 months and 19.2 months respectively (p = 0.049). Median OS was 104.4 and 52.8 months for patients with optimal cytoreduction (RT = 0) in the PDS and IDS group respectively (p < 0.05). Laparoscopy did not modify the preoperative consideration for PDS; however, 9 laparotomies were avoided based on laparoscopic findings after NACT. Conclusion: Laparoscopy for the assessment of surgical resectability in stage IIIC EOC has no impact on survival; but it still could be useful for the reduction of unnecessary laparotomies after NACT.

Modeling treatment outcomes for patients with advanced ovarian cancer: Projected benefits of a test to optimize treatment selection

ObjectiveFor patients with advanced stage epithelial ovarian cancer (EOC), substantial emphasis has been placed on diagnostic tests that can discern which of two treatment options – primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy followed by interval cytoreductive surgery (NACT+ICS) – optimizes patient-level outcomes. Our goal was to project potential life expectancy (LE) gains that could be achieved by use of such a test. MethodsWe developed a microsimulation model to project LE for patients with stage IIIC EOC. We compared: a “standard-of-care” strategy, in which patients were triaged to PCS vs. NACT+ICS based on current clinical practice; and a “test” strategy, in which patients were triaged based on results of a hypothetical test. We identified those test performance characteristics for which the test strategy outperformed the standard-of-care strategy, from a LE standpoint. Effects of parameter uncertainty were evaluated in sensitivity analysis. ResultsEven with a perfect test, the LE gain was modest (LE with test vs. standard-of-care strategy=67.6 vs. 66.4months; LE gain=1.2months). In order to outperform the standard-of-care, the test had to have a high probability of correctly identifying “resectable” patients at PCS (i.e. those for whom complete or optimal cytoreduction would be possible); this test property was more important than correct triage of unresectable patients to NACT+ICS. Results were sensitive to the proportion of patients whose underlying disease was resectable at PCS. ConclusionDiagnostic tests that are designed to triage patients with advanced stage EOC will likely have only a modest effect on LE.

OV21/PETROC: a randomized Gynecologic Cancer Intergroup phase II study of intraperitoneal versus intravenous chemotherapy following neoadjuvant chemotherapy and optimal debulking surgery in epithelial ovarian cancer

The purpose of this multistage, adaptively, designed randomized phase II study was to evaluate the role of intraperitoneal (i.p.) chemotherapy following neoadjuvant chemotherapy (NACT) and optimal debulking surgery in women with epithelial ovarian cancer (EOC). We carried out a multicenter, two-stage, phase II trial. Eligible patients with stage IIB-IVA EOC treated with platinum-based intravenous (i.v.) NACT followed by optimal (<1 cm) debulking surgery were randomized to one of the three treatment arms: (i) i.v. carboplatin/paclitaxel, (ii) i.p. cisplatin plus i.v./i.p. paclitaxel, or (iii) i.p. carboplatin plus i.v./i.p. paclitaxel. The primary end point was 9-month progressive disease rate (PD9). Secondary end points included progression-free survival (PFS), overall survival (OS), toxicity, and quality of life (QOL). Between 2009 and 2015, 275 patients were randomized; i.p. cisplatin containing arm did not progress beyond the first stage of the study after failing to meet the pre-set superiority rule. The final analysis compared i.v. carboplatin/paclitaxel (n = 101) with i.p. carboplatin, i.v./i.p. paclitaxel (n = 102). The intention to treat PD9 was lower in the i.p. carboplatin arm compared with the i.v. carboplatin arm: 24.5% (95% CI 16.2% to 32.9%) versus 38.6% (95% CI 29.1% to 48.1%) P = 0.065. The study was underpowered to detect differences in PFS: HR PFS 0.82 (95% CI 0.57-1.17); P = 0.27 and OS HR 0.80 (95% CI 0.47-1.35) P = 0.40. The i.p. carboplatin-based regimen was well tolerated with no reduction in QOL or increase in toxicity compared with i.v. administration alone. In women with stage IIIC or IVA EOC treated with NACT and optimal debulking surgery, i.p. carboplatin-based chemotherapy is well tolerated and associated with an improved PD9 compared with i.v. carboplatin-based chemotherapy. clinicaltrials.gov, NCT01622543.

Neutrophil-to-Lymphocyte Ratio and Platelet Count Predict Long-Term Outcome of Stage IIIC Epithelial Ovarian Cancer

Background/Aims: Prognostic value of neutrophil-to-lymphocyte ratio (NLR) and platelet count (PC) in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIC epithelial ovarian cancer (EOC) is controversial. Methods: A total of 370 stage IIIC EOC patients who underwent primary debulking surgery (PDS) at the Department of Gynecology of Liaoning Cancer Hospital and Institute between January 2003 and August 2016 and had full information were involved. Patients were stratified into a high NLR (H-NLR) group versus a low NLR (L-NLR) group and a high PC (H-PC) group versus a low PC (L-PC) group according to cutoff values calculated through receiver operating characteristic (ROC) curves. Prognostic values of NLR and PC for progression-free survival (PFS) and overall survival (OS) were assessed. Results: We identified the optimal cut-off value of 3.08 for NLR and 289.5*10⁹/L for PC. The median PFS and OS of the patients with H-NLR were shorter than L-NLR (PFS: 16.9 months vs. 19.5 months, hazard ratio [HR] 1.3, 95% confidence interval [CI] 1.03–1.63, P = 0.022; OS: 33.5 months vs. 46.8 months, HR 1.3, 95% CI 1.01–1.66, P = 0.001). The median PFS and OS of the patients with H-PC were shorter than L-PC (PFS: 15.3 months vs. 21.6 months, HR 1.3, 95% CI 1.04–1.63, P < 0.001; OS: 37.3 months vs. 46.1 months, HR 1.14, 95% CI 0.89–1.46, P = 0.306). Conclusions: H-NLR and H-PC could predict poor long-term outcome of patients with FIGO stage III EOC.

Surgical readmission and survival in women with ovarian cancer: Are short-term quality metrics incentivizing decreased long-term survival?

To determine the association between treatment with neoadjuvant chemotherapy (NACT) or primary debulking surgery (PDS) and readmission after surgical hospitalization as well as overall survival among women with stage IIIC epithelial ovarian cancer (EOC). We identified incident cases of stage IIIC EOC treated with both chemotherapy and surgery in the National Cancer Database (NCDB) from 2006 to 2012. 30-day readmissions were categorized as planned or unplanned. Log binomial models were used to estimate risk ratios and 95% confidence intervals. Survival analysis was performed using cox proportional hazards models. We identified 20,853 women with stage IIIC EOC. 15.6% (n=3242) were treated with NACT and 11.6% (n=2427) were readmitted within 30days of surgery, 59% (n=1421) were unplanned. NACT was associated with a 48% reduction in the risk of any readmission (aRR 0.52 95%CI 0.45-0.60) compared to PDS with adjustment for age, race, insurance, histology, year of diagnosis, and Charlson co-morbidity index score. However, in the same population, receipt of neoadjuvant chemotherapy was also associated with a 33% increase in the rate of death (HR 1.33 95%CI 1.29-1.40) with adjustment for the same factors. Among women with stage IIIC EOC, NACT is associated with both decreased rates of readmission and decreased survival compared to PDS. While selection bias may account for some of the observed differences in survival, the current focus on short-term hospital-wide quality metrics, such as postoperative readmission, in the ovarian cancer population, may be creating incentives inconsistent with long-term goals.

960P - Role of laparotomy-based parameters in assessment of optimal primary debulking surgery and long-term outcomes in patients with stage iiic epithelial ovarian cancer

960P - Role of laparotomy-based parameters in assessment of optimal primary debulking surgery and long-term outcomes in patients with stage iiic epithelial ovarian cancer

Altered iron homeostasis in mouse models of aging

For patients with advanced stage epithelial ovarian cancer (EOC), substantial emphasis has been placed on diagnostic tests that can discern which of two treatment options – primary cytoreductive surgery (PCS) or neoadjuvant chemotherapy followed by interval cytoreductive surgery (NACT + ICS) – optimizes patient-level outcomes. Our goal was to project potential life expectancy (LE) gains that could be achieved by use of such a test.We developed a microsimulation model to project LE for patients with stage IIIC EOC. We compared: a “standard-of-care” strategy, in which patients were triaged to PCS vs. NACT + ICS based on current clinical practice; and a “test” strategy, in which patients were triaged based on results of a hypothetical test. We identified those test performance characteristics for which the test strategy outperformed the standard-of-care strategy, from a LE standpoint. Effects of parameter uncertainty were evaluated in sensitivity analysis.Even with a perfect test, the LE gain was modest (LE with test vs. standard-of-care strategy = 67.6 vs. 66.4 months; LE gain = 1.2 months). In order to outperform the standard-of-care, the test had to have a high probability of correctly identifying “resectable” patients at PCS (i.e. those for whom complete or optimal cytoreduction would be possible); this test property was more important than correct triage of unresectable patients to NACT + ICS. Results were sensitive to the proportion of patients whose underlying disease was resectable at PCS.Diagnostic tests that are designed to triage patients with advanced stage EOC will likely have only a modest effect on LE.