Surgery For Advanced-stage Ovarian Cancer Research Articles

MIRRORS: a prospective cohort study assessing the feasibility of robotic interval debulking surgery for advanced-stage ovarian cancer

ObjectiveTo establish the feasibility and safety of robotic interval debulking surgery following the MIRRORS protocol (robot-assisted laparoscopic assessment prior to robotic or open surgery) in women with advanced-stage ovarian cancer....

Prognostic Significance of Preoperative Inflammation Markers on the Long-Term Outcomes in Peritoneal Carcinomatosis from Ovarian Cancer.

Ovarian cancer remains one of the most lethal gynaecological malignancies affecting women worldwide; therefore, attention has been focused on identifying new prognostic factors which might help the clinician to select cases who could benefit most from surgery versus cases in which neoadjuvant systemic therapy followed by interval debulking surgery should be performed. The aim of the current paper is to identify whether preoperative inflammation could serve as a prognostic factor for advanced-stage ovarian cancer. Material and methods: The data of 57 patients who underwent to surgery for advanced-stage ovarian cancer between 2014 and 2020 at the Cantacuzino Clinical Hospital were retrospectively reviewed. The receiver operating characteristic curve was used to determine the optimal cut-off value of different inflammatory markers for the overall survival analysis. The analysed parameters were the preoperative level of CA125, monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), neutrophil-to-lymphocyte ratio (NLR) and systemic inflammation index (SII). Results: Baseline CA125 > 780 µ/mL, NLR ≥ 2.7, MLR > 0.25, PLR > 200 and a systemic immune inflammation index (SII, defined as platelet × neutrophil-lymphocyte ratio) ≥ 84,1000 were associated with significantly worse disease-free and overall survival in a univariate analysis. In a multivariate analysis, MLR and SII were significantly associated with higher values of overall survival (p < 0.0001 and p = 0.0124); meanwhile, preoperative values of CA125, PLR and MLR were not associated with the overall survival values (p = 0.5612, p = 0.6137 and p = 0.1982, respectively). In conclusion, patients presenting higher levels of MLR and SII preoperatively are expected to have a poorer outcome even if complete debulking surgery is performed and should be instead considered candidates for neoadjuvant systemic therapy followed by interval surgery.

Case-mix adjustment to compare hospital performances regarding complications after cytoreductive surgery for ovarian cancer: a nationwide population-based study

ObjectiveComplication rates after cytoreductive surgery are important quality indicators for hospitals that treat patients with advanced-stage ovarian cancer. Case-mix factors are patient and tumor characteristics that may influence hospital outcomes...

The effects of neutral argon plasma versus electrocoagulation on tissue in advanced-stage ovarian cancer: a case series

BackgroundThe aim of surgery for advanced-stage ovarian cancer is a complete cytoreduction, because this is the most important independent prognostic factor for prolonged survival. Yet this can be difficult to achieve when there are micrometastases on the intestinal mesentery or intestines. The PlasmaJet device is an instrument to remove these micrometastases, but little is known about the depth of damage in human tissue compared to electrocoagulation devices.MethodsA prospective study was performed for the ex-vivo comparison of the histological depth of thermal damage of neutral argon plasma (PlasmaJet®) and electrocoagulation devices, in a series of 106 histological slides of 17 advanced-stage ovarian cancer patients. Depending on the tissue types resected during complete cytoreductive surgery, samples were collected from reproductive organs (uterus, ovaries), intestines (ileum, colon, rectum) and omentum, intestinal mesentery and peritoneum.ResultsAverage thermal damage depth was 0.15 mm (range 0.03–0.60 mm) after use of neutral argon plasma and 0.33 mm (range 0.08–1.80 mm) after use of electrocoagulation (p < 0.001). Greater disruption of the tissue surface was often observed after electrocoagulation.ConclusionOur case series suggests that the use of neutral argon plasma during cytoreductive surgery produces significantly less thermal damage than electrocoagulation treatment. It is therefore considered a thermally safe alternative, aiding in the achievement of cytoreductive surgery.

Stapled diaphragm resection: A new approach to diaphragmatic cytoreductive surgery for advanced-stage ovarian cancer

ObjectiveTo evaluate a novel technique for diaphragmatic full-thickness resection (DFTR) using a vascular stapler to perform cytoreductive surgeries in patients with advanced ovarian cancer. Study DesignSingle-center retrospective analysis of consecutive patients with advanced-stage ovarian cancer undergoing stapled diaphragmatic full-thickness resections (S-DFTRs) as part of cytoreductive surgeries between January 2018 and June 2022, according to the IDEAL recommendations. ResultsFifteen patients underwent cytoreductive surgeries with S-DFTRs. The median operative time was 300 (114–547) minutes. Cytoreduction was considered complete in all cases. All S-DFTRs were performed on the right diaphragm. Concomitant left diaphragmatic peritoneal stripping was performed in 5 cases (33.3%) and was associated with a conventional DFTR in 1 case (6.7%). Prophylactic intraoperative tube thoracostomy was never required. Four patients (26.7%) were admitted to the intensive care unit. Pleural effusion was observed in 9 patients (60.0%), and 4 (26.7%) required a postoperative pigtail catheter thoracostomy. Three patients (20.0%) required catheter placement on the right hemithorax (ipsilaterally to the S-DFTR) and 2 patients (13.3%) required catheters on the left hemithorax (contralaterally to the S-DFTR). Pneumothorax requiring tube thoracostomy was observed in 1 case (6.7%) on the left hemithorax (contralaterally to the S-DFTR). Pulmonary embolism and pneumonia were both observed once (6.7%). The median hospitalization length was 14 (5–36) days. During the follow-up, 6 patients (40.0%) had a recurrence, but none involved the pleura or the diaphragm. According to the IDEAL classification, this study could be ranked as stage 2a (development). ConclusionsThis technique appears to be a fast and safe method for performing diaphragmatic cytoreductive surgeries and could reduce postoperative complications.

Factors Predicting 30-Day Grade IIIa-V Clavien-Dindo Classification Complications and Delayed Chemotherapy Initiation after Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Prospective Cohort Study.

Simple SummaryBoth surgical outcome and timely initiation of chemotherapy are essential endpoints after cytoreductive surgery for advanced-stage epithelial ovarian cancer (AEOC). This was a multicenter prospective study of 300 primary AEOC patients who underwent cytoreductive surgery. We aimed to evaluate factors associated with 30-day severe postoperative complication as according to Clavien–Dindo classification (CDC) grade ≥IIIa and delayed initiation of chemotherapy defined as time to chemotherapy (TTC) >42 days after cytoreductive surgery for primary AEOC. The understanding of these risk factors and their consequences offers an opportunity to improve future perioperative care for AEOC. Our study highlights that patient with CDC grade ≥IIIa had a significant longer median TTC compared to patients without CDC grade ≥IIIa. Intraoperative upper-abdominal visceral injury was the strongest factor associated with both CDC grade ≥IIIa and TTC >42 days. In our analysis, patient performance status was the only preoperative modifiable risk factor for TTC >42 days.Objective: The aim of this study was to evaluate factors associated with 30-day postoperative Clavien–Dindo classification (CDC) grade IIIa or greater complications and delayed initiation of chemotherapy after cytoreductive surgery (CRS) for primary advanced-stage epithelial ovarian cancer (AEOC). Methods: This was a prospective study involving 300 patients who underwent primary or interval CRS for AEOC between February 2018 and September 2020. Postoperative complications were graded according to the CDC. Logistic regression analysis was used to evaluate factors predicting CDC grade ≥IIIa and time to chemotherapy (TTC) >42 days. Results: Interval CRS was performed in 255 (85%) patients. CDC grade ≥IIIa occurred in 51 (17%) patients. In multivariable analysis, age (p = 0.036), cardiovascular comorbidity (p < 0.001), diaphragmatic surgery (p < 0.001), intraoperative urinary tract injury (p = 0.017), and upper-abdominal visceral injury (e.g., pancreas, stomach, liver, or spleen) (p = 0.012) were associated with CDC grade ≥IIIa. In 26% of cases, TTC was >42 days (median (IQR) 39 (29–50) days) in patients with CDC grade ≥IIIa versus 33 (25–41) days in patients without CDC grade ≥ IIIa (p = 0.008). The adjusted odds ratio of developing TTC >42 days was significantly higher in patients associated with WHO performance grade ≥2 (p = 0.045), intraoperative bowel injury (p = 0.043), upper-abdominal visceral injury (p = 0.008), and postoperative CDC grade ≥IIIa (p = 0.032). Conclusions: Patients with advanced age, with cardiovascular comorbidity, and who required diaphragmatic surgery had an increased adjusted odds ratio of developing CDC grade ≥IIIa complications. CDC grade ≥IIIa complications were independently associated with TTC >42 days. Proper patient selection and prevention of intraoperative injury are essential in order to prevent postoperative complications and delayed initiation of chemotherapy.

ASO Visual Abstract: The Role of Adjuvant Use of the PlasmaJet® Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer—Results of the PlaComOv-Study, a Randomized, Controlled Trial in the Netherlands

ASO Visual Abstract: The Role of Adjuvant Use of the PlasmaJet® Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer—Results of the PlaComOv-Study, a Randomized, Controlled Trial in the Netherlands

Adjuvant Use of PlasmaJet Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: Results of the PlaComOv-study, a Randomized Controlled Trial in The Netherlands

ObjectiveStandard surgical treatment of advanced-stage ovarian carcinoma with electrosurgery cannot always result in complete cytoreductive surgery (CRS), especially when many small metastases are found on the mesentery and intestinal surface. We investigated whether adjuvant use of a neutral argon plasma device can help increase the complete cytoreduction rate.Patients and Methods327 patients with FIGO stage IIIB–IV epithelial ovarian cancer (EOC) who underwent primary or interval CRS were randomized to either surgery with neutral argon plasma (PlasmaJet) (intervention) or without PlasmaJet (control group). The primary outcome was the percentage of complete CRS. The secondary outcomes were duration of surgery, blood loss, number of bowel resections and colostomies, hospitalization, 30-day morbidity, and quality of life (QoL).ResultsComplete CRS was achieved in 119 patients (75.8%) in the intervention group and 115 patients (67.6%) in the control group (risk difference (RD) 8.2%, 95% confidence interval (CI) –0.021 to 0.181; P = 0.131). In a per-protocol analysis excluding patients with unresectable disease, complete CRS was obtained in 85.6% in the intervention group and 71.5% in the control group (RD 14.1%, 95% CI 0.042 to 0.235; P = 0.005). Patient-reported QoL at 6 months after surgery differed between groups in favor of PlasmaJet surgery (95% CI 0.455–8.350; P = 0.029). Other secondary outcomes did not differ significantly.ConclusionsAdjuvant use of PlasmaJet during CRS for advanced-stage ovarian cancer resulted in a significantly higher proportion of complete CRS in patients with resectable disease and higher QoL at 6 months after surgery. (Funded by ZonMw, Trial Register NL62035.078.17.)Trial RegistrationApproved by the Medical Ethics Review Board of the Erasmus University Medical Center Rotterdam, the Netherlands, NL62035.078.17 on 20-11-2017. Recruitment started on 30-1-2018.

Neoadjuvant chemotherapy in advanced-stage ovarian cancer - state of the art.

Ovarian cancer represents the fifth cause of cancer death among women, carrying one of the worst prognoses among gynaecological malignancies. The need to achieve no residual disease after surgery in order to optimize prognosis of advanced-stage ovarian cancer introduced the idea of neoadjuvant chemotherapy. The present review aims to summarize current state-of-the-art evidence regarding the efficacy and safety of neoadjuvant chemotherapy as well as novel insights regarding the usage of modern therapeutic regimens in the context of neoadjuvant chemotherapy. The last decade has been characterized by the breakthrough scientific evidence that neoadjuvant chemotherapy followed by interval debulking surgery for advanced-stage ovarian cancer may be comparable to primary debulking surgery. Neoadjuvant chemotherapy followed by interval debulking surgery is an acceptable - if not preferable - therapeutic approach in advanced-staged ovarian cancer patients because it is associated with higher optimal debulking surgery, fewer complications, and non-inferior survival outcomes. The addition of bevacizumab to chemotherapy contributes significantly to survival outcomes without causing side effects that outbalance the benefits. Patients with recurrent high-grade serous ovarian cancer and a germline or breast cancer mutation should be offered maintenance olaparib after a response to platinum-based chemotherapy. Finally, the role of hyperthermic intraperitoneal chemotherapy in the context of neoadjuvant chemotherapy remains unjustified.

Rethinking of radical surgery at interval debulking surgery for advanced-stage ovarian cancer undergoing neoadjvuant chemotherapy

Objective: The aim of this study was to evaluate the effects of disease burden, surgical complexity, and residual disease at interval debulking surgery (IDS) in advanced-stage ovarian cancer treated with neoadjuvant chemotherapy (NACT).

Cytoreductive surgery for advanced-stage ovarian cancer with upper abdominal disease performed by gynecologic oncologists alone versus multiple surgical specialties: Is there a difference in outcomes?

Objective: The purpose of this study was to evaluate the perioperative surgical outcomes of cytoreductive surgery that included upper abdominal disease in advanced-stage ovarian cancer performed by gynecologic oncologists alone versus those with other surgical specialties (other than gynecologic oncologists).

The Influence of the Preoperative Status on the Risk of Postoperative Complications After Cytoreductive Surgery for Advanced-stage Ovarian Cancer.

The aim of this study was to analyze the influence of preoperative status on the risk of developing further postoperative complications after debulking surgery for advanced-stage ovarian cancer. A total of 80 consecutive patients submitted to surgery between 2014 and 2019 for advanced-stage ovarian cancer were retrospectively reviewed. Among the 80 cases there were seven patients who developed serious postoperative complications requiring reintervention. Among these cases it seems that association of obesity, poor nutritional status (defined as a lower than 3.5 g/dl serum albumin level) and elderly age were significantly associated with the risk of developing further complications. When selecting the candidates for debulking surgery for advanced-stage ovarian cancer attention should be focused on excluding cases presenting such preoperative risk factors in order to decrease the postoperative morbidity.

Subtotal Colectomy as Part of Debulking Surgery for Advanced-stage Ovarian Cancer.

The presence of extensive lesions of peritoneal carcinomatosis is found in a significant number of cases of extended digestive resection surgery, such as subtotal colectomy. The aim of this study was to report a series of 17 cases that necessitated performing subtotal colectomy as part of cytoreductive surgery for advanced-stage ovarian cancer. Between 2012 and 2020 subtotal colectomy was associated as part of the debulking effort in 17 cases. The median age at the time of surgery was 59 years, while the initial stage at the time of diagnosis was IIIC in 14 cases, and respectively IV in three cases. Optimal debulking surgery was achieved in all cases. The continuity of the digestive tract was reestablished in 11 cases, while in the remaining 6 cases a terminal ileostomy was performed. Extended digestive tract resections may be needed in certain cases in order to maximize the debulking effort in patients with advanced-stage ovarian cancer.

The Influence of "Omental Cake" Presence on the Completeness of Cytoreduction in Advanced-stage Ovarian Cancer.

The presence of "omental cake" has been considered since long as a negative prognostic factor in patients diagnosed with advanced-stage ovarian cancer. The aim of this paper was to study the impact of "omental cake" presence on the perioperative outcomes in advanced-stage ovarian cancer. Between 2015 and 2020, 85 patients were submitted to surgery for advanced-stage ovarian cancer. Among cases diagnosed with "omental cake" the rate of complete cytoreduction was significantly diminished when compared to cases in which this entity was not revealed. In the meantime, the presence of omental cake among cases in which complete debulking was achievable was significantly associated with a higher number of digestive resections when compared to the other cases submitted to surgery and in which tumoral transformation of the omentum was encountered. The presence of "omental cake" is associated with a higher rate of incomplete resections. However, in cases in which complete debulking was achieved, the presence of omental cake was associated with a significantly higher number of digestive tract resections.

A novel classification of residual disease after interval debulking surgery for advanced-stage ovarian cancer to better distinguish oncologic outcome

Complete surgical resection affords the best prognosis at the time of interval debulking surgery. When complete surgical resection is unachievable, optimal residual disease is considered the next best alternative. Despite contradicting evidence on the survival benefit of interval debulking surgery if macroscopic residual disease remains, the current definition of "optimal" in patients undergoing interval debulking surgery is defined as largest diameter of disease measuring ≤1.0 cm, independent of the total volume of disease. To examine the relationship between volume and anatomic distribution of residual disease and oncologic outcomes among patients with advanced-stage epithelial ovarian/fallopian tube/primary peritoneal carcinoma undergoing neoadjuvant chemotherapy then interval debulking surgery. For patients who did not undergo a complete surgical resection, a surrogate for volume of residual disease was used to assess oncologic outcomes. Patient demographics, operative characteristics, anatomic site of residual disease, and outcome data were collected from medical records of patients with International Federation of Gynecology and Obstetrics stage IIIC and IV epithelial ovarian cancer undergoing interval debulking surgery from January 2010 to July 2015. Among patients who did not undergo complete surgical resection but had ≤1 cm of residual disease, the number of anatomic sites (single location vs multiple locations) with residual disease was used as a surrogate for volume of residual disease. The effect of residual disease volume on progression-free survival and overall survival was evaluated. Of 270 patients undergoing interval debulking surgery, 173 (64.1%) had complete surgical resection, 34 (12.6%) had ≤1 cm of residual disease in a single anatomic location, 47 (17.4%) had ≤1 cm of residual disease in multiple anatomic locations, and 16 (5.9%) were suboptimally debulked. Median progression-free survival for each group was 14, 12, 10, and 6 months, respectively (P<.001). Median overall survival for each group was: 58, 37, 26, and 33 months, respectively (P<.001). Following interval debulking surgery, patients with complete surgical resection have the best prognosis, followed by patients with ≤1 cm single-anatomic location disease. In contrast, despite being considered "optimally debulked," patients with ≤1 cm multiple-anatomic location disease have a survival similar to suboptimally debulked patients.

Asian perspective on the quality of debulking surgery for advanced-stage ovarian cancer: Results of an international survey

Asian perspective on the quality of debulking surgery for advanced-stage ovarian cancer: Results of an international survey

An evaluation of bowel resection and ostomy formation among patients undergoing cytoreductive surgery for advanced-stage ovarian cancer

An evaluation of bowel resection and ostomy formation among patients undergoing cytoreductive surgery for advanced-stage ovarian cancer

Pretreatment neutrophil-to-lymphocyte ratio and its dynamic change during neoadjuvant chemotherapy as poor prognostic factors in advanced ovarian cancer.

ObjectiveThe purpose of this study was to determine the prognostic implications of the pretreatment neutrophil-to-lymphocyte ratio (NLR) and its dynamic change during chemotherapy in patients with advanced epithelial ovarian cancer undergoing neoadjuvant chemotherapy.MethodsWe performed a retrospective analysis of 203 patients who underwent neoadjuvant chemotherapy prior to interval debulking surgery for advanced-stage ovarian cancer at Yonsei Cancer Hospital between 2007 and 2015. Pretreatment NLR was evaluated before starting neoadjuvant chemotherapy. Change in NLR was defined as the post-neoadjuvant NLR value divided by the initial value. The correlation of NLR and its dynamic change with chemotherapy response score, response rate, and recurrence was analyzed.ResultsThe NLR ranged from 0.64 to 22.8. In univariate analyses, a higher pretreatment NLR (>3.81) was associated with poor overall survival (OS), but not progression-free survival (PFS). Through multivariate analysis, high pretreatment NLR was shown to be an independent parameter affecting OS, but not necessarily PFS. Changes in NLR during chemotherapy were better predictors of PFS than baseline NLR. Patients with increased NLR during chemotherapy showed significantly poor PFS, and this change was an independent predictor of PFS.ConclusionPretreatment NLR and its dynamic change during chemotherapy may be important prognostic factors in patients who undergo neoadjuvant chemotherapy.

Tips and Tricks in Advanced Stage Ovarian Cancer (AOC) Surgery

Surgery for advanced stage ovarian cancer is aimed at obtaining maximal cytoreduction with no residual disease. Multiple factors relating to patient selection and associated patient medical comorbidities, surgical skills, availability of adequate theatre time and equipment influence the surgical outcome. Following is a brief synopsis of conduct of cytoreductive surgery for AOC at Pan-Birmingham Gynaecology Cancer Centre.

Role of systematic lymphadenectomy as part of primary debulking surgery for optimally cytoreduced advanced ovarian cancer: Reappraisal in the era of radical surgery.

The prognostic significance of pelvic and para-aortic lymphadenectomy during primary debulking surgery for advanced-stage ovarian cancer remains unclear. This study aimed to evaluate the survival impact of lymph node dissection (LND) in patients treated with optimal cytoreduction for advanced ovarian cancer. Data from 158 consecutive patients with stage IIIC–IV disease who underwent optimal cytoreduction (<1 cm) were obtained via retrospective chart review. Patients were classified into two groups: (1) lymph node sampling (LNS), node count <20; and (2) LND, node count ≥20. Progression-free (PFS) and overall survival (OS) were analyzed using the Kaplan–Meier method. Among the included patients, 96 and 62 patients underwent LND and LNS as primary debulking surgery, respectively. There were no differences in the extent of debulking surgical procedures, including extensive upper abdominal surgery, between the groups. Patients who underwent LND had a marginally significantly improved PFS (P = 0.059) and significantly improved OS (P < 0.001) compared with those who underwent LNS. In a subgroup with negative lymphadenopathy on preoperative computed tomography scans, revealed LND correlated with a better PFS and OS (P = 0.042, 0.001, respectively). Follow-ups of subsequent recurrences observed a significantly lower nodal recurrence rate among patients who underwent LND. A multivariate analysis identified LND as an independent prognostic factor for PFS (hazard ratio [HR], 0.629; 95% confidence interval [CI], 0.400–0.989) and OS (HR, 0.250; 95% CI, 0.137–0.456). In conclusion, systematic LND might have therapeutic value and improve prognosis for patients with optimally cytoreduced advanced ovarian cancer.