Surgery For Recurrent Ovarian Cancer Research Articles

A Risk Model for Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer: An Evidence-Based Proposal for Patient Selection

To develop a risk model for predicting complete secondary cytoreductive surgery (SCR) in patients with recurrent ovarian cancer. Individual data of 1075 patients with recurrent ovarian cancer undergoing SCR from 7 worldwide centers were pooled and analyzed. The risk model was developed based on the factors impacting on SCR surgical outcome. Additional data on 117 patients who were not included in the development of the model were used for external validation and to assess the discrimination of the model. Of the 1075 patients, 434 (40.4%) underwent complete resection. Complete secondary cytoreduction was associated with six variables: FIGO stage (odds ratio [OR] = 1.32, 95% confidence interval [95% CI]: 0.97-1.80), residual disease after primary cytoreduction (OR = 1.69, 95% CI: 1.26-2.27), progression-free interval (OR = 2.27, 95% CI: 1.71-3.01), Eastern Cooperative Oncology Group (ECOG) performance status (OR = 2.23, 95% CI: 1.45-3.44), CA125 (OR = 1.85, 95% CI: 1.41-2.44), and ascites at recurrence (OR = 2.79, 95% CI: 1.88-4.13). These variables were entered into the risk model and assigned scores ranging from 0 to 11.9. Patients with total scores of 0-4.7 were categorized as the low-risk group, in which the proportion of complete cytoreduction was 53.4% compared with 20.1% in the high-risk group (OR = 4.55, 95% CI: 3.43-6.04). In external validation, the sensitivity and specificity was 83.3% and 57.6%, respectively. Area under the curve of the receiver-operating characteristics for predicting complete SCR was 0.68 (95% CI: 0.60-0.79). This model and scoring system may well predict the outcome of SCR and could potentially be useful in future clinical trials to determine which patients with recurrent ovarian cancer should have SCR as part of their management.

A risk model for secondary cytoreductive surgery in recurrent ovarian cancer: An evidence-based proposal for patient selection.

5053 Background: This study aims to redefine the role of secondary cytoreductive surgery (SCR) and develop a risk model for predicting outcomes of SCR in patients with recurrent ovarian cancer. Methods: Individual data of patients with recurrent ovarian cancer undergoing SCR from seven world-wide centers were pooled analyzed. The risk model was developed based on the factors impacting on SCR outcome. Additional data of 117 patients were used for external validation and to assess the discrimination of the model. Results: Complete SCR was strongly associated with the improvement of survival, with a median survival of 57.7 months, when compared to 27.0 months and 15.6 months in those with residual disease of 0.1-1cm and >1cm, respectively (P< 0.0001). Of the 1075 patients, 434 (40.4%) underwent complete resection. Complete SCR was associated with six variables: FIGO stage (OR=1.32), residual disease after primary cytoreduction (OR=1.69), progression-free interval (OR=2.27), ECOG performance status (OR=2.23), CA125 (OR=1.85) and ascites at recurrence (OR=2.79). These variables were entered into the risk model and assigned scores ranging from 0 to 11.9. Patients with total scores of 0-4.7 were categorized as the low risk group, in which the proportion of complete cytoreduction was 53.4% compared to 20.1% in the high risk group (OR=4.55). In external validation, the sensitivity and specificity of the model was 83.3% and 57.6%, respectively. Conclusions: SCR may be recommended for selected patients with recurrent ovarian cancer. This model may well predict the outcome of SCR and determine who benefit from SCR.

Clinical Trials in Recurrent Ovarian Cancer

The 4th Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup was held in Vancouver, Canada, in June 2010. Representatives of 23 cooperative research groups studying gynecologic cancers gathered to establish international consensus on issues critical to the conduct of large randomized trials. Group C, 1 of the 3 discussion groups, examined recurrent ovarian cancer, and we report the consensus reached regarding 4 questions. These included the following: (1) What is the role of cytoreductive surgery for recurrent ovarian cancer? (2) How do we define distinct patient populations in need of specific therapeutic approaches? (3) Should end points for trials with recurrent disease vary from those of first-line trials? (4) Is CA-125 progression alone sufficient for entry/eligibility into clinical trials?

Hepatic resection as part of secondary cytoreductive surgery for recurrent ovarian cancer involving the liver

The aims of this study were to assess the surgical outcomes and to also determine the prognostic factors in patients with surgically resectable liver metastases for recurrent ovarian cancer. Between 1991 and 2008, 18 patients with recurrent ovarian cancer who underwent hepatic resection as part of secondary cytoreductive surgery were identified from the tumor registry pathology database. Parameters for safety, efficacy, and survival data were considered as primary endpoints. Hepatic resections included wedge resection (n = 4), unisegmentectomy (n = 13), and bisegmentectomy (n = 1). There were no surgery-related deaths. Only one patient (5.6%) had postoperative major complications. The median postoperative hospitalization was 15.5 days (range 11-46 days). The prognostic factors associated with improved survival were less abdominal than pelvic disease (38 vs. 11 months, P = 0.032), optimal cytoreduction (40 vs. 9 months, P = 0.0004), and negative margin status of the hepatic resection (40 vs. 9 months, P = 0.0196). The overall median survival after hepatic resection was 38 months (range 3-78 months). Hepatic resection for recurrent ovarian cancer is safe and is associated with a favorable outcome. Parenchymal liver metastases should not exclude attempts at optimal secondary cytoreductive surgery, and especially, patients with solitary liver metastases should be considered for hepatic resection.

Salvage cytoreduction for chemorefractory ovarian cancer with peritoneal carcinomatosis: A last chance or futile efforts?

The role of secondary cytoreductive surgery in recurrent ovarian cancer in the presence of carcinomatosis is increasingly accepted as being an effective management strategy for selected patients. However, in patients with chemorefractory disease, the role of cytoreduction remains controversial. The objective of this study was to evaluate if cytoreduction of peritoneal carcinomatosis in patients with chemorefractory recurrent ovarian cancer as salvage treatment confers any survival benefits. A retrospective review was performed on patients with chemorefractory ovarian cancer with peritoneal carcinomatosis who underwent cytoreduction as a salvage treatment. Survival was calculated using the Kaplan-Meier method. Univariate analysis was performed to examine potential prognostic factors using the log-rank test. A total of 16 patients were identified, of which 15 patients (94%) had FIGO Stage III ovarian cancer at initial diagnosis. The initial surgical effort was optimal in one patient (6%), and 13 patients (62%) had been on at least two lines of chemotherapy. The median progression-free and overall survival was 18 (95% CI 0-42) months and 36 (95% CI 14-58) months, respectively. The 1-, 3-year survival rate was 73% and 23%, respectively. ECOG status zero (P = 0.023) and younger patients (age < 51) (P = 0.066) appeared to be associated with an improved overall survival. Salvage cytoreduction may be considered a last chance effort to prolong survival in this group of patients with chemorefractory ovarian cancer who have a 'poor prognosis' and would otherwise not have been candidates for any proven or effective therapy.

Surgery in recurrent epithelial ovarian cancer: Benefits on Survival for patients with residual disease of 0.1–1 cm after secondary cytoreduction

Recent retrospective trials stated that a benefit of surgery for recurrent ovarian cancer may be limited to patients in whom a complete cytoreduction (R0) could be achieved. Most of them pointed out there was no difference in survival between residual disease of 0.1-1 cm (R1) and >1 cm (R2). The aim of this study was to evaluate survival benefits from cytoreduction to R1. Between 2002 and 2006, 123 patients with recurrent epithelial ovarian cancer undergoing secondary cytoreduction were identified from tumor registry databases. The median age at recurrence was 51 years (range: 28-84). Fifty-one (41.5%) patients had R0, 46 (37.4%) patients had R1, and 26 (21.1%) patients had R2 resection. The median survival of the entire cohort was 31.7 months, with an estimated 5-year survival of 31.1%. The median survival and estimated 5-year survival for patients with R1 were 31.1 months and 23.9%, and there were significant differences in survival when compared to 15.6 months and 6.4% in R2 (chi(2) = 7.45, P = 0.006), 63.2 months (mean survival) and 54.4% in complete cytoreduction (chi(2) = 8.93, P = 0.0028). Complete secondary cytoreduction is the strongest survival determinant in recurrent epithelial ovarian cancer, whereas patients with residual disease of 0.1-1 cm may also benefit from secondary cytoreduction.

Role of cytoreductive surgery in recurrent ovarian cancer

Ovarian cancer is the leading cause of death from gynecologic malignancy in western countries, primarily because over 60% of patients with ovarian cancer will experience disease recurrence. Primary cytoreductive surgery and combination chemotherapy are the cornerstones of the initial treatment for epithelial ovarian cancer. The management of recurrent ovarian cancer is less clear than that of primary disease. The management of recurrent ovarian cancer is largely based on systemic chemotherapy, with surgery being offered only in selected individuals. Despite this, the benefits of surgery has been shown in a meta-analysis by Bristow et al. where the survival is influenced by the completeness of cytoreduction. Therefore, epithelial ovarian cancer can be accepted as a chronic disease that consists of multiple recurrence and retreatments such as further surgeries and chemotherapies. The clinical applicability of this secondary surgery remains a controversial topic. Therefore, a trial on secondary surgery for r...

Role of cytoreductive surgery in recurrent ovarian cancer

Cytoreductive surgery is well established in patients with primary ovarian cancer. The benefit of surgery in patients with recurrent ovarian cancer remains a controversial matter. There is a large heterogeneity in surgical results published in the literature, possibly caused by infrastructure, surgeons’ philosophy and belief in adding various surgical skills. This might also be a result of different preoperative selection procedures. Further questions to be addressed are the definition of surgical end points and whether there are predictive factors for a successful surgery. The surgical end point in recurrent ovarian cancer should be complete resection. Predictive factors could help identify patients in whom complete resection is possible.

Secondary cytoreductive surgery including rectosigmoid colectomy for recurrent ovarian cancer: Operative technique and clinical outcome

Objective To describe the operative technique and associated clinical outcomes of patients undergoing rectosigmoid colectomy as a component of secondary cytoreductive surgery for recurrent ovarian cancer. Methods Consecutive patients undergoing rectosigmoid colectomy for recurrent epithelial ovarian cancer between 1/01 and 12/07 were retrospectively identified and clinical data abstracted from the medical record. The surgical technique, associated morbidity, and clinical outcomes are described. Results Fifty-six patients were identified. The median age at secondary surgery was 56 years; 78.6% had advanced-stage disease at initial diagnosis; 69.6% had grade 3 tumors; 73.2% had serous histology. Complete cytoreduction to no gross residual disease was achieved in 85.7% of cases. Concurrent distal ureterectomy/partial cystectomy was required in 8 cases (14.3%). The median number of regional cytoreductive procedures outside the pelvis was 1 (range = 0–4). A stapled coloproctostomy was performed in 98.2% of patients; a protective colostomy/ileostomy was constructed in 7 cases (12.5%), and one patient (1.8%) underwent end colostomy. The median EBL was 500 cm 3 and the median operative time was 225 min. Blood transfusion was administered to 48.2% of patients. Post-operative morbidity occurred in 23.2% of patients, with a bowel fistula rate of 5.4% and a mortality rate of 1.8%. The median LOS was 9 days. Post-operative platinum-based chemotherapy was administered in 73.2% of patients. The median overall survival time from secondary surgery was 38.4 months. Conclusions Rectosigmoid colectomy can contribute significantly to a maximal cytoreductive surgical effort for recurrent ovarian cancer. Despite technical differences, including a frequent requirement for resection of the distal urinary tract, morbidity is comparable to rectosigmoid colectomy performed for primary cytoreduction and the associated survival outcome appears favorable.

Surgery for Recurrent Ovarian Cancer: Role of Peritoneal Carcinomatosis: Exploratory Analysis of the DESKTOP I Trial About Risk Factors, Surgical Implications, and Prognostic Value of Peritoneal Carcinomatosis

Almost all retrospective trials pointed out that a benefit of surgery for recurrent ovarian cancer may be limited to patients in whom a macroscopic complete resection could be achieved. Peritoneal carcinomatosis has been reported to be either a negative predictor for resectability or a negative prognostic factor, or both. The role of peritoneal carcinomatosis in a multicenter trial was investigated. Exploratory analysis of the DESKTOP I trial (multicenter trial of patients undergoing surgery for recurrent ovarian cancer, 2000 to 2003). A total of 125 patients (50%) who underwent surgery for recurrent ovarian cancer had peritoneal carcinomatosis. Univariate analyses showed worse overall survival for patients with peritoneal carcinomatosis compared with patients without carcinomatosis (P < .0001). Patients with and without peritoneal carcinomatosis had a complete resection rate of 26% and 74%, respectively (P < .0001). This corresponded with the observation that patients with complete resection had a better prognosis than those with minimal residual disease of 1 to 5 mm, which commonly reflects peritoneal carcinomatosis (P = .0002). However, patients who underwent complete resection, despite peritoneal carcinomatosis, had a 2-year survival rate of 77%, which was similar to the 2-year survival rate of patients with completely debulked disease who did not have peritoneal carcinomatosis (81%) (P = .96). Analysis of prognostic factors did not show any independent effect of peritoneal carcinomatosis on survival in patients who underwent complete resection. Peritoneal carcinomatosis was a negative predictor for complete resection but had no effect on prognosis if complete resection could be achieved. Improving surgical skills might be one step to increase the proportion of patients who might benefit from surgery for recurrent disease.

Surgery in recurrent ovarian cancer

Surgery in recurrent ovarian cancer

The significance of debulking surgery in recurrent ovarian cancer

The significance of debulking surgery in recurrent ovarian cancer

Surgery for Recurrent Ovarian Cancer: Role of Peritoneal Carcinomatosis: Exploratory Analysis of the DESKTOP I Trial About Risk Factors, Surgical Implications, and Prognostic Value of Peritoneal Carcinomatosis

Surgery for Recurrent Ovarian Cancer: Role of Peritoneal Carcinomatosis: Exploratory Analysis of the DESKTOP I Trial About Risk Factors, Surgical Implications, and Prognostic Value of Peritoneal Carcinomatosis

Predictive value of PET-CT imaging versus AGO-scoring in patients planned for cytoreductive surgery in recurrent ovarian cancer

Predictive value of PET-CT imaging versus AGO-scoring in patients planned for cytoreductive surgery in recurrent ovarian cancer

Predictive value of PET–CT imaging versus AGO-scoring in patients planned for cytoreductive surgery in recurrent ovarian cancer

Objective To assess the predictive value of positron emission tomography computed tomography (PET–CT) imaging in comparison to AGO-scoring in patients planned for cytoreductive surgery in recurrent ovarian cancer. Materials and methods 33 patients who had received a PET–CT for suspicion of recurrent ovarian cancer between 12/2003 and 08/2007 were included in the retrospective analysis. Indication for PET–CT was based on blood tumor markers Ca 125 or Ca 72-4 and clinical symptoms. Scanning was performed on a Philips Gemini System covering the body from the neck to the thighs one hour after administration of 200 MBq fluorodesoxyglucose. PET–CT, surgery and the patient records were reviewed to analyze the predictive value of PET–CT in comparison to an AGO-scoring system based on clinical parameters with regard to the prediction of full resectability of abdominal tumor spread. Results The statistical analysis of this data showed a sensitivity of 73% (95% C.I., 39–94%) and specificity of 80% (95% C.I., 29–97%) for AGO-scoring with a positive predictive value of 89% and a negative predictive value of 57%. PET–CT achieved a sensitivity of 100% (95% C.I., 72–100%) and specificity of 60% (95% C.I. 15–94%), with a positive predictive value of 85% and negative predictive value of 100%. Further analysis of the data of operated patients with concordant PET–CT and AGO-score (12/16) showed a very good prediction of full resectability with a sensitivity of 100% (95% C.I., 63–100%), specificity of 75% (95% C.I., 20–96%), positive predictive value of 89% and negative predictive value of 100%. Conclusion PET–CT and the AGO-score offer good tools to determine patients for full resectability in recurrent ovarian cancer. PET–CT has a higher negative and the AGO score a higher positive predictive value, and the combination of both improves the diagnostic accuracy.

Tertiary cytoreductive surgery in recurrent ovarian cancer: Selection criteria and survival outcome

Tertiary cytoreductive surgery in recurrent ovarian cancer: Selection criteria and survival outcome

Platinum and taxane intraperitoneal chemotherapy after secondary cytoreductive surgery for recurrent ovarian carcinoma

16043 Background: Intraperitoneal chemotherapy (IP) after primary optimal debulking for advanced stage epithelial ovarian carcinoma improves survival. The objective of this research is to describe our experience with IP taxane and platinum chemotherapy after optimal secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer. Methods: We retrospectively reviewed charts from January 2006 to January 2007 and identified approximately 30 patients who received IP chemotherapy for optimally debulked advanced ovarian carcinoma. Of these patients, 8 were treated at first recurrence with cytoreductive surgery followed by second-line IP chemotherapy with intravenous docetaxel (70 mg/m2) and IP cisplatin (75–85 mg/m2) on day 1 and IP paclitaxel (60 mg/m2) on day 8, every 21 days. Results: The median disease free interval from completion of initial chemotherapy to recurrence was 19 months. All patients who underwent secondary cytoreductive surgery were considered optimally debulked (less than 1 cm residual disease), with 6 patients having no residual disease. One patient required rectal resection and another patient had ileocecal resection without a protective ostomy. All patients had insertion of an intraperitoneal venous access device for infusion of IP chemotherapy at the time of cytoreduction. While four patients have completed all 6 cycles of IP chemotherapy, one patient completed only 3 cycles due to catheter related toxicity requiring removal of the port (abdominal pain). This patient did not undergo concurrent bowel surgery. In addition, two patients have completed 3 cycles and two patients are currently scheduled to begin IP chemotherapy. Only two patients experienced grade 3 or 4 neutropenia. No other grade 3 or 4 toxicities were identified. A median of 5 cycles (range 2–5 cycles) was required to achieve a CA125 nadir. Complete clinical response was obtained in all patients at a median follow up of 9 months (range 4–10 months). Conclusions: In optimally debulked, platinum-sensitive patients following secondary cytoreductive surgery for recurrent ovarian cancer, intraperitoneal taxane and platinum chemotherapy is feasible with acceptable toxicity and provides another option for treatment. No significant financial relationships to disclose.

Cytoreductive surgery for recurrent ovarian cancer

The issue facing clinicians managing ovarian cancer has evolved over the past three decades from treatment for cure and subsequently palliation, to prolongation of survival for most patients. The purpose of this paper is to review the data, rationale, and issues surrounding cytoreductive surgery in recurrent ovarian cancer and its potential role in this new paradigm shift. Abundant retrospective series report prolongation of survival with secondary cytoreductive surgery in recurrent ovarian cancer. Selection bias, publication bias, and subsequent therapies, however, are confounding factors for survival. As management of ovarian cancer has recently evolved to a treatment of a 'chronic disease', surgery (which has a definite role in primary therapy) should be considered. No prospective randomized studies have been performed to date, and therefore adoption of this method of management has been limited. The absence of good data leaves clinicians without clear direction on how to best manage patients. Patients with favorable characteristics such as a long disease-free interval, good performance status, a single or few small intra-abdominal recurrences may benefit from secondary cytoreduction. A prospective randomized study is needed.

Re: “En bloc resection of diaphragm with lung for recurrent ovarian cancer: A case report”

In a recent communication in Gynecologic Oncology, dos Santos et al. describe the clinical course of a recurrent ovarian cancer patient, with a 4-year treatment-free interval, who successfully underwent, an “en bloc resection of the diaphragm with lung” [1]. While an interesting case report, a statement in the discussion, which appears to be the fundamental justification for the performance of this procedure in this patient's management, must be challenged: “secondary cytoreductive surgery for recurrent ovarian cancer is performed with the goal of complete excision of macroscopic tumor.

Tertiary cytoreductive surgery in recurrent ovarian cancer: Selection criteria and survival outcome

Studies of tertiary cytoreductive surgery (TCS) in recurrent epithelial ovarian cancer are limited, and appropriate patient selection remains a clinical challenge. We sought to evaluate the impact of TCS on survival and to determine predictors of optimal tertiary resection. Between January 1997 and July 2004, 47 women with recurrent epithelial ovarian cancer underwent TCS at two institutions. All patients received initial platinum and taxane-based chemotherapy following primary cytoreductive surgery. Clinico-pathologic factors and survival were retrospectively abstracted from medical records. Optimal TCS was defined as microscopic residual disease. Thirty of 47 (64%) patients underwent optimal TCS. Size of tumor implants<5 cm on preoperative imaging was the only significant predictor of achieving optimal TCS. Overall survival after TCS was statistically longer in patients with microscopic versus macroscopic residual disease (24 versus 16 months, p=0.03). After controlling for age, time to progression and optimal TCS, only the presence of diffuse disease at tertiary exploration remained a significant poor predictor of survival. However, in a cohort of patients with limited disease implants, multivariate analysis indicated that optimal TCS retained prognostic significance as a positive predictor of survival. Twelve patients (26%) experienced severe postoperative complications, including six with pulmonary embolism, four with fistulae and two with postoperative myocardial infarctions. Size of disease implants on preoperative imaging may guide the selection of candidates for TCS. In those patients with limited disease implants at laparotomy, optimal TCS is associated with improved survival.