A novel algorithm for the treatment strategy for advanced epithelial ovarian cancer: consecutive imaging, frailty assessment, and diagnostic laparoscopy

A retrospective study was performed. Patients who were diagnosed with EOC from March 2012 to March 2015 were enrolled in this study. The protocol recieved Institutional Review Board approval of the Yonsei University College of Medicine (No. 4–2017-0068) and was performed in accordance with the ethnical standards described in the Declaration of Helsinki. Preoperative clinical and radiological evaluations included chest radiography, pelvic ultrasonography, computed tomography (CT), and a serum carbohydrate antigen (CA) 125 level assessment. A gynecologic oncology team at a single institute conducted all procedures, and a dedicated radiologist at the same institute reviewed all data from preoperative imaging.

A flow diagram of the patient selection process with a proposed treatment algorithm is presented in Fig. 1. High tumor dissemination (HTD) was defined as carcinomatosis, including bulky nodules (nodules >4 cm or plaques) on the diaphragm surface and mesentery or liver metastasis [14]. HTD was determined based on preoperative CT scanning and was assumed to be present when any of the following findings were suspected: (1) retroperitoneal lymph nodes >1 cm above the renal hilum; (2) diffuse small bowel adhesion/thickening; (3) perisplenic lesions >1 cm; (4) small bowel mesentery lesions >1 cm; (5) superior mesenteric artery lesion root >1 cm; (6) lesser sac lesion >1 cm; (7) diffuse peritoneal thickening >4 mm at the lateral colic gutters, anterior abdominal wall, diaphragm, and pelvic peritoneal reflections; (8) carcinomatosis with bulky nodules >4 cm; and (9) liver parenchymal metastasis.

Patients were categorized into three groups according to the treatment intention. Those with no evidence of HTD were categorized into the PDS surgery group, and underwent primary staging laparotomy. Patients with evidence of HTD on CT scans were further divided into the following two groups according to a frailty assessment: (1) the neoadjuvant chemotherapy (NACT) group, in which patients underwent ascites cytology followed by NACT; and (2) the DLS group, in which patients underwent DLS to determine possibility of optimal debulking surgery. Patients with an older age (>75 years), with distant metastases, and with poor performance status (American Society of Anesthesiologists physical status classification system ≥3) were more likely to be categorized into the NACT group. In the DLS group, tumor resectability was evaluated using the Fagotti scoring system and consensus among surgeons who participated in the procedure. The following 7 parameters were assessed: (1) omental cake, (2) peritoneal carcinomatosis, (3) diaphragmatic carcinomatosis, (4) mesenteral retraction, (5) bowel infiltration, (6) stomach infiltration, and (7) superficial liver metastases [9]. Each parameter was assigned 2 points if present and 0 points otherwise. A conversion to laparotomy for PDS was considered when the laparoscopy-based score was less than 8 (Fig. 2).

Patients in the PDS, NACT, and DLS groups were compared with respect to their clinical features and surgical outcomes. Survival outcomes were also analyzed and compared among the 3 groups. Progression-free survival (PFS) was defined as the interval between the date that treatment was started and the date of documented disease progression or death from any cause. Overall survival (OS) was defined as the interval between the date treatment started and the date of death due to any cause. If a patient was lost to follow-up, that patient was censored at the last date of contact.