Optimal Cytoreductive Surgery Is an Independent Prognostic Indicator in Stage IV Epithelial Ovarian Cancer with Hepatic Metastases

doi:10.1006/gyno.2000.5841

Gynecologic Oncology

Volume 78, Issue 2, August 2000, Pages 171-175

https://doi.org/10.1006/gyno.2000.5841 Get rights and content

Abstract

Objectives. The aim of this study was to determine the value of optimal cytoreduction in stage IV epithelial ovarian cancer.

Methods. A retrospective review was performed of 37 women with stage IV epithelial ovarian cancer treated by radical surgery.

Results. Optimal surgery to less than 2 cm tumor deposits was performed in 16 of the 37 cases (43%) and tumor debulking to less than 1 cm tumor deposits in 6 cases (16.2%). Twenty-three cases (62%) were designated stage IV because of the presence of liver metastases alone. Although no patients died within 2 weeks of surgery, 7 of the 37 cases (22%) failed to survive more than 50 days after primary surgery. The overall median survival was 11 months with overall 2- and 5-year survivals of 23 and 9%, respectively. On multivariate analysis comparing age, histological type, tumor grade, place of surgery, secondary surgical procedure, performance of bowel surgery, presence of liver metastases, and optimal cytoreduction, only optimal surgery and residual tumor deposits of less than 2 cm, or less than 1 cm, remained highly significant (P = 0.0029 and 0.0086, respectively). Even when assessing only the 27 cases who were designated as having stage IV disease because of the presence of liver metastases, by multivariate analysis, only optimal surgery and residual tumor deposits of less than 2 cm, or less than 1 cm, remained significant (P = 0.023 and 0.036, respectively). Site of metastases designating stage IV status was not associated with a reduced likelihood of achieving optimal debulking (P = 0.18).

Conclusion. Optimal cytoreduction in women with stage IV epithelial ovarian cancer with or without hepatic metastases is associated with a more favorable outcome survival.

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Cited by (60)

Surgical Management of Gynecologic Cancers
2021, Surgical Oncology Clinics of North America
Video-assisted thoracic surgery in the primary management of advanced ovarian carcinoma with moderate to large pleural effusions: A Memorial Sloan Kettering Cancer Center Team Ovary Study
2020, Gynecologic Oncology
Citation Excerpt :
Approximately 10% of patients presenting with advanced EOC will have stage IV disease. The benefit of cytoreductive surgery in patients with malignant pleural effusions compared with other stage IV disease criteria has been explored previously [14,16–21]. In a large retrospective Gynecologic Oncology Group (GOG) study of 360 patients with stage IV EOC undergoing PDS followed by six cycles of platinum/paclitaxel, Winter et al. demonstrated that residual tumor was highly associated with recurrence-free survival and OS [5].
We assessed the utility of video-assisted thoracic surgery (VATS) in defining extent of intrathoracic disease in advanced ovarian carcinoma with moderate-to-large pleural effusions.
Beginning in 2001, VATS was performed on all patients with suspected advanced ovarian carcinoma and moderate-to-large pleural effusions, evaluating for macroscopic intrathoracic disease. The algorithm recommended primary debulking surgery (PDS) for ≤1 cm, neoadjuvant chemotherapy (NACT)/interval debulking surgery (IDS) for >1 cm intrathoracic disease. We reviewed records of patients undergoing VATS from 10/01–01/19. Differences between treatment groups were tested using standard statistical techniques.
One-hundred patients met eligibility criteria (median age, 60; median CA-125 level, 1158 U/mL; medium serum albumin, 3.8 g/dL). Macroscopic pleural disease was found in 70 (70%). After VATS, 50 (50%) underwent attempted PDS (PDS group), 50 (50%) received NACT (NACT/IDS group). Forty-seven (94%) underwent IDS. Median overall survival (OS) for the entire cohort (n = 100) was 44.5 months (95% CI: 37.8–51.7). The PDS group had significantly longer survival than the NACT/IDS group [45.8 (95% CI: 40.5–87.8) vs. 37.4 months (95% CI: 33.3–45.2); p = .016]. On multivariable analysis, macroscopic intrathoracic disease (HR 2.18, 95% CI: 1.14–4.18; p = .019) and age ≥ 65 (HR 1.98, 95% CI: 1.16–3.40; p = .013) were independently associated with elevated death risk. Patients with the best outcome had no macroscopic disease at VATS and underwent PDS (median OS, 87.8 months).
VATS is useful in therapeutic decision-making for PDS vs. NACT/IDS in advanced ovarian cancer with moderate-to-large pleural effusions.
F-18 FDG PET/CT metabolic tumor volume predicts overall survival in patients with disseminated epithelial ovarian cancer
2017, European Journal of Radiology
We evaluated the prognostic impact of quantitative assessment by maximum standardized uptake value (SUVmax), metabolic tumour volume (MTV) and tumour lesion glycolysis (TLG) on [F-18] FDG PET/CT for patients with peritoneal carcinomatosis from epithelial ovarian cancer (EOC).
Thirty-one patients with EOC underwent PET/CT for an early restaging after cytoreductive surgery, having been diagnosed with carcinomatosis (before chemotherapy). The SUVmax, MTV (cm³; 42% threshold) and TLG (g) were registered on residual peritoneal lesions. The patients were followed up 20 ± 12 months thereafter. The PET/CT results were compared to overall survival (OS).
The Kaplan-Meier survival analysis for the SUVmax did not reveal significant differences in OS (p = 0.48). The MTV survival analysis showed a significant higher OS in patients presenting with a higher tumour burden than those with less tumour burden (p = 0.01; 26 vs. 14 months), whereas TLG exhibited a similar trend though not significant (p = 0.06). Apart from chemo-resistance, the higher the MTV, the better will be the response to chemotherapy.
Quantitative assessment by MTV rather than by SUVmax and TLG on PET/CT may be helpful for stratifying patients who present with peritoneal carcinomatosis from EOC, in order to implement the appropriate therapeutic regimen.
Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: Redefining 'optimal' residual disease
2012, Gynecologic Oncology
Citation Excerpt :
In connection with this issue, we will analyze the impact of complete cytoreduction on survival in advanced ovarian cancer patients drawing from the review of the literature. Since the landmark GOG studies reported by Hoskins et al., a number of studies have confirmed that overall survival is significantly improved in advanced ovarian cancer patients with optimal residual disease after maximal cytoreductive surgery [6–18,32,36–43,45–56]. Although these studies demonstrated a strong association between survival improvement and maximal cytoreductive surgery, the majority of these included patients who did not receive the paclitaxel-platinum combination chemotherapy and did not conduct a survival analysis for patients with no gross or microscopic residual disease.
Over the past 40 years, the survival of patients with advanced ovarian cancer has greatly improved due to the introduction of combination chemotherapy with platinum and paclitaxel as standard front-line treatment and the progressive incorporation of increasing degrees of maximal cytoreductive surgery. The designation of “optimal” surgical cytoreduction has evolved from residual disease ≤ 1 cm to no gross residual disease. There is a growing body of evidence that patients with no gross residual disease have better survival than those with optimal but visible residual disease. In order to achieve this, more radical cytoreductive procedures such as radical pelvic resection and extensive upper abdominal procedures are increasingly performed. However, some investigators still suggest that tumor biology is a major determinant in survival and that optimal surgery cannot fully compensate for tumor biology. The aim of this review is to outline the theoretical rationale and historical evolution of primary cytoreductive surgery, to re-evaluate the preferred surgical objective and procedures commonly required to achieve optimal cytoreduction in the platinum/taxane era based on contemporary evidence, and to redefine the concept of “optimal” residual disease within the context of future surgical developments and analysis of treatment outcomes.
FDG-PET/CT in advanced ovarian cancer staging: Value and pitfalls in detecting lesions in different abdominal and pelvic quadrants compared with laparoscopy
2011, European Journal of Radiology
Ovarian carcinoma (OC) is a common cancer in the Western Countries, and an important cause of death in patients suffering with gynaecologic malignancies. The majority of patients present with advanced disease at the time of diagnosis. Treatment with debulking surgery followed by chemotherapy is the standard approach while chemotherapy is contemplated when surgery is not possible. A correct pre-operative staging is important to ensure a most appropriate management. Laparoscopy (LPS) is the standard diagnostic tool for the assessment of intraperitoneal infiltration but is invasive and requires general anaesthesia. FDG-PET/CT is increasingly used for staging different types of cancer, and the aim of this study is to assess the value of FDG-PET/CT in staging advanced OC and its sensitivity to detect lesions in different quadrants of the abdominal-pelvic area compared to laparoscopy.
From September 2004 till April 2008, 40 patients with high suspicion of OC were referred to our hospital for diagnostic LPS to explore the possibility of optimal debulking surgery. Those who were not suitable for surgery were referred for chemotherapy. Before chemotherapy, the patients underwent an FDG-PET/CT scan. The findings in 9 quadrants of abdominal-pelvic area (total 360 quadrants) for PET/CT and LPS were recorded and compared.
In 14/360 areas (3.8%), surgical evaluation was not possible because of presence of adhesions, thus the number of areas explored by laparoscopy was 346. Tumour was found in 308 quadrants (38 quadrants free of disease). PET/CT was positive in all 40 patients with true negative results in 26/346 quadrants (7.5%), and true positives results in 243/346 quadrants (70.2%). False positive and negative PET/CT results were found in 12/346 and 65/346 quadrants, respectively. False positive PET/CT findings were evenly present in all quadrants. False negative PET/CT findings were present in 31/109 (28.4%) upper abdominal quadrants (epigastrium and diaphragmatic areas). Final analysis showed a sensitivity and specificity for PET/TC of 78.9 and 68.4% respectively with a positive predictive value of 95.3%. A significant difference was noted between mean SUVmax associated with lesions smaller or larger than 0.5 cm (p = 0.006).
Our results suggest that PET/CT may prove a useful tool for pre-surgical staging of ovarian cancer with a sensitivity and specificity of 78 and 68%, respectively. However, it may be used in combination with laparoscopy for better results. PET/CT showed an adequate correlation between SUVmax values and laparoscopy findings of lesions >5 mm, but a high rate of false negative results in lesions <5 mm such as in carcinomatosis. PET/CT should be used carefully in early stage disease, with low risk of peritoneal infiltration, because of high rate of false positive results, to avoid unnecessary therapy procedures.
Diaphragmatic surgery during primary debulking in 89 patients with stage IIIB-IV epithelial ovarian cancer
2010, Gynecologic Oncology
The aim of this study was to describe the role of diaphragmatic surgery in achieving optimal debulking in patients with advanced ovarian cancer and the assessment of the relative post-operative complications.
Retrospective review was performed of medical records of 89 patients with epithelial ovarian cancer who underwent diaphragmatic surgery during their primary debulking surgery between September 1993 and December 2007. Four different approaches were performed: coagulation (group 1), stripping (group 2), combination stripping with coagulation (group 3) and diaphragm full thickness resection (group 4). Cytoreductive outcome, morbidity, overall survival (OS) and disease-free survival (DFS) were analysed.
Eight (8.9%) patients had FIGO stage IIIB, 64 (72%) stage IIIC and 17 (19.1%) stage IV disease. In 20 patients (22%) the diaphragmatic disease was coagulated, in 31 patients (35%) was only stripped, in 31 patients (35%) a combination of these techniques was applied and in 7 (8%) the disease was resected with the adjacent infiltrated part of the diaphragm muscle and the pleura above it. Debulking to no residual tumor was achieved in 90%, 86%, 86% and 100% for groups 1, 2, 3 and 4 respectively. Median DFS was 15, 15, 17 and overall survival OS for groups 1, 2, and 3 was 40, 42, and 50 months respectively and was not yet reached for group 4. Minor and major complications were comparable among the groups. Pleural effusion was the most frequent associated complication and chest tube placement (17%) or thoracocentesis (12%) was necessary for the relief of respiratory distress. The perioperative mortality rate was 0%. The majority of cases were treated in the last five years of our 15-year experience.
Diaphragmatic surgery increases the rates of optimal primary debulking surgery and improves survival with an acceptable and manageable morbidity rate. In patients with thick (> 0.3 cm) or large (> 4 cm) lesions stripping the diaphragm or full thickness resection of the diaphragmatic muscle is preferred.

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Regular ArticleOptimal Cytoreductive Surgery Is an Independent Prognostic Indicator in Stage IV Epithelial Ovarian Cancer with Hepatic Metastases

Abstract

Gynecol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Clin Oncol

Gynecol Oncol

Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma

Natl Cancer Inst Monogr

Role of cytoreductive surgical treatment in the management of advanced ovarian cancer

Cancer Treat Rep

Regular Article
Optimal Cytoreductive Surgery Is an Independent Prognostic Indicator in Stage IV Epithelial Ovarian Cancer with Hepatic Metastases