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Onishi J, Odajima S, Koike Y, Takenaka S, Tanabe H. Portal vein thrombosis and hepatic infarction due to hepatic mobilization after primary debulking surgery for advanced ovarian cancer: A case report. J Obstet Gynaecol Res 2024. [PMID: 39245463 DOI: 10.1111/jog.16081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2024] [Accepted: 08/26/2024] [Indexed: 09/10/2024]
Abstract
Hepatic mobilization is essential in debulking surgery for resecting diaphragmatic lesions in advanced ovarian cancer. However, hepatic mobilization potentially induces postoperative portal vein thrombosis and hepatic infarction. No reports exist regarding these postoperative complications of gynecological surgeries. Thus, we reported a case of portal vein thrombosis and hepatic infarction after ovarian cancer surgery with upper abdominal surgery. The 51-year-old female patient who had been diagnosed with advanced ovarian and early endometrial cancer underwent primary debulking surgery. Ultimately, she underwent the following surgical procedures: a hysterectomy, bilateral salpingo-oophorectomy, total parietal peritonectomy, low anterior resection, ileostomy, and appendicectomy. The hepatic enzymatic and D-dimer levels were elevated, postoperatively. Contrast-enhanced computed tomography revealed portal vein thrombosis and an infarction of the hepatic S3 region. The portal vein thrombosis resolved post-administration of unfractionated heparin. The hepatic infarction improved. Meticulous intra- and postoperative management should encompass the deliberation of the potential risk of these postoperative complications.
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Affiliation(s)
- Junki Onishi
- Department of Gynecology, National Cancer Center East Hospital, Chiba, Japan
| | - Suguru Odajima
- Department of Gynecology, National Cancer Center East Hospital, Chiba, Japan
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yuki Koike
- Department of Gynecology, National Cancer Center East Hospital, Chiba, Japan
| | - Shin Takenaka
- Department of Gynecology, National Cancer Center East Hospital, Chiba, Japan
| | - Hiroshi Tanabe
- Department of Gynecology, National Cancer Center East Hospital, Chiba, Japan
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Kim MS, Lee AJ, Shim SH, Jang EB, Kim NK, Kim MK, Suh DH, Kim J, Son JH, Kong TW, Chang SJ, Hwang DW, Park SJ, Kim HS, Yoo JG, Lee SJ, Lee YY. Comparison of Outcomes in Bowel Resections by Gynecologic Oncologists Versus General Surgeons During Maximal Cytoreductive Surgery for Advanced Ovarian Cancer: Gynecologic Oncology Research Investigators Collaboration Study (GORILLA-3006). Ann Surg Oncol 2024; 31:6040-6047. [PMID: 38961041 DOI: 10.1245/s10434-024-15643-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/06/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND This report describes the oncologic outcomes for patients with advanced ovarian cancer who had bowel surgery performed by gynecologic oncologists (GOs) and compares the outcomes with those for bowel surgery performed by general surgeons (GSs) during maximal cytoreductive surgery. METHODS Patients from six academic institutions who had FIGO stage III or IV ovarian cancer and underwent any bowel surgeries during maximal cytoreductive surgery were eligible for the study. The patients were divided into two groups according to whether bowel surgery was performed by a GO or a GS. In both groups, the GOs were mainly involved in extra bowel debulking procedures. Perioperative and survival outcomes were compared between the two groups. RESULTS The 761 patients in this study included 113 patients who underwent bowel surgery by a GO and 648 who had bowel surgery by a GS. No discernible differences were observed in age, American Society of Anesthesiology (ASA) score, FIGO stage, histologic type, timing of cytoreductive surgery (primary or interval debulking surgery), or complications between the two groups. The GO group exhibited a shorter operation time than the GS group. Kaplan-Meier analysis showed no survival differences between the two groups. In the Cox analysis, non-serous cell types and gross residual diseases were associated with adverse effects on overall survival. However, performance of bowel surgery by a GO did not have an impact on survival. CONCLUSION Performance of bowel surgery by a GO during maximal cytoreductive surgery is both feasible and safe. These results should be reflected in the training system for GOs regarding bowel surgery, and further research is needed to confirm that GOs can play a more leading role in performing extra-uterine procedures.
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Affiliation(s)
- Myeong-Seon Kim
- Department of Obstetrics and Gynecology, Chung-Ang University Gwangmyeong Hospital, College of Medicine Chung-Ang University, Seoul, Republic of Korea
| | - A Jin Lee
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Eun Bi Jang
- Department of Obstetrics and Gynecology, Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Nam Kyeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Min Kyung Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Jeeyeon Kim
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Joo-Hyuk Son
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Tae-Wook Kong
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Republic of Korea
| | - Dong Won Hwang
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Soo Jin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Geun Yoo
- Department of Obstetrics and Gynecology, Daejeon St Mary's Hospital, The Catholic University of Korea, Daejeon, Republic of Korea
| | - Sung Jong Lee
- Department of Obstetrics and Gynecology, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoo-Young Lee
- Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Pietschmann M, Jaeger A, Reuter S, Schmalfeldt B. The Impact of Upper Abdominal Surgery Regarding the Outcome of Patients with Advanced Ovarian Cancer. Geburtshilfe Frauenheilkd 2024; 84:866-875. [PMID: 39229631 PMCID: PMC11368464 DOI: 10.1055/a-2331-0900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/17/2024] [Indexed: 09/05/2024] Open
Abstract
Objective Residual tumor after cytoreductive surgery is the most important prognostic parameter for the outcome of patients with advanced ovarian cancer (5-year survival rate FIGO III 39%, FIGO IV 20%). As more than half of the patients suffer from upper abdominal tumor burden, surgery in this area is inevitable in order to achieve adequate cytoreduction. Our analysis focuses on the impact of upper abdominal interventions (UAI) regarding residual tumor and prognosis (OS, PFS). Methods A total of n = 261 patients with advanced primary ovarian cancer stage FIGO III and IV and radical cytoreductive surgery at the Gynecologic Cancer Center Hamburg-Eppendorf between 2014 and 2019 were analyzed in a retrospective study design and divided into two groups: one with UAI (n = 160) and one without UAI (n = 101). Results Patients with UAI showed significantly more often a residual tumor of less than 1 cm (R1) than patients without UAI and had a significantly longer OS (59 vs. 45 months [p = 0.041]). Deperitonealization of the diaphragm was the most common (144/160) and prognostically most relevant procedure for UAI. Especially the subgroup with FIGO IIIC stage seemed to benefit most from UAI. However, in multivariate analysis residual tumor burden was the strongest prognostic parameter for survival, followed by FIGO stage and UAI. Mortality was low within in the UAI group (0.6%). Conclusion UAI is an essential part of cytoreductive surgery in advanced ovarian cancer patients with tumor spread into the upper abdomen as it significantly prolongs survival. The procedure appears to be safe with low mortality. Achieving R1 rather than R2 due to radical surgery combined with UAI should be preferred compared to the early termination of the operation, as this has a significant impact on the prognosis of the patients.
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Affiliation(s)
| | - Anna Jaeger
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Reuter
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Schmalfeldt
- Department of Gynecology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Bianchi T, Grassi T, Bazzurini L, Testa F, Corti J, Pecis Cavagna G, Bombelli M, Lissoni AA, Di Martino G, Trezzi G, De Ponti E, Fruscio R, Landoni F. The paradigm shift in advanced ovarian cancer: Outcomes of extensive primary cytoreductive surgery. A single-center retrospective analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108523. [PMID: 38996586 DOI: 10.1016/j.ejso.2024.108523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 06/16/2024] [Accepted: 06/29/2024] [Indexed: 07/14/2024]
Abstract
OBJECTIVE The standard surgical treatment of advanced ovarian carcinoma is primary debulking surgery (PDS) aiming to complete cytoreduction. The need to achieve complete cytoreduction has shifted the surgical paradigm to more complex procedures, whose impact on morbidity is controversial. The objective of this retrospective analysis is to explore the impact of extensive PDS on morbidity and oncologic outcomes in a real-world scenario. METHODS A retrospective single-center analysis was performed on 137 patients with advanced high-grade ovarian carcinoma (HGOC) who received PDS in 2015-2020. Patients treated in 2015-2017 (Group 1) were compared to patients treated in 2018-2020 (Group 2). The two periods were chosen according to the higher complexity of surgical procedures introduced in 2018. RESULTS The increase in complete cytoreduction observed in Group2 (RD 0: 33 % vs 61 %, p = 0,008) was related to a higher surgical complexity (Aletti Score: 4 vs 6, p = 0,003) and did not reflect an increase in peri-operative complications (CCI: 20,9 vs 20,9, p = 0,11). After a median FUP of 44 months, PFS and OS at 24 months were 33,60 % vs 47,33 % (p = 0,288) and 72,10 % vs 80,37 % (p = 0,022) in Group 1 and 2, respectively. CONCLUSIONS An extensive surgical effort leads to a significant increase in complete cytoreduction with acceptable morbidity. Arm-in-arm with novel maintenance therapies, it contributes to increasing the outcomes of patients with advanced HGOC.
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Affiliation(s)
- Tommaso Bianchi
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Tommaso Grassi
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Luca Bazzurini
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Filippo Testa
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Jasmine Corti
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Giorgia Pecis Cavagna
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Martina Bombelli
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Andrea Alberto Lissoni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Giampaolo Di Martino
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Gaetano Trezzi
- Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Elena De Ponti
- Medical Physics, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Robert Fruscio
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy.
| | - Fabio Landoni
- Department of Medicine and Surgery, University of Milano-Bicocca, Milano, Italy; Clinic of Obstetrics and Gynecology, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
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Mohamed NE, Abdel Fattah NF, Seadawy MG, Lymona AM, Nasr SS, El Leithy AA, Abdelwahed FM, Nassar A. The clinical importance of IFN-γ and human epididymis protein 4 in Egyptian patients with epithelial ovarian cancer combined with HPV infection. Hum Immunol 2024; 85:111089. [PMID: 39173571 DOI: 10.1016/j.humimm.2024.111089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Revised: 08/13/2024] [Accepted: 08/14/2024] [Indexed: 08/24/2024]
Abstract
BACKGROUND High-grade Epithelial Ovarian Cancer (HGEOC) is an aggressive disease that usually presents at an advanced stage. Thus, detecting the circulating cytokines (IFNγ and TNF-α) may serve as a biomarker to identify malignancy and manage therapeutic decisions. OBJECTIVES Assessing the clinical importance of inflammatory mediators and tumor markers in EOC Egyptian patients compared with benign cases. Moreover, identifying the distinct inflammatory mediators in EOC patients combined with HPV infection. METHODS This study was conducted on 61 Egyptian patients, divided into 25 patients with HGEOC, 22 patients with LGEOC, and 14 benign ovarian tumor cases. Measurements of serum HE4, CA125, CEA, and CA19-9 were determined by Roche Elecsys immunoassays. Serum levels of TNF-α and IFN-γ were measured using quantitative sandwich ELISA. Quantitative genotyping of HPV DNA types 16, 18, and 45 was assessed for the HPV DNA-positive samples. RESULTS HPV DNA was detected in 25.53 % of malignant cases, HPV 16 was detected in 50 % of HPV-positive cases, and only 1 case of HPV 18 was detected out of 12 positive cases. The Human Epididymis protein 4 (HE4) was statistically different between patients with EOC and benign cases (p-value = 0.007) and between HPV DNA positive and HPV DNA negative cases (p-value = 0.008). The serum levels of IFN- γ were statistically different between HGEOC and LGEOC (p-value < 0.001), while the serum levels of TNF-α didn't differ statistically between the two groups. CONCLUSION IFN-γ could be used as a biomarker to discriminate HGEOC and LGEOC. Initial evidence for the possible association between HE4 and the progression of HPV-associated EOC was speculated.
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Affiliation(s)
- Nourhan E Mohamed
- Zoology Department, Faculty of Science, Cairo University, Cairo, Egypt
| | - Nasra F Abdel Fattah
- Virology and Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohamed G Seadawy
- Biodefense Center for Infectious and Emerging Diseases, Ministry of Defense, Cairo, Egypt
| | - Ahmed M Lymona
- Surgical Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Sarah S Nasr
- Cancer Epidemiology and Biostatistics Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Asmaa A El Leithy
- College of Biotechnology, Misr University for Science and Technology, Giza, Egypt
| | - Fatma M Abdelwahed
- Medical Biochemistry and Molecular Biology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Auhood Nassar
- Virology and Immunology Unit, Cancer Biology Department, National Cancer Institute, Cairo University, Cairo, Egypt.
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Ćwiertnia A, Borzyszkowska D, Golara A, Tuczyńska N, Kozłowski M, Poncyljusz W, Sompolska-Rzechuła A, Kotrych K, Cymbaluk-Płoska A. Ovarian Cancer Staging-How CT Scan Descriptions Differ from Surgical Findings. J Clin Med 2024; 13:4560. [PMID: 39124826 PMCID: PMC11312800 DOI: 10.3390/jcm13154560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Revised: 07/23/2024] [Accepted: 07/31/2024] [Indexed: 08/12/2024] Open
Abstract
Ovarian cancer is one of the most common causes of cancer death in women worldwide. Most often, it is detected in an advanced stage due to its insidious onset and lack of symptoms in stages I and II. That is why imaging diagnostics is so important. Therefore, we assessed the consistency of the image seen on CT with the actual image assessed during surgery. Objectives: The aim of this study is to compare preoperative evaluation based on CT reports with those obtained during ovarian cancer surgery to determine whether CT is helpful in assessing the possibility of optimal or complete cytoreduction. Methods: This retrospective study included patients diagnosed with ovarian cancer who underwent diagnostic laparoscopy or laparotomy with cytoreduction. We compared ovarian cancer lesions described by radiologists on CT scans to those described during laparoscopy or laparotomy; the Wilcoxon signed-rank test for paired observations was used to compare the variables. Results: We observed that the morphology of the tumor, mesenteric infiltration, and the assessment of the involvement of the abdominal, para-aortic, and iliac lymph nodes may differ in CT examination and during surgery. Conclusions: The site of the tumor exit on a CT scan does not always reflect the original site seen during surgery.
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Affiliation(s)
- Adrianna Ćwiertnia
- Department of Reconstructive Surgery and Gynecological Oncology, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (D.B.); (N.T.); (A.C.-P.)
| | - Dominika Borzyszkowska
- Department of Reconstructive Surgery and Gynecological Oncology, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (D.B.); (N.T.); (A.C.-P.)
| | - Anna Golara
- Department of Reconstructive Surgery and Gynecological Oncology, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (D.B.); (N.T.); (A.C.-P.)
| | - Natalia Tuczyńska
- Department of Reconstructive Surgery and Gynecological Oncology, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (D.B.); (N.T.); (A.C.-P.)
| | - Mateusz Kozłowski
- Department of Reconstructive Surgery and Gynecological Oncology, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (D.B.); (N.T.); (A.C.-P.)
| | - Wojciech Poncyljusz
- Department of Diagnostic Imaging and Interventional Radiology, University Clinical Hospital No. 1, Pomeranian Medical University in Szczecin, 71-252 Szczecin, Poland;
| | - Agnieszka Sompolska-Rzechuła
- Department of Applied Mathematics in Economics, Faculty of Economics, West Pomerania University of Technology Szczecin, Janickiego 31, 71-270 Szczecin, Poland;
| | - Katarzyna Kotrych
- Institute of X-ray Diagnostic and CT, USG and MRI Scanning Workroom, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, 70-204 Szczecin, Poland;
| | - Aneta Cymbaluk-Płoska
- Department of Reconstructive Surgery and Gynecological Oncology, University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Al. Powstańców Wielkopolskich 72, 70-111 Szczecin, Poland; (D.B.); (N.T.); (A.C.-P.)
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Lof P, van Soolingen NJ, Piek JMJ, Aarts JWM, Retèl VP, Bukman M, Smorenburg CH, van Driel WJ, Amant F, Trum JW, Lok CAR. Preferences and considerations for interval cytoreductive surgery in advanced ovarian cancer: The patient's perspective. Gynecol Oncol 2024; 187:227-234. [PMID: 38823307 DOI: 10.1016/j.ygyno.2024.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 05/05/2024] [Accepted: 05/16/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE Treatment of advanced-stage ovarian cancer contains cytoreductive surgery (CRS) and chemotherapy. Achieving successful CRS (≤ 1 cm residual disease) is prognostically important, but may not be feasible peri-operatively while still risking complications. Therefore, patients' treatment expectations are important to discuss. We investigated patient considerations for interval CRS. METHODS Patients with advanced-stage ovarian cancer planned for interval CRS completed a questionnaire about the impact of chance of successful CRS, survival benefit and becoming care-dependent on decision-making regarding CRS. The questionnaire included a vignette study, in which patients repeatedly chose between two treatment scenarios with varying levels for chance of successful CRS, survival benefit and risk of complications including stoma. Patient preferences were analyzed, including differences between patients aged < 70 and ≥ 70 years. RESULTS Among 85 included patients, 31 (37%) patients considered interval CRS worthwhile irrespective of survival benefit and 33 (39%) irrespective of chance of successful surgery. However, 34 patients (41%) considered interval CRS only worthwhile if survival benefit was > 12 months, while 41 (49%) thought so if chance of successful surgery was ≥ 25%. Older patients considered these factors more important. Overall, 27% considered becoming permanently dependent of home care unacceptable. In the vignette study (n = 72) risk of complications and stoma were considered less important than chance of successful CRS and survival benefit. CONCLUSION Survival benefit, chance of successful surgery and becoming care-dependent are important factors in patient's decision for interval CRS, while risk of complications and stoma are less important. Our results are useful in shared decision-making for interval CRS in ovarian cancer.
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Affiliation(s)
- Pien Lof
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Neeltje J van Soolingen
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Jurgen M J Piek
- Department of Obstetrics and Gynecology, Catharina Hospital, Catharina Cancer Institute, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Johanna W M Aarts
- Department of Obstetrics and Gynecology, Cancer Center Amsterdam, Amsterdam University Medical Centers, University of Amsterdam, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands
| | - Valesca P Retèl
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Department of Health Technology and Services Research, University of Twente, Hallenweg 5, 7522 NH Enschede, The Netherlands
| | - Maarten Bukman
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA Rotterdam, The Netherlands
| | - Carolina H Smorenburg
- Department of Medical Oncology, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Willemien J van Driel
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Frédéric Amant
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands; Division of Gynecologic Oncology, UZ Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Johannes W Trum
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Christianne A R Lok
- Department of Gynecologic Oncology, Center for Gynecologic Oncology Amsterdam, The Netherlands Cancer Institute, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Zhang Y, Yao W, Zhou J, Zhang L, Chen Y, Li F, Gu H, Wang H. Impact of surgical compliance on survival prognosis of patients with ovarian cancer and associated influencing factors: A propensity score matching analysis of the SEER database. Heliyon 2024; 10:e33639. [PMID: 39040330 PMCID: PMC11261776 DOI: 10.1016/j.heliyon.2024.e33639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 06/24/2024] [Accepted: 06/25/2024] [Indexed: 07/24/2024] Open
Abstract
Purpose To evaluate the impact of surgical compliance on overall survival (OS) and cancer-specific survival (CSS) in ovarian cancer patients and identify factors influencing surgical compliance. Materials and methods Data from patients with ovarian cancer in the SEER database (2004-2015) were analyzed to compare the characteristics of patients with high and low surgical compliance. Kaplan-Meier curves and Cox regression models were used to assess the impact of surgical compliance on survival outcomes. Nomograms incorporating surgical compliance and independent prognostic factors were constructed to predict OS and CSS and were validated using internal validation sets. Predictive accuracy was evaluated using Harrell's concordance index (C-index), decision curve analysis (DCA), receiver operating characteristic (ROC) curves, and calibration plots. Binary logistic regression analysis identified factors significantly affecting surgical compliance, and propensity score matching (PSM) was used to adjust for confounders. Results Among the 41,859 patients, 783 (1.87 %) demonstrated poor surgical compliance, while 41,076 (98.13 %) exhibited good compliance. Surgical compliance has emerged as an independent prognostic indicator for ovarian cancer. Patients with high compliance had significantly better OS and CSS rates (P < 0.0001). The prognostic models were internally validated and showed strong discriminative and calibration capabilities. Factors affecting compliance included older age, advanced pathological stage, metastasis, elevated CA-125 levels, and lower income. After PSM, Kaplan-Meier analysis revealed significantly improved survival in patients with good compliance (P < 0.0001). Conclusion Surgical compliance is a pivotal and independent predictor of overall and cancer-specific survival in patients undergoing OC. Factors contributing to lower surgical compliance include advanced age, later tumor stage, metastatic spread, elevated CA-125 levels, and reduced family income.
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Affiliation(s)
- Yanhua Zhang
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Wenlei Yao
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Jianbo Zhou
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Lingyan Zhang
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Yanhong Chen
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Fangfang Li
- Department of Oncology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Haidong Gu
- Department of Anesthetic, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
| | - Hongyou Wang
- Department of Obstetrics and Gynecology, Binhai County People's Hospital, Yancheng, 224500, Jiangsu, China
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Liu L, Zhang W, Wang Y, Wu J, Fan Q, Chen W, Zhou L, Li J, Li Y. Radiomics combined with clinical and MRI features may provide preoperative evaluation of suboptimal debulking surgery for serous ovarian carcinoma. Abdom Radiol (NY) 2024:10.1007/s00261-024-04343-3. [PMID: 39003651 DOI: 10.1007/s00261-024-04343-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/10/2024] [Accepted: 04/16/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE To develop and validate a model for predicting suboptimal debulking surgery (SDS) of serous ovarian carcinoma (SOC) using radiomics method, clinical and MRI features. METHODS 228 patients eligible from institution A (randomly divided into the training and internal validation cohorts) and 45 patients from institution B (external validation cohort) were collected and retrospectively analyzed. All patients underwent abdominal pelvic enhanced MRI scan, including T2-weighted imaging fat-suppressed fast spin-echo (T2FSE), T1-weighted dual-echo magnetic resonance imaging (T1DEI), diffusion weighted imaging (DWI), and T1 with contrast enhancement (T1CE). We extracted, selected and eliminated highly correlated radiomic features for each sequence. Then, Radiomic models were made by each single sequence, dual-sequence (T1CE + T2FSE), and all-sequence, respectively. Univariate and multivariate analyses were performed to screen the clinical and MRI independent predictors. The radiomic model with the highest area under the curve (AUC) was used to combine the independent predictors as a combined model. RESULTS The optimal radiomic model was based on dual sequences (T2FSE + T1CE) among the five radiomic models (AUC = 0.720, P < 0.05). Serum carbohydrate antigen 125, the relationship between sigmoid colon/rectum and ovarian mass or mass implanted in Douglas' pouch, diaphragm nodules, and peritoneum/mesentery nodules were considered independent predictors. The AUC of the radiomic-clinical-radiological model was higher than either the optimal radiomic model or the clinical-radiological model in the training cohort (AUC = 0.908 vs. 0.720/0.854). CONCLUSIONS The radiomic-clinical-radiological model has an overall algorithm reproducibility and may help create individualized treatment programs and improve the prognosis of patients with SOC.
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Affiliation(s)
- Li Liu
- Department of Radiology, The People's Hospital of Yubei District of Chongqing City, No. 23 ZhongyangGongyuanBei Road, Yubei District, Chongqing, 401120, China
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China
| | - Wenfei Zhang
- Department of Radiology, The People's Hospital of Yubei District of Chongqing City, No. 23 ZhongyangGongyuanBei Road, Yubei District, Chongqing, 401120, China
| | - Yudong Wang
- Institute of Clinical Algorithms, InferVision, Ocean International Center, Chaoyang District, Beijing, 100020, China
| | - Jiangfen Wu
- Institute of Clinical Algorithms, InferVision, Ocean International Center, Chaoyang District, Beijing, 100020, China
| | - Qianrui Fan
- Institute of Clinical Algorithms, InferVision, Ocean International Center, Chaoyang District, Beijing, 100020, China
| | - Weidao Chen
- Institute of Clinical Algorithms, InferVision, Ocean International Center, Chaoyang District, Beijing, 100020, China
| | - Linyi Zhou
- Department of Radiology, Daping Hospital, Army Medical Center, Army Medical University, 10# Changjiangzhilu, Chongqing, 40024, China
| | - Juncai Li
- Department of Surgery, The People's Hospital of Yubei District of Chongqing City, No. 23 ZhongyangGongyuanBei Road, Yubei District, Chongqing, 401120, China.
| | - Yongmei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Yuanjiagang, Yuzhong District, Chongqing, 400016, China.
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10
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Kahn RM, Boerner T, Kim M, Lam C, Gordhandas S, Yeoshoua E, Zhou QC, Iasonos A, Al-Niaimi A, Gardner GJ, Long Roche K, Sonoda Y, Zivanovic O, Grisham RN, Abu-Rustum NR, Chi DS. A pre-operative scoring model to estimate the risk of blood transfusion over an ovarian cancer debulking surgery (BLOODS score): a Memorial Sloan Kettering Cancer Center Team Ovary study. Int J Gynecol Cancer 2024; 34:1051-1059. [PMID: 38950927 PMCID: PMC11237961 DOI: 10.1136/ijgc-2024-005660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024] Open
Abstract
OBJECTIVES To develop a pre-operative tool to estimate the risk of peri-operative packed red blood cell transfusion in primary debulking surgery. METHODS We retrospectively reviewed an institutional database to identify patients who underwent primary debulking surgery for ovarian cancer at a single center between January 1, 2001 and May 31, 2019. Receiver operating characteristic curve and area under the receiver operating characteristic curve (AUC) were calculated. Five-fold cross-validation was applied to the multivariate model. Significant variables were assigned a 'BLOODS' (BLood transfusion Over an Ovarian cancer Debulking Surgery) score of +1 if present. A total BLOODS score was calculated for each patient, and the odds of receiving a transfusion was determined for each score. RESULTS Overall, 1566 patients met eligibility criteria; 800 (51%) underwent a peri-operative blood transfusion. Odds ratios (OR) were statistically significant for American Society of Anesthesiologists scores of 3 and 4 (OR 1.34, 95% confidence interval (95% CI) 1.09 to 1.63), pre-operative levels of cancer antigen 125 (CA125) (OR 2.43, 95% CI 1.98 to 2.99), platelets (OR 1.59, 95% CI 1.45 to 1.74), obesity (OR 0.76, 95% CI 0.60 to 0.96), presence of carcinomatosis (OR 2.45, 95% CI 1.93 to 3.11), bulky upper abdominal disease (OR 2.86, 95% CI 2.32 to 3.54), pre-operative serum albumin level (OR 0.31, 95% CI 0.24 to 0.40), and pre-operative hemoglobin level (OR 0.56, 95% CI 0.51 to 0.61). The corrected AUC was 0.748 (95% CI 0.693 to 0.804). BLOODS scores of 0 and 5 corresponded to 11% and 73% odds, respectively, of receiving a peri-operative blood transfusion. CONCLUSIONS We developed a universal pre-operative scoring system, the BLOODS score, to help identify patients with ovarian cancer who would benefit from surgical planning and blood-saving techniques. The BLOODS score was directly proportional to the American Society of Anesthesiologists score, presence of upper abdominal disease, carcinomatosis, CA125 level, and platelets level. We believe this model can help physicians with surgical planning and can benefit patient outcomes.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Michael Kim
- Department of Obstetrics and Gynecology, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, New York, USA
| | - Clarissa Lam
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Sushmita Gordhandas
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Qin C Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Ahmed Al-Niaimi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Rachel N Grisham
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, New York, USA
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11
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Chen Y, Sun Z, Cai S, Hu Y, Jiang R, Xiang L, Zang R. Supragastric lesser sac: an insidious site for surgical exploration during the debulking surgery in advanced ovarian cancer. J Gynecol Oncol 2024; 35:e25. [PMID: 38130134 PMCID: PMC11107271 DOI: 10.3802/jgo.2024.35.e25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 09/08/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023] Open
Abstract
OBJECTIVE Metastases in the supragastric lesser sac (SGLS) are not only occult but are also barriers to complete resection of ovarian cancer. We describe a cohort of patients with SGLS disease undergoing debulking surgery. METHODS We identified all patients who underwent evaluation and eventual resection of SGLS disease as part of cytoreductive surgery for stage IIIC-IVB high-grade epithelial ovarian cancer at our institution from January 2018 to August 2022. RESULTS Thirty-three of 286 patients (11.5%) underwent resection of SGLS disease. Metastases in the SGLS were identified by preoperative imaging in 4 of 33 patients (12.1%). The median peritoneal cancer index score was 22 (range, 9-33). Through surgical exploration, metastases were frequently seen in the right diaphragm (100%), hepatorenal recess (97%), lesser omentum (81.8%), left diaphragm (78.8%), supracolic omentum (75.8%), anterior transverse mesocolon (72.7%), splenic hilum (63.6%), ligamentum teres hepatis (60.6%), and gallbladder fossa (51.5%). The lesser omentum was normal in 6 of 33 (18.2%) patients, despite metastases within the SGLS. A total of 54.5% of patients underwent complex surgery (surgical complexity scores; median, 8; range, 3-14). Complete resections were achieved in 19 (57.6%) patients. No complications were related to the resection of SGLS disease. The median length of progression-free survival was 24.8 months (95% confidence interval=16.6-32.9). CONCLUSION Metastases to the SGLS are not uncommon in advanced ovarian cancer, particularly those with widely disseminated disease. Disease in this recess is rarely identified by preoperative imaging and deserves systematic surgical exploration to attain complete cytoreduction.
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Affiliation(s)
- Yulian Chen
- Ovarian Cancer Program, Department of Gynecologic Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhuozhen Sun
- Ovarian Cancer Program, Department of Gynecologic Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Songqi Cai
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yan Hu
- Department of Nuclear Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rong Jiang
- Ovarian Cancer Program, Department of Gynecologic Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Libing Xiang
- Ovarian Cancer Program, Department of Gynecologic Oncology, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Rongyu Zang
- Ovarian Cancer Program, Department of Gynecologic Oncology, Zhongshan Hospital, Fudan University, Shanghai, China
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12
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Chase DM, Mahajan A, Scott DA, Hawkins N, Kalilani L. The impact of varying levels of residual disease following cytoreductive surgery on survival outcomes in patients with ovarian cancer: a meta-analysis. BMC Womens Health 2024; 24:179. [PMID: 38491366 PMCID: PMC10941390 DOI: 10.1186/s12905-024-02977-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 02/17/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Residual disease following cytoreductive surgery in patients with ovarian cancer has been associated with poorer survival outcomes compared with no residual disease. We performed a meta-analysis to assess the impact of varying levels of residual disease status on survival outcomes in patients with ovarian cancer who have undergone primary cytoreductive surgery or interval cytoreductive surgery in the setting of new therapies for this disease. METHODS Medline, Embase, and Cochrane databases (January 2011 - July 2020) and grey literature, bibliographic and key conference proceedings, were searched for eligible studies. Fixed and random-effects meta-analyses compared progression and survival by residual disease level across studies. Heterogeneity between comparisons was explored via type of surgery, disease stage, and type of adjuvant chemotherapy. RESULTS Of 2832 database and 16 supplementary search articles screened, 50 studies were selected; most were observational studies. The meta-analysis showed that median progression-free survival and overall survival decreased progressively with increasing residual disease (residual disease categories of 0 cm, > 0-1 cm and > 1 cm). Compared with no residual disease, hazard ratios (HR) for disease progression increased with increasing residual disease category (1.75 [95% confidence interval: 1.42, 2.16] for residual disease > 0-1 cm and 2.14 [1.34, 3.39] for residual disease > 1 cm), and also for reduced survival (HR versus no residual disease, 1.75 [ 1.62, 1.90] for residual disease > 0-1 cm and 2.32 [1.97, 2.72] for residual disease > 1 cm). All comparisons were significant (p < 0.05). Subgroup analyses showed an association between residual disease and disease progression/reduced survival irrespective of type of surgery, disease stage, or type of adjuvant chemotherapy. CONCLUSIONS This meta-analysis provided an update on the impact of residual disease following primary or interval cytoreductive surgery, and demonstrated that residual disease was still highly predictive of progression-free survival and overall survival in adults with ovarian cancer despite changes in ovarian cancer therapy over the last decade. Higher numerical categories of residual disease were associated with reduced survival than lower categories.
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Affiliation(s)
- Dana M Chase
- David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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13
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Xu X, Chen Y, Zhang X, Wang Y. Association between the quantitative characteristics of dual-energy spectral CT and cytoreduction surgery outcome in patients with advanced epithelial ovarian cancers: A prospective observational study. Medicine (Baltimore) 2024; 103:e37437. [PMID: 38457565 PMCID: PMC10919493 DOI: 10.1097/md.0000000000037437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/06/2024] [Accepted: 02/08/2024] [Indexed: 03/10/2024] Open
Abstract
This study aimed to explore the association between the quantitative characteristics of dual-energy spectral CT and cytoreduction surgery outcome in patients with advanced epithelial ovarian carcinoma (EOC). In this prospective observational study, patients with advanced EOC (federation of gynecology and obstetrics stage III-IV) treated in the Department of Gynecological Oncology at our Hospital between June 2021 and March 2022 were enrolled. All participants underwent dual-energy spectral computed tomography (DECT) scanning 2 weeks before cytoreductive surgery. The quantitative data included peritoneal cancer index (PCI) determined by DECT, CT value at 70 keV, normalized iodine concentration, normalized water concentration, effective atomic number (effective-Z), and slopes of the spectral attenuation curves (slope λ Hounsfield unit). Fifty-five participants were included. The patients were 57.2 ± 9.8 years of age, and 72.7% were menopausal. The maximal diameter of tumors was 8.6 (range, 2.9-19.7) cm, and 76.4% were high-grade serous carcinomas. Optimal cytoreduction was achieved in 43 patients (78.2%). Compared with the optimal cytoreductive group, the suboptimal cytoreductive group showed a higher PCI (median, 21 vs 6, P < .001), higher 70 keV CT value (69.5 ± 16.6 vs 57.1 ± 13.0, P = .008), and higher slope λ Hounsfield unit (1.89 ± 0.66 vs 1.39 ± 0.60, P = .015). The multivariable analysis showed that the PCI (OR = 1.74, 95%CI: 1.24-2.44, P = .001) and 70 keV CT value (OR = 1.07, 95%CI: 1.01-1.13, P = .023) were independently associated with a suboptimal cytoreductive surgery. The area under the receiver operating characteristics curve of PCI and 70 keV CT value was 0.903 (95%CI: 0.805-1.000, P = .000) and 0.740 (95%CI: 0.581-0.899, P = .012), respectively. High PCI and 70 keV CT value are independently associated with suboptimal cytoreductive surgery in patients with advanced EOC. The PCI determined by DECT might be a better predictor for suboptimal cytoreduction.
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Affiliation(s)
- Xiaojuan Xu
- Department of Diagnostic Imaging, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan Chen
- Department of Diagnostic Imaging, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinxin Zhang
- Department of Diagnostic Imaging, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yilin Wang
- Department of Diagnostic Imaging, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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14
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Kahn RM, Chang SJ, Chi DS. Extra-abdominal cytoreductive techniques in ovarian cancer: how far can (should) we go? Int J Gynecol Cancer 2024; 34:379-385. [PMID: 38438179 DOI: 10.1136/ijgc-2023-004630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024] Open
Abstract
Complex surgery is an essential component in the management of advanced ovarian cancer. Furthermore, achieving complete gross resection in cytoreductive surgery appears to be associated with significant survival benefits in patients with advanced ovarian cancer. The goal of this review is to demonstrate the advancement of surgical techniques in gynecologic oncology surgery, including resection of disease within the intrathoracic and inguinal regions. This progress has expanded the option of surgery to more patients, especially those who would have previously been deemed inoperable. In this review we describe the most notable studies and reports of surgical resection of ovarian cancer involving cardiophrenic/supradiaphragmatic lymph nodes, mediastinum, lung pleura or parenchyma, and the inguinal region. We also describe the growing role that video-assisted thoracic surgery has played in advanced ovarian cancer diagnosis and management. The studies, series, and reports described demonstrate that comprehensive surgical procedures outside of the abdomen or pelvis can be both safe and feasible in properly selected patients. They also suggest that resection of disease outside of the abdomen or pelvis may benefit appropriately selected patients. Future studies are necessary to identify which patients may benefit most from upfront surgery versus neoadjuvant chemotherapy when ovarian cancer metastasis is present in the thoracic or inguinal regions.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Suk-Joon Chang
- Obstetrics and Gynecology, Ajou University School of Medicine, Suwon, Korea (the Republic of)
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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15
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Kahn RM, Ma X, Gordhandas S, Yeoshoua E, Ellis RJ, Zhang X, Aviki EM, Abu-Rustum NR, Gardner GJ, Sonoda Y, Zivanovic O, Long Roche K, Jewell E, Boerner T, Chi DS. Regionalizing ovarian cancer cytoreduction to high-volume centers and the impact on patient travel in New York State. Gynecol Oncol 2024; 182:141-147. [PMID: 38262237 PMCID: PMC10960664 DOI: 10.1016/j.ygyno.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/29/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE To evaluate the theoretical impact of regionalizing cytoreductive surgery for ovarian cancer (OC) to high-volume facilities on patient travel. METHODS We retrospectively identified patients with OC who underwent cytoreduction between 1/1/2004-12/31/2018 from the New York State Cancer Registry and Statewide Planning and Research Cooperative System. Hospitals were stratified by low-volume (<21 cytoreductive surgical procedures for OC annually) and high-volume centers (≥21 procedures annually). A simulation was performed; outcomes of interest were driving distance and time between the centroid of the patient's residence zip code and the treating facility zip code. RESULTS Overall, 60,493 patients met inclusion criteria. Between 2004 and 2018, 210 facilities were performing cytoreductive surgery for OC in New York; 159 facilities (75.7%) met low-volume and 51 (24.3%) met high-volume criteria. Overall, 10,514 patients (17.4%) were treated at low-volume and 49,979 (82.6%) at high-volume facilities. In 2004, 78.2% of patients were treated at high-volume facilities, which increased to 84.6% in 2018 (P < .0001). Median travel distance and time for patients treated at high-volume centers was 12.2 miles (IQR, 5.6-25.5) and 23.0 min (IQR, 15.2-37.0), and 8.2 miles (IQR, 3.7-15.9) and 16.8 min (IQR, 12.4-26.0) for patients treated at low-volume centers. If cytoreductive surgery was centralized to high-volume centers, median distance and time traveled for patients originally treated at low-volume centers would be 11.2 miles (IQR, 3.8-32.3; P < .001) and 20.2 min (IQR, 13.6-43.0; P < .001). CONCLUSIONS Centralizing cytoreductive surgery for OC to high-volume centers in New York would increase patient travel burden by negligible amounts of distance and time for most patients.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiaoyue Ma
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Sushmita Gordhandas
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ryan J Ellis
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Xiuling Zhang
- New York State Cancer Registry, New York State Department of Health, Albany, NY, USA
| | - Emeline M Aviki
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Elizabeth Jewell
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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16
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Ghirardi V, Trozzi R, Scambia G, Fagotti A. Current and future trials about HIPEC in ovarian cancer. Bull Cancer 2024; 111:254-260. [PMID: 36863924 DOI: 10.1016/j.bulcan.2023.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/16/2022] [Accepted: 01/25/2023] [Indexed: 03/04/2023]
Abstract
Due to the typical peritoneal spread of the disease, together with cytoreductive surgery and adjuvant platinum-based chemotherapy, the role of hyperthermic intraperitoneal chemotherapy (HIPEC) is gainig more interest in advanced ovarian cancer (AOC) treatment. Indeed, the addition of hyperthemia seems to enhance the cytotoxic effect of chemotherapy directly delivered on peritoneal surface. So far, data on HIPEC administration during the primary debulking surgery (PDS) have been controversial. Indeed, despite flaws and biases, a survival advantage in a subgroup analysis of a prospective randomized trial of PDS+HIPEC treated patients was not demonstrated, whilst positive results are coming from a large retrospective cohort of patients treated with HIPEC after upfront surgery. In this setting, larger prospective data from an ongoing trial are expected by 2026. Contrariously, the addition of HIPEC with cisplatin 100mg/m2 at the time of interval debulking surgery (IDS) has shown to prolong both progression-free and overall survival by prospective randomized data, despite few controversies on the methodology and the results of this trial arose among the experts. So far, available high quality data on HIPEC treatment after surgery for disease recurrence failed to demonstrate a survival benefit in this group of patients, however few trials are ongoing and results are awaited. With this article, we aim to discuss the main findings of available evidence and the objectives of ongoing trials on the addition of HIPEC to various timing of cytoreductive surgery in AOC, also in view of the development of precision medicine and targeted therapies in AOC treatment.
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Affiliation(s)
- Valentina Ghirardi
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy.
| | - Rita Trozzi
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Giovanni Scambia
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
| | - Anna Fagotti
- Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli - IRCCS, Universita' Cattolica del Sacro Cuore, Rome, Italy
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Meurette J, Daraï E, Tajahmady A, Fouard A, Ducastel A, Collin-Bund V, Jochum F, Lecointre L, Querleu D, Akladios C. [Arguments for centralization of surgical treatment of ovarian cancer in France based on morbidity and mortality data]. Bull Cancer 2024; 111:239-247. [PMID: 36797128 DOI: 10.1016/j.bulcan.2022.12.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 02/16/2023]
Abstract
OBJECTIVE To examine the current state for ovarian cancer surgery in France from 2009 to 2016 and to examine the impact of the volume of activity on morbidity and mortality by institution. MATERIAL AND METHOD National retrospective study analyzing surgical sessions for ovarian cancer from the program of medicalization of information systems (PMSI), from January 2009 to December 2016. Institutions were divided according to the number of annual curative procedures into 3 groups: A<10; B: 10-19; C≥20. A propensity score (PS) and the Kaplan-Meier method were employed for statistical analyses. RESULTS In total, 27,105 patients were included. The 1-month mortality rate in group A, B and C was 1.6; 1 and 0.7 %, respectively (P<0.001). Compared to group C, the Relative Risk (RR) of death within the first month was 2.22 for group A and 1.32 for group B (P<0.01). After MS, the 3- and 5-year survival in group A+B and group C were 71.4 and 60.3% (P<0.05) and 56.6, and 60.3% (P<0.05), respectively. The 1-year recurrence rate was significantly lower in group C (P<0.0001). CONCLUSION An annual volume of activity>20 advanced stage ovarian cancers is associated with a decrease in morbidity, mortality, recurrence rate and improved survival.
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Affiliation(s)
- Jacques Meurette
- Caisse nationale d'assurance maladie, 50, avenue du Pr André-Lemierre, 93170 Paris, France
| | - Emile Daraï
- Hôpital Tenon, service de gynécologie-obstétrique, Paris, France
| | - Ayden Tajahmady
- Caisse nationale d'assurance maladie, 50, avenue du Pr André-Lemierre, 93170 Paris, France
| | - Annie Fouard
- Caisse nationale d'assurance maladie, 50, avenue du Pr André-Lemierre, 93170 Paris, France
| | - Anne Ducastel
- Caisse nationale d'assurance maladie, 50, avenue du Pr André-Lemierre, 93170 Paris, France
| | - Virginie Collin-Bund
- Hôpitaux universitaires de Strasbourg, service de gynécologie-obstétrique, Strasbourg, France
| | - Floriane Jochum
- Hôpitaux universitaires de Strasbourg, service de gynécologie-obstétrique, Strasbourg, France
| | - Lise Lecointre
- Hôpitaux universitaires de Strasbourg, service de gynécologie-obstétrique, Strasbourg, France
| | - Denis Querleu
- Hôpitaux universitaires de Strasbourg, service de gynécologie-obstétrique, Strasbourg, France
| | - Chérif Akladios
- Hôpitaux universitaires de Strasbourg, service de gynécologie-obstétrique, Strasbourg, France.
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18
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Jia Y, Jiang Y, Fan X, Zhang Y, Li K, Wang H, Ning X, Yang X. Preoperative serum level of CA153 and a new model to predict the sub-optimal primary debulking surgery in patients with advanced epithelial ovarian cancer. World J Surg Oncol 2024; 22:64. [PMID: 38395933 PMCID: PMC10885626 DOI: 10.1186/s12957-024-03336-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
OBJECTIVE The aim of this study was to establish a preoperative model to predict the outcome of primary debulking surgery (PDS) for advanced ovarian cancer (AOC) patients by combing Suidan predictive model with HE4, CA125, CA153 and ROMA index. METHODS 76 AOC Patients in revised 2014 International Federation of Gynecology and Obstetrics (FIGO) stage III-IV who underwent PDS between 2017 and 2019 from Yunnan Cancer Hospital were included. Clinical data including the levels of preoperative serum HE4, CA125, CA153 and mid-lower abdominal CT-enhanced scan results were collected. The logistics regression analysis was performed to find factors associated with sub-optimal debulking surgery (SDS). The receiver operating characteristic curve was used to evaluate the predictive performances of selected variables in the outcome of primary debulking surgery. The predictive index value (PIV) model was constructed to predict the outcome of SDS. RESULTS Optimal surgical cytoreduction was achieved in 61.84% (47/76) patients. The value for CA125, HE4, CA153, ROMA index and Suidan score was lower in optimal debulking surgery (ODS) group than SDS group. Based on the Youden index, which is widely used for evaluating the performance of predictive models, the best cutoff point for the preoperative serum HE4, CA125, CA153, ROMA index and Suidan score to distinguish SDS were 431.55 pmol/l, 2277 KU/L, 57.19 KU/L, 97.525% and 2.5, respectively. Patients with PIV≥5 may not be able to achieve optimal surgical cytoreduction. The diagnostic accuracy, NPV, PPV and specificity for diagnosing SDS were 73.7%, 82.9%, 62.9% and 72.3%, respectively. In the constructed model, the AUC of the SDS prediction was 0.770 (95% confidence interval: 0.654-0.887), P<0.001. CONCLUSION Preoperative serum CA153 level is an important non-invasive predictor of primary SDS in advanced AOC, which has not been reported before. The constructed PIV model based on Suidan's predictive model plus HE4, CA125, CA153 and ROMA index can noninvasively predict SDS in AOC patients, the accuracy of this prediction model still needs to be validated in future studies.
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Affiliation(s)
- Yue Jia
- Department of Gynecology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, Yunnan, P. R. China, 650118
| | - Yaping Jiang
- Department of Gynecology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, Yunnan, P. R. China, 650118
| | - Xiaoqi Fan
- Department of Gynecology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, Yunnan, P. R. China, 650118
| | - Ya Zhang
- Department of Radiology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Yunnan Cancer Center, Kunming, Yunnan, P. R. China, 650118
| | - Kun Li
- Department of Radiology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Yunnan Cancer Center, Kunming, Yunnan, P. R. China, 650118
| | - Haohan Wang
- Department of Gynecology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, Yunnan, P. R. China, 650118
| | - Xianling Ning
- Department of Gynecology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, Yunnan, P. R. China, 650118
| | - Xielan Yang
- Department of Gynecology, The Third Affiliated Hospital of Kunming Medical University, Yunnan Cancer Hospital, Kunming, Yunnan, P. R. China, 650118.
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19
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Wang J, Wang X, Yin W, Zhang S. Survival impact and safety of intrathoracic and abdominopelvic cytoreductive surgery in advanced ovarian cancer: a systematic review and meta-analysis. Front Oncol 2024; 14:1335883. [PMID: 38304874 PMCID: PMC10830636 DOI: 10.3389/fonc.2024.1335883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 01/02/2024] [Indexed: 02/03/2024] Open
Abstract
Purpose Achieving no residual disease is essential for increasing overall survival (OS) and progression-free survival (PFS) in ovarian cancer patients. However, the survival benefit of achieving no residual disease during both intrathoracic and abdominopelvic cytoreductive surgery is still unclear. This meta-analysis aimed to assess the survival benefit and safety of intrathoracic and abdominopelvic cytoreductive surgery in advanced ovarian cancer patients. Methods We systematically searched for studies in online databases, including PubMed, Embase, and Web of Science. We used Q statistics and I-squared statistics to evaluate heterogeneity, sensitivity analysis to test the origin of heterogeneity, and Egger's and Begg's tests to evaluate publication bias. Results We included 4 retrospective cohort studies, including 490 patients, for analysis; these studies were assessed as high-quality studies. The combined hazard ratio (HR) with 95% confidence interval (CI) for OS was 1.92 (95% CI 1.38-2.68), while the combined HR for PFS was 1.91 (95% CI 1.47-2.49). Only 19 patients in the four studies reported major complications, and 4 of these complications were surgery related. Conclusion The maximal extent of cytoreduction in the intrathoracic and abdominopelvic tract improves survival outcomes, including OS and PFS, in advanced ovarian cancer patients with acceptable complications. Systematic Review Registration PROSPERO, identifier CRD42023468096.
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Affiliation(s)
- Jiaxi Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Xingyu Wang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
| | - Wanjun Yin
- Weifang Medical University, Weifang, China
| | - Shiqian Zhang
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, China
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20
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Agusti N, Bonaldo G, Kahn RM, Rosati A, Nachira D, Pan TL, Mburu A, Kochiashvili G, Paredes P, Hsu HC, Davies-Oliveira J, Ramirez PT. Cardiophrenic lymph nodes in advanced ovarian cancer. Int J Gynecol Cancer 2024; 34:150-158. [PMID: 38097346 DOI: 10.1136/ijgc-2023-004963] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2024] Open
Abstract
Epithelial ovarian cancer most commonly presents at advanced stages, and prognosis is influenced by residual disease following cytoreduction. The significance of cardiophrenic lymph node resection at the time of cytoreductive surgery in advanced ovarian cancer remains a topic of debate. Enlarged cardiophrenic lymph nodes are detected through high-resolution imaging; however, the optimal imaging technique in determining feasibility of node resection remains uncertain. Similarly, the impact of excision of cardiophrenic lymph nodes on progression-free and overall survival remains elusive. The indications for resection of cardiophrenic lymph nodes are not addressed in standard ovarian cancer guidelines. Patients with cardiophrenic lymph nodes exceeding 1 cm in size may be considered for resection if complete intra-abdominal cytoreduction is feasible to no gross residual. The surgical approach might be either by open access or by video-assisted thoracoscopic surgery (minimally invasive approach), and major complications following cardiophrenic lymph nodes resection are low. Pathological cardiophrenic lymph nodes are associated with a poorer overall prognosis and can serve as a prognostic parameter; however, the therapeutic benefit of cardiophrenic lymph nodes resection remains inconclusive.
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Affiliation(s)
- Nuria Agusti
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Giulio Bonaldo
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padova, Padova, Italy
| | - Ryan M Kahn
- Department of Obstetrics & Gynecology, Weill Cornell Medicine, New York, New York, USA
| | - Andrea Rosati
- Dipartimento per la salute della Donna e del Bambino e di Sanita Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Dania Nachira
- Department of General Thoracic Surgery, Fondazione Policlinico Universitario "A.Gemelli", IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Teresa L Pan
- Department of Obstetrics and Gynecology, Medical University Innsbruck, Innsbruck, Austria
| | - Anisa Mburu
- Department of Gynecology and Obstetrics, Aga Khan Hospital Mombasa, Mombasa, Kenya
| | - Gvantsa Kochiashvili
- Department of Gynecologic Oncology, Caucasus Medical Centre, Tbilisi, Georgia
- Department of Surgery, David Tvildiani Medical University, Tbilisi, Georgia
| | - Pilar Paredes
- Department of Nuclear Medicine, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Heng-Cheng Hsu
- Department of Obstetrics and Gynecology, National Taiwan University Hospital Hsin-Chu Branch, Hsinchu, Taiwan
| | | | - Pedro T Ramirez
- Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas, USA
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21
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Andreou M, Kyprianidou M, Cortas C, Polycarpou I, Papamichael D, Kountourakis P, Giannakou K. Prognostic Factors Influencing Survival in Ovarian Cancer Patients: A 10-Year Retrospective Study. Cancers (Basel) 2023; 15:5710. [PMID: 38136256 PMCID: PMC10742060 DOI: 10.3390/cancers15245710] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 12/24/2023] Open
Abstract
OBJECTIVE To analyze the factors associated with overall survival (OS) and progression-free survival (PFS) in patients with ovarian cancer in Cyprus. METHODS We retrospectively analyzed data from patients with histologically confirmed epithelial ovarian cancer (EOC) and primary peritoneal cancer (PPC). RESULTS A total of 106 women diagnosed with ovarian cancer were included, with a median age at diagnosis of 58 years. The Kaplan-Meier survival analysis showed a median OS of 41 months (95% C.I = 36.9, 45.1), and the FIGO stage (p < 0.001), type of surgery (p < 0.001) and performance status (p < 0.001) were identified as statistically significant prognostic factors for OS. PFS analysis revealed the FIGO stage (p = 0.006) and the performance status (p < 0.001) as significant prognostic factors. Additionally, a Cox regression analysis for median OS was performed for patients with high-grade serous carcinoma, identifying the performance status, FIGO stage, and type of surgery as prognostic factors in univariate analysis. However, in the subsequent multivariate analysis, the performance status and the FIGO stage were confirmed to be the only statistically significant prognostic factors for OS (p < 0.05). CONCLUSIONS This study confirms that the FIGO stage, performance status, and surgery type were considered as prognostic factors for OS in ovarian cancer.
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Affiliation(s)
- Maria Andreou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia 1516, Cyprus; (M.A.); (M.K.); (I.P.)
| | - Maria Kyprianidou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia 1516, Cyprus; (M.A.); (M.K.); (I.P.)
| | - Christos Cortas
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, Nicosia 2006, Cyprus; (C.C.); (D.P.); (P.K.)
| | - Irene Polycarpou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia 1516, Cyprus; (M.A.); (M.K.); (I.P.)
| | - Demetris Papamichael
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, Nicosia 2006, Cyprus; (C.C.); (D.P.); (P.K.)
| | - Panteleimon Kountourakis
- Department of Medical Oncology, Bank of Cyprus Oncology Centre, Nicosia 2006, Cyprus; (C.C.); (D.P.); (P.K.)
- Department of Medical Oncology, Mediterranean Hospital of Cyprus, Limassol 3117, Cyprus
| | - Konstantinos Giannakou
- Department of Health Sciences, School of Sciences, European University Cyprus, Nicosia 1516, Cyprus; (M.A.); (M.K.); (I.P.)
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22
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Polan RM, Slota JM, Barber EL. Postoperative complications in women with ovarian cancer stratified by cytoreductive surgery outcome. J Surg Oncol 2023; 128:891-901. [PMID: 37382209 PMCID: PMC10529113 DOI: 10.1002/jso.27380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To compare 30-day postoperative complications for patients with advanced ovarian cancer who underwent resection to no gross residual disease versus optimal and suboptimal cytoreduction. METHODS A retrospective cohort study of women drawn from the National Surgical Quality Improvement Program who underwent cytoreductive surgery for advanced ovarian cancer between 2014 and 2019 was performed. Exposure of interest was extent of surgical resection defined as no gross residual disease; residual disease <1 cm (optimal); and residual disease >1 cm (suboptimal). Primary outcome was postoperative complication. Associations were examined with bivariable tests and multivariable logistic regression. RESULTS A total of 2248 women underwent cytoreductive surgery; 68.4% (n = 1538) underwent resection to no gross residual disease, 22.4% (n = 504) had an optimal, and 9.2% (n = 206) had a suboptimal cytoreduction. Optimal cytoreduction patients had the highest rates of any postoperative complication (35.5%, p < 0.001). They also had the longest operative times and procedures that were most surgically complex (203 min, 43.6 relative value units, both p < 0.05). However, patients who underwent optimal cytoreduction did not have increased odds of major complications (adjusted odds ratio: 1.20, 95% confidence interval: 0.91-1.58). CONCLUSION Patients who underwent optimal cytoreduction had more postoperative complications, required the most operating room time, and represented more complex surgeries compared with suboptimal cytoreduction or resection to no gross residual disease.
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Affiliation(s)
- Rosa M Polan
- Division of Gynecology Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Jennifer M Slota
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University, Chicago, Illinois, USA
| | - Emma L Barber
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University, Chicago, Illinois, USA
- Department of Oncology, Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
- Department of Gynecology, Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, Illinois, USA
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23
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Betts LJ, Johnson K, Bassette E, Slife C, Khandalavala J. Bilateral Ovarian Torsion Due to a Giant Mucinous Cystadenoma, Contralateral Mature Teratoma, and Paratubal Cyst in a Young Adult. Cureus 2023; 15:e44913. [PMID: 37814767 PMCID: PMC10560543 DOI: 10.7759/cureus.44913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2023] [Indexed: 10/11/2023] Open
Abstract
Giant ovarian cysts (>10 cm) are rare due to the widespread use of routine imaging. However, in the absence of compressive symptoms, giant cysts remain a diagnostic challenge, especially in patients with larger body habitus. Complications of benign ovarian cysts are infrequent but can include torsion of the adnexa. Bilateral torsion is a rare emergency that can threaten a patient's future fertility. In this case, we report on a 24-year-old female with bilateral torsion due to a triad of adnexal masses including a 30 cm mucinous cystadenoma, a 10 cm mature teratoma, and an 8 cm paratubal cyst. Controlled fluid aspiration was performed prior to en bloc resection of the cystadenoma due to the emergent nature of the case and lack of malignant features.
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Affiliation(s)
- Lucas J Betts
- Radiology, Creighton University School of Medicine, Omaha, USA
| | - Kalley Johnson
- Plastic Surgery, Creighton University School of Medicine, Omaha, USA
| | - Emma Bassette
- Obstetrics and Gynecology, Creighton University School of Medicine, Omaha, USA
| | - Cameron Slife
- Obstetrics and Gynecology, Creighton University School of Medicine, Omaha, USA
| | - Jimmy Khandalavala
- Obstetrics and Gynecology, Creighton University School of Medicine, Omaha, USA
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24
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Generali M, Annunziata G, Pirillo D, D’Ippolito G, Ciarlini G, Aguzzoli L, Mandato VD. The role of minimally invasive surgery in epithelial ovarian cancer treatment: a narrative review. Front Med (Lausanne) 2023; 10:1196496. [PMID: 37387787 PMCID: PMC10301737 DOI: 10.3389/fmed.2023.1196496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/23/2023] [Indexed: 07/01/2023] Open
Abstract
Objectives The aim of this narrative review is to summarize the available evidence on the use of minimal invasive surgery (MIS) in the management of epithelial ovarian cancer (EOC). Background MIS is currently performed to stage and treat EOC at different stage of presentation. We will evaluate risks and benefits of minimally invasive surgery for early stage EOC treatment, then potential advantages provided by staging laparoscopy in identifying patients suitable for primary cytoreductive surgery (PDS) will be discussed. Finally we will investigate the growing role of MIS in the treatment of advanced EOC after neoadjuvant chemotherapy (NACT) and in the treatment of EOC recurrence. Methods An electronic database search was performed on PubMed, Medline, and Google Scholar for relevant studies up to December 2022. Conclusion LPS represents a feasible surgical procedure for the staging and treatment in early, advanced and EOC relapse in selected patients treated in high-volume oncological centers by surgeons with adequate experience in advanced surgical procedures. Despite the increasing use of MIS over the last few years, randomized clinical trials are still needed to prove its effectiveness.
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25
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Gaillard M, Meylaerts L, Govaerts K. Extrapelvic Endometriosis Mimicking Peritoneal Surface Malignancy: Case Report and a Review of Literature. Indian J Surg Oncol 2023; 14:131-143. [PMID: 37359914 PMCID: PMC10284773 DOI: 10.1007/s13193-022-01683-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/06/2022] [Indexed: 12/04/2022] Open
Abstract
Extrapelvic endometriosis is a rare presentation of endometriosis with atypical clinical symptoms. It can mimic peritoneal surface malignancy, as well as some abdominal infectious diseases. A 29-year-old Moroccan woman presented with abdominal pain, progressive abdominal distention, and an intermittent inflammatory syndrome. Imaging revealed multiple, progressively growing abdominal cysts. She had elevated tumor markers CA125 and CA19.9. Despite thorough investigation, several differential diagnoses persisted for a long time. Definitive pathological diagnosis could only be established after debulking surgery. Literature review on malignant and benign conditions causing multicystic abdominal distention is provided. When definitive diagnosis is not established, but suspicion for peritoneal malignancy remains, a debulking procedure can be undertaken. Organ preservation can be pursued whenever benign disease is still considered. In case of malignancy, short-term (curative) debulking procedure with or without hyperthermic intraperitoneal chemotherapy (HIPEC) can be proposed.
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Affiliation(s)
- Marie Gaillard
- Department of Surgical Oncology, Ziekenhuis Oost Limburg, Genk, Belgium
| | | | - Kim Govaerts
- Department of Radiology, Ziekenhuis Oost Limburg, Genk, Belgium
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26
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Son JH, Dong SR, Kim J, Kim J, Kong TW, Chang SJ. Significance of cholecystectomy in cytoreductive surgery for advanced ovarian cancer. BMC Surg 2023; 23:60. [PMID: 36941661 PMCID: PMC10026427 DOI: 10.1186/s12893-023-01956-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 02/23/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND There have been no studies concerning the complications or benefits of cholecystectomy in ovarian cancer. In this study, we aimed to evaluate the outcomes of cholecystectomy performed during various time periods of the disease course and suggest a management strategy for cholecystectomy in ovarian cancer. METHODS We retrospectively reviewed the medical records of patients with advanced ovarian cancer who underwent cholecystectomy during the cytoreductive surgery from 2009 to 2020. Cholecystectomy was primarily indicated when the gallbladder and surrounding structures were considered to have metastatic tumor invasion. If the final pathologic results showed free of malignant tumor, patients were placed into the no-infiltration group. Clinical outcomes including the recurrence rate and complications were analyzed. RESULTS A total of 62 patients underwent cholecystectomy, 48 of whom (77.4%) underwent cholecystectomy during primary or interval debulking surgery, whereas 14 (22.6%) underwent cholecystectomy during the follow-up period (five with benign disease and 9 with disease recurrence). Among the patients, 32 (51.6%) patients were included in the no-infiltration group in the final pathology. There were no complications observed in the no-infiltration group (n = 32). Seven (78%) of the nine patients who received cholecystectomy for disease recurrence had metastatic disease in the porta-hepatis or lesser sac at the time of primary surgery. However, no recurrent lesions were observed around the porta-hepatis in patients who received cholecystectomy during primary treatment. CONCLUSION Considering the safety of the procedure, as well as the risk of disease recurrence or cholecystitis, a cholecystectomy can be offered to patients with ovarian cancer who have metastatic lesions around the gallbladder and porta-hepatis at the time of primary surgery.
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Affiliation(s)
- Joo-Hyuk Son
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, 16499, Suwon, Republic of Korea
| | - Su Ryeon Dong
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, 16499, Suwon, Republic of Korea
| | - Jisoo Kim
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, 16499, Suwon, Republic of Korea
| | - Jeeyeon Kim
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, 16499, Suwon, Republic of Korea
| | - Tae-Wook Kong
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, 16499, Suwon, Republic of Korea
| | - Suk-Joon Chang
- Department of Obstetrics and Gynecology, Ajou University School of Medicine, 164 Worldcup-ro, Yeongtong-gu, 16499, Suwon, Republic of Korea.
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27
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Kahn RM, McMinn E, Yeoshoua E, Boerner T, Zhou Q, Iasonos A, Long Roche K, Zivanovic O, Gardner GJ, Sonoda Y, O'Cearbhaill RE, Grisham RN, Tew W, Jones D, Huang J, Park BJ, Abu-Rustum NR, Chi DS. Intrathoracic surgery as part of primary cytoreduction for advanced ovarian cancer: Going to the next level - A Memorial Sloan Kettering Cancer Center study. Gynecol Oncol 2023; 170:46-53. [PMID: 36621269 PMCID: PMC10023324 DOI: 10.1016/j.ygyno.2022.12.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
OBJECTIVE We investigated the feasibility, safety, and survival outcomes of intrathoracic cytoreduction during primary debulking surgery (PDS) for advanced ovarian cancer. METHODS We conducted a database review of patients with stage IIIB-IV ovarian (including fallopian tube and primary peritoneal) carcinoma who underwent PDS at our institution from 01/01/2006-9/30/2021. Patients who underwent intrathoracic cytoreduction as part of primary treatment were included. Patients who received neoadjuvant chemotherapy or surgery for reasons other than cytoreduction were excluded. RESULTS Among 178 patients identified for inclusion, complete gross resection (CGR) in the abdomen and thorax was achieved in 131 (74%); 45 (25%) had optimal cytoreduction, and 2 (1%) had suboptimal cytoreduction. Thirty-one patients (17%) had at least one grade ≥ 3 complication; 8 were possibly related to intrathoracic cytoreduction. There were no deaths within 30 days following surgery. Median length of follow-up among survivors was 53.4 months. Among all patients, the median PFS was 33.6 months (95% CI: 24.7-61.9) and the 3-year PFS rate was 48.9% (95% CI: 41.2%-56.2%). Median OS was 81.3 months (95% CI: 68.9-103). When stratified by residual disease status, median PFS was 51.8 months when CGR was achieved versus 16.7 months with residual disease (HR: 2.17; P < .001) and median OS was 97.6 months when CGR was achieved versus 65.9 months with residual disease (HR: 2.05; P = .003). CONCLUSIONS Intrathoracic cytoreduction during PDS for advanced ovarian cancer is both safe and feasible. CGR can be achieved in patients with intrathoracic disease if properly selected, and could significantly improve both PFS and OS.
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Affiliation(s)
- Ryan M Kahn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Erin McMinn
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Effi Yeoshoua
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Thomas Boerner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Qin Zhou
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Alexia Iasonos
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Kara Long Roche
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States of America
| | - Oliver Zivanovic
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States of America
| | - Ginger J Gardner
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States of America
| | - Yukio Sonoda
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States of America
| | - Roisin E O'Cearbhaill
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - Rachel N Grisham
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - William Tew
- Gynecologic Medical Oncology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Medicine, Weill Cornell Medical College, New York, NY, United States of America
| | - David Jones
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Surgery, Weill Cornell Medical College, New York, NY, United States of America
| | - James Huang
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Surgery, Weill Cornell Medical College, New York, NY, United States of America
| | - Bernard J Park
- Thoracic Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of Surgery, Weill Cornell Medical College, New York, NY, United States of America
| | - Nadeem R Abu-Rustum
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States of America
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America; Department of OB/GYN, Weill Cornell Medical College, New York, NY, United States of America.
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Penn CA, Alvarez RD. Current Issues in the Management of Patients With Newly Diagnosed Advanced-Stage High-Grade Serous Carcinoma of the Ovary. JCO Oncol Pract 2023; 19:116-122. [PMID: 36603168 DOI: 10.1200/op.22.00461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Ovarian cancer is the most common cause of mortality in patients with gynecologic malignancies. Advanced-stage high-grade serous carcinoma accounts for most ovarian cancer cases. Current issues in the management of patients with newly diagnosed advanced-stage high-grade serous ovarian cancer include decisions on primary versus interval cytoreduction, hyperthermic intraperitoneal chemotherapy, maintenance therapy, incorporation of bevacizumab, and germline and somatic genetic testing. Evidence and guidelines regarding these topics are addressed in this review.
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Affiliation(s)
- Courtney A Penn
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Ronald D Alvarez
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
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Navarro AS, Gomez CM, Angeles MA, Fuzier R, Ruiz J, Picard M, Martinez A, Ferron G. Open abdominal vacuum pack technique for the management of severe abdominal complications after cytoreductive surgery in ovarian cancer. Gynecol Oncol 2023; 170:108-113. [PMID: 36681011 DOI: 10.1016/j.ygyno.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 12/27/2022] [Accepted: 01/11/2023] [Indexed: 01/21/2023]
Abstract
INTRODUCTION The aim of this study was to evaluate the indications and management of grade III-IV postoperative complications in patients requiring vacuum-assisted open abdomen after debulking surgery for ovarian carcinomatosis. METHODS Retrospective study of prospectively collected data from patients who underwent a cytoreductive surgery by laparotomy for an epithelial ovarian cancer that required postoperative management of an open abdomen. An abdominal vacuum-assisted wound closure (VAWC) was applied in cases of abdominal compartmental syndrome (ACS) or intra-abdominal hypertension, to prevent ACS. The fascia was closed with a suture or a biologic mesh. The primary aim was to achieve primary fascial closure. Secondary outcomes considered included complications of cytoreductive surgery (CRS) and open abdominal wounds (hernia, fistula). RESULTS Two percent of patients who underwent CRS required VAWC during the study's patient inclusion period. VAWC indications included: (i) seven cases of gastro-intestinal perforation, (ii) three necrotic enterocolitis, (iii) two intestinal ischemia, (iv) three anastomotic leakages and (v) four intra-abdominal hemorrhages. VAWC was used to treat indications (i) to (iv) (which represented 73.7% of cases), to prevent compartmental syndrome. Primary fascia closure was achieved in 100% of cases, in four cases (21.0%) a biologic mesh was used. Median hospital stay was 65 days (range: 18-153). Four patients died during hospitalization, three of these within 30 days of VAWC completion. CONCLUSION VAWC for managing open abdominal wounds is a reliable technique to treat surgical post-CRS complications in advanced ovarian cancer and reduces the early post-operative mortality in cases presenting with severe complications.
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Affiliation(s)
- Anne-Sophie Navarro
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France.
| | | | - Martina Aida Angeles
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Régis Fuzier
- Department of Anesthesia Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Jean Ruiz
- Intensive care unit, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, CHU Toulouse, Toulouse, France
| | - Muriel Picard
- Intensive care unit, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, CHU Toulouse, Toulouse, France
| | - Alejandra Martinez
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
| | - Gwénaël Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer de Toulouse (IUCT) - Oncopole, Toulouse, France
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30
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Nasioudis D, Latif NA, Ko EM, Cory L, Kim SH, Simpkins F, Morgan MA, Giuntoli RL. Facility level variation in the utilization of neoadjuvant chemotherapy is associated with higher surgical morbidity for patients with advanced stage epithelial ovarian carcinoma. Gynecol Oncol 2023; 169:41-46. [PMID: 36502768 DOI: 10.1016/j.ygyno.2022.10.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/24/2022] [Accepted: 10/30/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Investigate outcomes for advanced stage epithelial ovarian cancer (EOC) patients based on facility-level utilization of neoadjuvant chemotherapy (NACT). METHODS Stage III-IV EOC patients diagnosed between 2010 and 2016 were identified in the National Cancer Database. Percentage of patients managed with NACT was calculated for facilities, reporting ≥120 patients. Facilities with lowest and highest quartile of NACT rate comprised the low and high-utilizing groups. Clinico-pathological characteristics were collected, and appropriate statistical analysis performed. RESULTS High- and low-utilizing facilities managed on average 54.1% and 25.4% of patients with NACT respectively. Patients managed at high-utilizing facilities were significantly more likely to be >65 (p = 0.029), have stage IV disease (p < 0.001) and comorbidities (p < 0.001). Patients managed with primary debulking surgery (PDS) at low-utilizing facilities were significantly more likely to be >65, have stage IV disease, and have comorbidities (all, p < 0.001). Patients undergoing PDS at low-utilizing facilities were significantly less likely to achieve complete gross resection (p < 0.001), and were significantly more likely to experience 90-day mortality (p < 0.001), and unplanned 30-day readmission (p < 0.001). After controlling for age, comorbidities, race, insurance status, stage, grade and histology, high-utilizing facilities trended towards better overall survival (OS) (HR: 0.92, 95% CI: 0.85-0.99). Overall, patients undergoing PDS had better OS compared to those who had NACT (median 42 vs 27 months, p < 0.001). CONCLUSIONS Despite treating an EOC population with more advanced disease and comorbidities, high-utilizing facilities have lower surgical morbidity and mortality with no detrimental impact on long-term survival. Careful patient selection to minimize the morbidity and mortality associated with PDS is pivotal.
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Affiliation(s)
- Dimitrios Nasioudis
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Nawar A Latif
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Emily M Ko
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Lori Cory
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarah H Kim
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Fiona Simpkins
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark A Morgan
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert L Giuntoli
- Division of Gynecologic Oncology, Penn Medicine, University of Pennsylvania, Philadelphia, PA, USA
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31
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Chan SK, Steinmetz NF. microRNA-181a silencing by antisense oligonucleotides delivered by virus-like particles. J Mater Chem B 2023; 11:816-825. [PMID: 36597907 PMCID: PMC9898218 DOI: 10.1039/d2tb02199d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Cowpea chlorotic mottle virus (CCMV) is a positive-sense RNA virus that can be repurposed for gene delivery applications. Understanding the self-assembly process of the virus enabled to remove its genome and replace it with desired nucleic acids, and we and others have previously reported using CCMV virus-like particle (VLP) to encapsulate siRNA, mRNA, as well as CpG oligodeoxynucleotides. In this study, the CCMV VLP was applied to encapsulate two different formats of anti-miR-181a oligonucleotides: naked RNA and chemically stabilized RNA to knockdown highly regulated miR-181a in ovarian cancer cells. miR-181a expression in ovarian tumors is associated with high aggressiveness, invasiveness, resistance to chemotherapy, and overall poor prognosis. Therefore, miR-181a is an important target for ovarian cancer therapy. qPCR data and cancer cell migration assays demonstrated higher knockdown efficacy when anti-miR-181a oligonucleotides were encapsulated and delivered using the VLPs resulting in reduced cancer cell invasiveness. Importantly, delivery of anti-miR-181a oligonucleotide into cells could be achieved without the aid of a transfection agent or surface modification. These results highlight the opportunity of plant-derived VLPs as nucleic acid carriers.
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Affiliation(s)
- Soo Khim Chan
- Department of NanoEngineering, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.
| | - Nicole F. Steinmetz
- Department of NanoEngineering, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA.,Department of Bioengineering, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA,Department of Radiology, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA,Center for Nano-ImmunoEngineering, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA,Center for Engineering in Cancer, Institute for Engineering in Medicine, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA,Moores Cancer Center, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA,Institute for Materials Discovery and Design, University of California San Diego, 9500 Gilman Dr, La Jolla, CA 92093, USA
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32
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Matak L, Mikuš M, Ćorić M, Spagnol G, Matak M, Vujić G. Comparison end-to-end anastomosis with ostomy after secondary surgical cytoreduction for recurrent high-grade serous ovarian cancer: observational single-center study. Arch Gynecol Obstet 2023; 308:231-237. [PMID: 36680573 DOI: 10.1007/s00404-023-06918-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 01/08/2023] [Indexed: 01/22/2023]
Abstract
We conducted an observational single-center cohort study on patients with recurrent high-grade serous ovarian carcinoma that underwent secondary surgical cytoreduction with extent of partial ileectomy and/or colectomy, followed by adjuvant chemotherapy (Paclitaxel-Carboplatin). All patients performed previously primary debulking surgery without residual disease, followed by three cycles of adjuvant chemotherapy. The aim of this study was to compare survival in patients with ostomy or end-to-end anastomosis that underwent secondary cytoreduction. Furthermore, we investigated the morbidity, the rate, timing and complications of the ostomy or end-to-end anastomosis after secondary cyto-reduction.
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Affiliation(s)
- Luka Matak
- Department of Obstetrics and Gynecology, General Hospital Zadar, Bože Peričića 5, 23000, Zadar, Croatia.
| | - Mislav Mikuš
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Mario Ćorić
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
| | - Giulia Spagnol
- Department of Women and Children's Health, Clinic of Gynecology and Obstetrics, University of Padua, Padua, Italy
| | - Magdalena Matak
- Department of Dermatovenearology, General Hospital Zadar, Zadar, Croatia
| | - Goran Vujić
- Department of Obstetrics and Gynecology, University Hospital Center Zagreb, Zagreb, Croatia
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Ghirardi V, Fagotti A, Ansaloni L, Valle M, Roviello F, Sorrentino L, Accarpio F, Baiocchi G, Piccini L, De Simone M, Coccolini F, Visaloco M, Bacchetti S, Scambia G, Marrelli D. Diagnostic and Therapeutic Pathway of Advanced Ovarian Cancer with Peritoneal Metastases. Cancers (Basel) 2023; 15:407. [PMID: 36672356 PMCID: PMC9856580 DOI: 10.3390/cancers15020407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/27/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
Over two thirds of ovarian cancer patients present with advanced stage disease at the time of diagnosis. In this scenario, standard treatment includes a combination of cytoreductive surgery and carboplatinum-paclitaxel-based chemotherapy. Despite the survival advantage of patients treated with upfront cytoreductive surgery compared to women undergoing neo-adjuvant chemotherapy (NACT) and interval debulking surgery (IDS) due to high tumor load or poor performance status has been demonstrated by multiple studies, this topic is still a matter of debate. As a consequence, selecting the adequate treatment through an appropriate diagnostic pathway represents a crucial step. Aiming to assess the likelihood of leaving no residual disease at the end of surgery, the role of the CT scan as a predictor of cytoreductive outcomes has shown controversial results. Similarly, CA 125 level as an expression of tumor load demonstrated limited applicability. On the contrary, laparoscopic assessment of disease distribution through a validated scoring system was able to identify, with the highest specificity, patients undergoing suboptimal cytoreduction and therefore best suitable for NACT-IDS. Against this background, with this article, we aim to provide a comprehensive review of available evidence on the diagnostic and treatment pathways of advanced ovarian cancer.
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Affiliation(s)
- Valentina Ghirardi
- UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario a Gemelli (IRCCS), Catholic University of Sacred Heart, 00167 Rome, Italy
| | - Anna Fagotti
- UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario a Gemelli (IRCCS), Catholic University of Sacred Heart, 00167 Rome, Italy
| | - Luca Ansaloni
- Unit of General Surgery, San Matteo Hospital, 27100 Pavia, Italy
| | - Mario Valle
- Peritoneal Tumours Unit, IRCCS Regina Elena National Cancer Institute, 00144 Rome, Italy
| | - Franco Roviello
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery, and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Lorena Sorrentino
- SC Chirurgia Generale d’Urgenza ed Oncologica, AOU Policlinico di Modena, 41124 Modena, Italy
| | - Fabio Accarpio
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Gianluca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, 25123 Brescia, Italy
| | - Lorenzo Piccini
- General and Peritoneal Surgery, Department of Surgery, Pisa University Hospital, 56100 Pisa, Italy
| | | | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, 56100 Pisa, Italy
| | - Mario Visaloco
- U.O.C Pronto Soccorso Generale. Con O.B.I., Azienda Ospedaliera Universitaria “G. Martino”, 98124 Messina, Italy
| | - Stefano Bacchetti
- AOUD Center Advanced Surgical Oncology, DAME University of Udine, 33100 Udine, Italy
| | - Giovanni Scambia
- UOC Ginecologia Oncologica, Dipartimento per la Salute della Donna e del Bambino e della Salute Pubblica, Fondazione Policlinico Universitario a Gemelli (IRCCS), Catholic University of Sacred Heart, 00167 Rome, Italy
| | - Daniele Marrelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery, and Neurosciences, University of Siena, 53100 Siena, Italy
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Bryant A, Johnson E, Grayling M, Hiu S, Elattar A, Gajjar K, Craig D, Vale L, Naik R. Residual Disease Threshold After Primary Surgical Treatment for Advanced Epithelial Ovarian Cancer, Part 1: A Systematic Review and Network Meta-Analysis. Am J Ther 2023; 30:e36-e55. [PMID: 36608071 PMCID: PMC9812425 DOI: 10.1097/mjt.0000000000001584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We present a systematic review and network meta-analysis (NMA) that is the precursor underpinning the Bayesian analyses that adjust for publication bias, presented in the same edition in AJT. The review assesses optimal cytoreduction for women undergoing primary advanced epithelial ovarian cancer (EOC) surgery. AREAS OF UNCERTAINTY To assess the impact of residual disease (RD) after primary debulking surgery in women with advanced EOC. This review explores the impact of leaving varying levels of primary debulking surgery. DATA SOURCES We conducted a systematic review and random-effects NMA for overall survival (OS) to incorporate direct and indirect estimates of RD thresholds, including concurrent comparative, retrospective studies of ≥100 adult women (18+ years) with surgically staged advanced EOC (FIGO stage III/IV) who had confirmed histological diagnoses of ovarian cancer. Pairwise meta-analyses of all directly compared RD thresholds was previously performed before conducting this NMA, and the statistical heterogeneity of studies within each comparison was evaluated using recommended methods. THERAPEUTIC ADVANCES Twenty-five studies (n = 20,927) were included. Analyses demonstrated the prognostic importance of complete cytoreduction to no macroscopic residual disease (NMRD), with a hazard ratio for OS of 2.0 (95% confidence interval, 1.8-2.2) for <1 cm RD threshold versus NMRD. NMRD was associated with prolonged survival across all RD thresholds. Leaving NMRD was predicted to provide longest survival (probability of being best = 99%). The results were robust to sensitivity analysis including only those studies that adjusted for extent of disease at primary surgery (hazard ratio 2.3, 95% confidence interval, 1.9-2.6). The overall certainty of evidence was moderate and statistical adjustment of effect estimates in included studies minimized bias. CONCLUSIONS The results confirm a strong association between complete cytoreduction to NMRD and improved OS. The NMA approach forms part of the methods guidance underpinning policy making in many jurisdictions. Our analyses present an extension to the previous work in this area.
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Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eugenie Johnson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael Grayling
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ahmed Elattar
- Pan-Birmingham Gynaecological Oncology Cancer Centre, Birmingham, United Kingdom
| | - Ketankumar Gajjar
- Nottingham City hospital, Obstetrics and Gynaecology, Nottingham, United Kingdom; and
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Gateshead, United Kingdom
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35
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Phung MT, Webb PM, DeFazio A, Fereday S, Lee AW, Bowtell DDL, Fasching PA, Goode EL, Goodman MT, Karlan BY, Lester J, Matsuo K, Modugno F, Brenton JD, Van Gorp T, Pharoah PDP, Schildkraut JM, McLean K, Meza R, Mukherjee B, Richardson J, Grout B, Chase A, McKinnon Deurloo C, Terry KL, Hanley GE, Pike MC, Berchuck A, Ramus SJ, Pearce CL. Lifestyle and personal factors associated with having macroscopic residual disease after ovarian cancer primary cytoreductive surgery. Gynecol Oncol 2023; 168:68-75. [PMID: 36401943 PMCID: PMC10398872 DOI: 10.1016/j.ygyno.2022.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The presence of macroscopic residual disease after primary cytoreductive surgery (PCS) is an important factor influencing survival for patients with high-grade serous ovarian cancer (HGSC). More research is needed to identify factors associated with having macroscopic residual disease. We analyzed 12 lifestyle and personal exposures known to be related to ovarian cancer risk or inflammation to identify those associated with having residual disease after surgery. METHODS This analysis used data on 2054 patients with advanced stage HGSC from the Ovarian Cancer Association Consortium. The exposures were body mass index, breastfeeding, oral contraceptive use, depot-medroxyprogesterone acetate use, endometriosis, first-degree family history of ovarian cancer, incomplete pregnancy, menopausal hormone therapy use, menopausal status, parity, smoking, and tubal ligation. Logistic regression models were fit to assess the association between these exposures and having residual disease following PCS. RESULTS Menopausal estrogen-only therapy (ET) use was associated with 33% lower odds of having macroscopic residual disease compared to never use (OR = 0.67, 95%CI 0.46-0.97, p = 0.033). Compared to nulliparous women, parous women who did not breastfeed had 36% lower odds of having residual disease (OR = 0.64, 95%CI 0.43-0.94, p = 0.022), while there was no association among parous women who breastfed (OR = 0.90, 95%CI 0.65-1.25, p = 0.53). CONCLUSIONS The association between ET and having no macroscopic residual disease is plausible given a strong underlying biologic hypothesis between this exposure and diagnosis with HGSC. If this or the parity finding is replicated, these factors could be included in risk stratification models to determine whether HGSC patients should receive PCS or neoadjuvant chemotherapy.
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Affiliation(s)
- Minh Tung Phung
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Penelope M Webb
- Population Health Program, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Anna DeFazio
- Centre for Cancer Research, The Westmead Institute for Medical Research, Sydney, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; Department of Gynaecological Oncology, Westmead Hospital, Sydney, NSW, Australia; The Daffodil Centre, The University of Sydney, a joint venture with Cancer Council NSW, Sydney, NSW, Australia
| | - Sian Fereday
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Alice W Lee
- Department of Public Health, California State University, Fullerton, Fullerton, CA, USA
| | - David D L Bowtell
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia; Sir Peter MacCallum Department of Oncology, The University of Melbourne, Parkville, Victoria, Australia
| | - Peter A Fasching
- David Geffen School of Medicine, Department of Medicine Division of Hematology and Oncology, University of California at Los Angeles, Los Angeles, California, USA; Department of Gynecology and Obstetrics, Comprehensive Cancer Center Erlangen-EMN, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ellen L Goode
- Department of Quantitative Health Sciences, Division of Epidemiology, Mayo Clinic, Rochester, MN, USA
| | - Marc T Goodman
- Samuel Oschin Comprehensive Cancer Institute, Cancer Prevention and Genetics Program, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Community and Population Health Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Beth Y Karlan
- David Geffen School of Medicine, Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Jenny Lester
- David Geffen School of Medicine, Department of Obstetrics and Gynecology, University of California at Los Angeles, Los Angeles, CA, USA
| | - Keitaro Matsuo
- Division of Cancer Epidemiology and Prevention, Aichi Cancer Center Research Institute, Nagoya, Japan
| | - Francesmary Modugno
- Women's Cancer Research Center, Magee-Women's Research Institute and Hillman Cancer Center, Pittsburgh, PA, USA; Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburg, PA, USA
| | - James D Brenton
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, UK
| | - Toon Van Gorp
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University Hospital Leuven, Leuven Cancer Institute, Leuven, Belgium
| | - Paul D P Pharoah
- Centre for Cancer Genetic Epidemiology, Department of Oncology, University of Cambridge, Cambridge, UK; Centre for Cancer Genetic Epidemiology, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | | | - Karen McLean
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Rafael Meza
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Department of Integrative Oncology, BC Cancer Research Institute, Vancouver, Canada
| | - Bhramar Mukherjee
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA; Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jean Richardson
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Patient Advocate
| | | | | | | | - Kathryn L Terry
- Department of Epidemiology, Harvard TH Chan School of Public Health, Boston, MA, USA; Obstetrics and Gynecology Epidemiology Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Gillian E Hanley
- University of British Columbia Faculty of Medicine, Department of Obstetrics & Gynecology, Vancouver, Canada
| | - Malcolm C Pike
- Department of Preventive Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew Berchuck
- Division of Gynecologic Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Susan J Ramus
- School of Clinical Medicine, Faculty of Medicine and Health, University of NSW, Sydney, New South Wales, Australia; Adult Cancer Program, Lowy Cancer Research Centre, University of NSW, Sydney, New South Wales, Australia
| | - Celeste Leigh Pearce
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.
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Hu Q, Shen G, Li Y, Xie Y, Ma X, Jiang L, Lv Q. Lymphocyte-to-monocyte ratio after primary surgery is an independent prognostic factor for patients with epithelial ovarian cancer: A propensity score matching analysis. Front Oncol 2023; 13:1139929. [PMID: 37035193 PMCID: PMC10075326 DOI: 10.3389/fonc.2023.1139929] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 02/27/2023] [Indexed: 04/11/2023] Open
Abstract
Background The aim of this study was to elucidate the prognostic value of preoperative lymphocyte-to-monocyte ratio (LMR) after primary surgery in epithelial ovarian cancer (EOC) patients using a propensity score matching (PSM) analysis. Methods We retrospectively reviewed consecutive EOC patients who underwent primary surgery between January 2008 and December 2019. Patients were divided into two groups according to the optimal cutoff value of preoperative LMR. PSM (1:1) was conducted to eliminate confounding factors. A Cox proportional hazards model and the Kaplan-Meier estimator were employed to investigate the potential prognostic factors. Results A total of 368 EOC patients were included in this study. The optimal cutoff value of LMR was identified as 4.65. Low preoperative LMR was significantly correlated with low albumin, high CA125 level, more blood loss, a high likelihood of ascites, advanced FIGO stage, and poor differentiation (all p < 0.05). After matching, Kaplan-Meier curves showed that the group with LMR < 4.65 experienced significantly shorter OS (p = 0.015). Multivariate Cox analysis revealed that low LMR (HR = 1.49, p = 0.041), advanced FIGO stage (HR = 5.25, p < 0.001), and undefined residual disease (HR = 3.77, p = 0.002) were independent factors in predicting poor OS. A forest plot revealed that LMR had better prognostic value in younger EOC patients, patients with BMI ≥ 25 kg/m2 and albumin ≥ 35 g/L, CA125 ≥ 35 U/L, patients who had undergone optimal surgery, and those who had completed chemotherapy. Additionally, low-LMR patients who had undergone incomplete chemotherapy had a shorter median OS compared with those who completed chemotherapy treatment (48.5 vs. 105.9 months, p = 0.026). Conclusions LMR could be used as an independent prognostic factor for EOC patients after primary surgery; a noticeable negative effect of LMR was observed among EOC patients with age < 65, good preoperative nutritional status, and more aggressive tumor biology, and among those who underwent optimal surgery. Completing adjuvant chemotherapy is essential to improve survival outcomes among EOC patients with LMR < 4.65 after surgery.
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Affiliation(s)
- Qian Hu
- Department of Obstetrics and Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Guihua Shen
- Department of Obstetrics and Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ye Li
- Department of Obstetrics and Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Ya Xie
- Gynecology Department, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiao Ma
- Department of Obstetrics and Gynecology, Beijing Pinggu Hospital, Beijing, China
| | - Lijuan Jiang
- Department of Obstetrics and Gynecology, Shunyi Maternal and Children’s Hospital of Beijing Children’s Hospital, Beijing, China
| | - Qiubo Lv
- Department of Obstetrics and Gynecology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Qiubo Lv,
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Ohta T, Tanaka M, Taki S, Nakagawa H, Nagase S. Honeycomb-like Structured Film, a Novel Therapeutic Device, Suppresses Tumor Growth in an In Vivo Ovarian Cancer Model. Cancers (Basel) 2022; 15:cancers15010237. [PMID: 36612230 PMCID: PMC9818543 DOI: 10.3390/cancers15010237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 10/17/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023] Open
Abstract
Ovarian cancer cell dissemination can lead to the mortality of patients with advanced ovarian cancer. Complete surgery for no gross residual disease contributes to a more favorable prognosis than that of patients with residual disease. HCFs have highly regular porous structures and their 3D porous structures act as scaffolds for cell adhesion. HCFs are fabricated from biodegradable polymers and have been widely used in tissue engineering. This study aimed to show that HCFs suppress tumor growth in an in vivo ovarian cancer model. The HCF pore sizes had a significant influence on tumor growth inhibition, and HCFs induced morphological changes that rounded out ovarian cancer cells. Furthermore, we identified gene ontology (GO) terms and clusters of genes downregulated by HCFs. qPCR analysis demonstrated that a honeycomb structure downregulated the expression of CXCL2, FOXC1, MMP14, and SNAI2, which are involved in cell proliferation, migration, invasion, angiogenesis, focal adhesion, extracellular matrix (ECM), and epithelial-mesenchymal transition (EMT). Collectively, HCFs induced abnormal focal adhesion and cell morphological changes, subsequently inhibiting the differentiation, proliferation and motility of ovarian cancer cells. Our data suggest that HCFs could be a novel device for inhibiting residual tumor growth after surgery, and could reduce surgical invasiveness and improve the prognosis for patients with advanced ovarian cancer.
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Affiliation(s)
- Tsuyoshi Ohta
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan
- Correspondence: ; Tel.: +81-23-628-5393
| | - Masaru Tanaka
- Institute for Materials Chemistry and Engineering, Kyushu University, CE41 744 Motooka, Nishi, Fukuoka 819-0395, Japan
| | - Seitaro Taki
- Toyoda Gosei Co., Ltd., 1-1, Higashitakasuka, Futatudera, Miwa-cho, Ama-gun, Aichi 490-1207, Japan
| | - Hiroyuki Nakagawa
- Toyoda Gosei Co., Ltd., 1-1, Higashitakasuka, Futatudera, Miwa-cho, Ama-gun, Aichi 490-1207, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Faculty of Medicine, Yamagata University, Yamagata 990-9585, Japan
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Egger EK, Buchen MA, Recker F, Stope MB, Strunk H, Mustea A, Marinova M. Predicting incomplete cytoreduction in patients with advanced ovarian cancer. Front Oncol 2022; 12:1060006. [PMID: 36591482 PMCID: PMC9798233 DOI: 10.3389/fonc.2022.1060006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 11/21/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose The most important prognostic factor for survival in ovarian cancer patients is complete cytoreduction. The preoperative prediction of suboptimal cytoreduction, considered as any residual disease at the end of surgery, could prevent futile surgery and morbidity. Here, we aimed to identify markers in the preoperative abdominal CT scans of an unselected cohort of patients with ovarian cancer that are predictive of incomplete cytoreduction. Methods This is a single-institution retrospective analysis of 105 epithelial ovarian cancer (EOC) patients treated with surgical cytoreduction between 2010 and 2020. Twenty-two variables on preoperative abdominal CT scans were compared to the intraoperative macroscopic findings by Fisher's exact test. Parameters with a significant correlation between intraoperative findings and imaging were analyzed by multivariate binary logistic regression analysis regarding the surgical outcome of complete versus incomplete cytoreduction. Results Complete cytoreduction (CC), indicated by the absence of macroscopic residual disease, was achieved in 79 (75.2%) of 105 patients and 46 (63.9%) of 72 International Federation of Gynecology and Obstetrics (FIGO) stage III and IV patients. Twenty patients (19%) were incompletely cytoreduced due to miliary carcinomatosis of the small bowel, and six patients (5.7%) had various locations of residual disease. Thirteen variables showed a significant correlation between imaging and surgical findings. Large-volume ascites, absence of numerically increased small lymph nodes at the mesenteric root, and carcinomatosis of the transverse colon in FIGO stage III and IV patients decreased the rate of CC to 26.7% in the multivariate analysis. Conclusion Large-volume ascites, the absence of numerically increased small lymph nodes at the mesenteric root, and carcinomatosis of the transverse colon are markers in preoperative CT scans predicting a low chance for complete cytoreduction in unselected ovarian cancer patients in a real-world setting.
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Affiliation(s)
- Eva K. Egger
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Marie Antonia Buchen
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Florian Recker
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Matthias B. Stope
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Holger Strunk
- Medicine Center Bonn, Medical Care Center, Bonn, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Milka Marinova
- Department of Nuclear Medicine, University Hospital Bonn, Bonn, Germany
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Marrelli D, Ansaloni L, Federici O, Asero S, Carbone L, Marano L, Baiocchi G, Vaira M, Coccolini F, Di Giorgio A, Framarini M, Gelmini R, Palopoli C, Accarpio F, Fagotti A. Cytoreductive Surgery (CRS) and HIPEC for Advanced Ovarian Cancer with Peritoneal Metastases: Italian PSM Oncoteam Evidence and Study Purposes. Cancers (Basel) 2022; 14:6010. [PMID: 36497490 PMCID: PMC9740463 DOI: 10.3390/cancers14236010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 11/25/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Ovarian cancer is the eighth most common neoplasm in women with a high mortality rate mainly due to a marked propensity for peritoneal spread directly at diagnosis, as well as tumor recurrence after radical surgical treatment. Treatments for peritoneal metastases have to be designed from a patient's perspective and focus on meaningful measures of benefit. Hyperthermic intraperitoneal chemotherapy (HIPEC), a strategy combining maximal cytoreductive surgery with regional chemotherapy, has been proposed to treat advanced ovarian cancer. Preliminary results to date have shown promising results, with improved survival outcomes and tumor regression. As knowledge about the disease process increases, practice guidelines will continue to evolve. In this review, we have reported a broad overview of advanced ovarian cancer management, and an update of the current evidence. The future perspectives of the Italian Society of Surgical Oncology (SICO) are discussed conclusively.
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Affiliation(s)
- Daniele Marrelli
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Luca Ansaloni
- Unit of General Surgery San Matteo Hospital, 27100 Pavia, Italy
| | - Orietta Federici
- Surgical Oncology, Peritoneum and Abdomen Pathologies, National Cancer Institute Regina Elena, 00144 Rome, Italy
| | - Salvatore Asero
- Unit of Surgical Oncology, Soft Tissue Tumors, Department of Oncology, Azienda Ospedaliera di Rilievo Nazionale e di Alta Specializzazione Garibaldi, 95123 Catania, Italy
| | - Ludovico Carbone
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Luigi Marano
- Unit of General Surgery and Surgical Oncology, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Gianluca Baiocchi
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, 25123 Brescia, Italy
| | - Marco Vaira
- Candiolo Cancer Institute, FPO–IRCCS, Candiolo, 10060 Torino, Italy
| | - Federico Coccolini
- General, Emergency and Trauma Surgery, Pisa University Hospital, 56122 Pisa, Italy
| | - Andrea Di Giorgio
- Surgical Unit of Peritoneum and Retroperitoneum, Fondazione Policlinico Universitario A. Gemelli–IRCCS, 00168 Rome, Italy
| | - Massimo Framarini
- Surgery and Advanced Oncological Therapy Unit, Ospedale GB. Morgagni-L. Pierantoni, AUSL Forlì, 47121 Forlì-Cesena, Italy
| | - Roberta Gelmini
- Unit of Emergency General Surgery and Surgical Oncology, AOU Policlinico di Modena, 41125 Modena, Italy
| | - Carmen Palopoli
- Unit of PSG and OBI, Azienda Ospedaliera Universitaria G. Martino, 98124 Messina, Italy
| | - Fabio Accarpio
- CRS and HIPEC Unit, Pietro Valdoni, Umberto I Policlinico di Roma, 00161 Roma, Italy
| | - Anna Fagotti
- Unit of Ovarian Carcinoma, Fondazione Policlinico Universitario A. Gemelli–IRCCS, 00168 Rome, Italy
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Kuusela K, Norppa N, Auranen A, Saarelainen S. Maximal surgical effort increases the risk of postoperative complications in the treatment of advanced ovarian cancer. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2525-2530. [PMID: 35717320 DOI: 10.1016/j.ejso.2022.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 05/30/2022] [Accepted: 06/06/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Surgery is the cornerstone of the treatment for advanced ovarian cancer. Reaching complete cytoreduction resulting in no gross residual disease often requires complex surgery. The aim of this study was to assess the impact of increased surgical radicality on the risk of complications in the treatment of advanced ovarian cancer. MATERIALS AND METHODS All consecutive patients with advanced ovarian cancer (FIGO Stage IIIB-IVB) who had undergone primary or interval debulking surgery during a six-year study period were identified. In the midst of the study period, a surgical practice change towards maximal surgical effort occurred. Two groups were formed for the analysis: cohort A, that consisted of patients operated before the surgical paradigm shift and cohort B, that consisted of patients operated under the period of increased surgical radicality. RESULTS 252 patients were included in the analysis. Complete resection (R0) was achieved in 21.3% of surgeries in cohort A and in 51.2% in cohort B. The total postoperative complication rate was 76.2%. Most of the complications (86.5%) were minor (Clavien-Dindo I-IIIA). The patients in cohort B were at increased risk for complications, OR 2.94 (95%CI 1.58-5.47; p = 0.001). As for the approach to cytoreduction (primary vs. interval debulking), there was no statistically significant association with the occurrence of postoperative complications (p = 0.659). CONCLUSION In the present study more extensive surgeries led to better surgical results but increased postoperative morbidity. Postoperative complication rates were similar in both primary and interval debulking surgeries.
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Affiliation(s)
| | - Niina Norppa
- Tampere University Hospital, Department of Obsteterics and Gynecology, PO BOX 2000, FI-33521, Tampere, Finland
| | - Annika Auranen
- Tampere University Hospital, Department of Obsteterics and Gynecology, PO BOX 2000, FI-33521, Tampere, Finland; Tays Cancer Centre, PO BOX 2000, FI-33521, Tampere, Finland
| | - Sami Saarelainen
- Tampere University Hospital, Department of Obsteterics and Gynecology, PO BOX 2000, FI-33521, Tampere, Finland.
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Droste A, Anic K, Hasenburg A. Laparoscopic Surgery for Ovarian Neoplasms - What is Possible, What is Useful? Geburtshilfe Frauenheilkd 2022; 82:1368-1377. [PMID: 36467976 PMCID: PMC9715350 DOI: 10.1055/a-1787-9144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022] Open
Abstract
The use of minimally invasive surgical techniques is becoming increasingly important in gynecologic oncology due to technical advances and the increasing level of surgical expertise. In addition to laparoscopic approaches for the treatment of benign neoplasms, minimally invasive surgical methods have also become established in some areas for treating gynecologic malignancies. For tumor entities such as endometrial and cervical carcinoma, there are conclusive studies emphasizing the role of laparoscopy in surgical therapy. By contrast, due to a lack of prospective data with survival analyses, no clear conclusions can be drawn on the significance of laparoscopy in the surgical treatment of ovarian carcinoma. However, some smaller, mostly retrospective case-control studies and cohort studies open the way for a discussion, positing the possibility that laparoscopic surgical procedures, particularly for early ovarian carcinoma, are technically feasible and of a quality equivalent to that of conventional longitudinal laparotomy, and may also be associated with lower perioperative morbidity. In this article we discuss the most important aspects of using minimally invasive surgical techniques for ovarian carcinoma based on the current literature. In particular we look at the relevance of laparoscopy as a primary approach for surgical staging of early ovarian carcinoma, and we evaluate the role of diagnostic laparoscopy in assessing the operability of advanced ovarian carcinoma.
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Affiliation(s)
- Annika Droste
- 611615Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany,Korrespondenzadresse Dr. med. univ. Annika Droste Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Klinik und Poliklinik für
Geburtshilfe und FrauengesundheitLangenbeckstraße 155131
MainzGermany
| | - Katharina Anic
- 611615Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany
| | - Annette Hasenburg
- 611615Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany
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Nectin-4 as Blood-Based Biomarker Enables Detection of Early Ovarian Cancer Stages. Cancers (Basel) 2022; 14:cancers14235867. [PMID: 36497350 PMCID: PMC9739558 DOI: 10.3390/cancers14235867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/25/2022] [Accepted: 11/27/2022] [Indexed: 11/30/2022] Open
Abstract
Ovarian cancer is the third most common gynecological malignancy and has the highest mortality rate. Owing to unspecific symptoms, ovarian cancer is not detected until an advanced stage in about two-thirds of cases. Therefore, it is crucial to establish reliable biomarkers for the early stages to improve the patients’ prognosis. The aim of this study is to investigate whether the ADAM17 substrates Nectin-4, Heparin-binding EGF-like growth factor (HB-EGF) and Amphiregulin (AREG) could function as potential tumor markers for ovarian cancer. In this study a set of 231 sera consisting of 131 ovarian cancer patients and 100 healthy age-matched controls were assembled. Nectin-4, HB-EGF and AREG levels of preoperatively collected sera were determined by enzyme-linked immunosorbent assay (ELISA). Our analysis revealed that Nectin-4 and HB-EGF were significantly increased compared to the age-matched control group (p < 0.0001, p = 0.016). Strikingly, significantly higher Nectin-4 and HB-EGF levels were detected in early-stage FIGO I/II (p <0.001; p = 0.025) compared to healthy controls. Eighty-four percent (16/19) of patients with low Ca-125 levels showed increased Nectin-4 levels. Our study proposes Nectin-4 and HB-EGF as promising blood-based biomarkers for the detection of early stages of ovarian cancer patients that would not have been detected by Ca-125.
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Gong X, Liu X. In-depth analysis of the expression and functions of signal transducers and activators of transcription in human ovarian cancer. Front Oncol 2022; 12:1054647. [DOI: 10.3389/fonc.2022.1054647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 11/14/2022] [Indexed: 11/30/2022] Open
Abstract
BackgroundSignal transducers and activators of transcription (STAT) transcription factors, a family of genes encoding transcription factors, have been linked to the development of numerous types of tumors. However, there is a relative paucity of a comprehensive investigation of the expression and functional analysis of STATs in ovarian cancer (OV).MethodGene expression profile interaction analysis (GEPI2A), Metascape, The Cancer Genome Atlas (TCGA), Kaplan-Meier Plotter, Linkedomics, and CancerSEA databases were used for expression analysis and functional enrichment of STATs in ovarian cancer patients. We screened potential predictive genes and evaluated their prognostic value by constructing the minor absolute shrinkage and selection operator (LASSO) Cox proportional risk regression model. We explored STAT5A expression and its effects on cell invasion using ovarian cancer cells and a tissue microarray.ResultsThe expression level of STAT1 was higher, but that of STAT2-6 was lower in cancerous ovarian tissues compared to normal tissues, which were closely associated with the clinicopathological features. Low STAT1, high STAT4, and 6 mRNA levels indicated high overall survival. STAT1, 3, 4, and 5A were collectively constructed as prognostic risk models. STAT3, and 5A, up-regulating in the high-risk group, were regarded as risk genes. In subsequent validation, OV patients with a low level of P-STAT5A but not low STAT5A had a longer survival time (P=0.0042). Besides, a negative correlation was found between the expression of STAT5A and invasion of ovarian cancer cells (R= -0.38, p < 0.01), as well as DNA repair function (R= -0.36, p < 0.01). Furthermore, transient overexpression of STAT5A inhibited wound healing (21.8%, P<0.0001) and cell migration to the lower chamber of the Transwell system (29.3%, P<0.0001), which may be achieved by regulating the expression of MMP2.ConclusionIt is suggested that STAT1, STAT4, and STAT6 may be potential targets for the proper treatment of ovarian cancer. STAT5A and P-STAT5A, biomarkers identified in ovarian cancer, may offer new perspectives for predicting prognosis and assessing therapeutic effects.
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de Bree E, Michelakis D, Anagnostopoulou E. The current role of secondary cytoreductive surgery for recurrent ovarian cancer. Front Oncol 2022; 12:1029976. [PMID: 36338689 PMCID: PMC9633943 DOI: 10.3389/fonc.2022.1029976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 10/10/2022] [Indexed: 11/18/2022] Open
Abstract
Ovarian cancer represents worldwide the second most frequent and the most fatal gynecological malignancy, with approximately two thirds of the patients presenting with advanced disease. Cytoreductive surgery, primary or after neoadjuvant chemotherapy, in combination with platinum-based chemotherapy is the standard of care for these patients. Despite the improvement in quality of cytoreductive surgery as well as development of novel drugs and chemotherapy regimens, still most women with ovarian cancer will ultimately develop recurrent disease and die of their disease. In contrast to the management of primary disease, the standard treatment of patients with recurrent ovarian cancer remains a topic of debate. While platinum-based or second line systemic chemotherapy, depending on the time after last platinum treatment, is standard of care, the role of secondary cytoreductive surgery has been a controversial issue for the last decades. Potential outcome benefit must be also weighed against the risk of severe surgical morbidity, impairment of quality of life and costs. In platinum-resistant recurrent disease, i.e., relapse after less than 6 months from the last platinum-based chemotherapy for primary disease, secondary cytoreduction seems generally not to be indicated due to its aggressive biological behavior and the absence of effective systemic treatment. In this comprehensive review, the current role of cytoreductive surgery in platinum-sensitive recurrent ovarian cancer is discussed thoroughly in view of the results of most recent randomized trials and a meta-analysis. There seems to be definitely a role for secondary cytoreductive surgery in selected patients with ovarian cancer recurrence in whom complete resection of macroscopic disease is feasible. However, its role should be continuously reviewed due to the changing systemic treatment of patients with ovarian cancer recurrence over time.
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Bryant A, Hiu S, Kunonga PT, Gajjar K, Craig D, Vale L, Winter-Roach BA, Elattar A, Naik R. Impact of residual disease as a prognostic factor for survival in women with advanced epithelial ovarian cancer after primary surgery. Cochrane Database Syst Rev 2022; 9:CD015048. [PMID: 36161421 PMCID: PMC9512080 DOI: 10.1002/14651858.cd015048.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ovarian cancer is the seventh most common cancer among women and a leading cause of death from gynaecological malignancies. Epithelial ovarian cancer is the most common type, accounting for around 90% of all ovarian cancers. This specific type of ovarian cancer starts in the surface layer covering the ovary or lining of the fallopian tube. Surgery is performed either before chemotherapy (upfront or primary debulking surgery (PDS)) or in the middle of a course of treatment with chemotherapy (neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS)), with the aim of removing all visible tumour and achieving no macroscopic residual disease (NMRD). The aim of this review is to investigate the prognostic impact of size of residual disease nodules (RD) in women who received upfront or interval cytoreductive surgery for advanced (stage III and IV) epithelial ovarian cancer (EOC). OBJECTIVES To assess the prognostic impact of residual disease after primary surgery on survival outcomes for advanced (stage III and IV) epithelial ovarian cancer. In separate analyses, primary surgery included both upfront primary debulking surgery (PDS) followed by adjuvant chemotherapy and neoadjuvant chemotherapy followed by interval debulking surgery (IDS). Each residual disease threshold is considered as a separate prognostic factor. SEARCH METHODS We searched CENTRAL (2021, Issue 8), MEDLINE via Ovid (to 30 August 2021) and Embase via Ovid (to 30 August 2021). SELECTION CRITERIA We included survival data from studies of at least 100 women with advanced EOC after primary surgery. Residual disease was assessed as a prognostic factor in multivariate prognostic models. We excluded studies that reported fewer than 100 women, women with concurrent malignancies or studies that only reported unadjusted results. Women were included into two distinct groups: those who received PDS followed by platinum-based chemotherapy and those who received IDS, analysed separately. We included studies that reported all RD thresholds after surgery, but the main thresholds of interest were microscopic RD (labelled NMRD), RD 0.1 cm to 1 cm (small-volume residual disease (SVRD)) and RD > 1 cm (large-volume residual disease (LVRD)). DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. Where possible, we synthesised the data in meta-analysis. To assess the adequacy of adjustment factors used in multivariate Cox models, we used the 'adjustment for other prognostic factors' and 'statistical analysis and reporting' domains of the quality in prognosis studies (QUIPS) tool. We also made judgements about the certainty of the evidence for each outcome in the main comparisons, using GRADE. We examined differences between FIGO stages III and IV for different thresholds of RD after primary surgery. We considered factors such as age, grade, length of follow-up, type and experience of surgeon, and type of surgery in the interpretation of any heterogeneity. We also performed sensitivity analyses that distinguished between studies that included NMRD in RD categories of < 1 cm and those that did not. This was applicable to comparisons involving RD < 1 cm with the exception of RD < 1 cm versus NMRD. We evaluated women undergoing PDS and IDS in separate analyses. MAIN RESULTS We found 46 studies reporting multivariate prognostic analyses, including RD as a prognostic factor, which met our inclusion criteria: 22,376 women who underwent PDS and 3697 who underwent IDS, all with varying levels of RD. While we identified a range of different RD thresholds, we mainly report on comparisons that are the focus of a key area of clinical uncertainty (involving NMRD, SVRD and LVRD). The comparison involving any visible disease (RD > 0 cm) and NMRD was also important. SVRD versus NMRD in a PDS setting In PDS studies, most showed an increased risk of death in all RD groups when those with macroscopic RD (MRD) were compared to NMRD. Women who had SVRD after PDS had more than twice the risk of death compared to women with NMRD (hazard ratio (HR) 2.03, 95% confidence interval (CI) 1.80 to 2.29; I2 = 50%; 17 studies; 9404 participants; moderate-certainty). The analysis of progression-free survival found that women who had SVRD after PDS had nearly twice the risk of death compared to women with NMRD (HR 1.88, 95% CI 1.63 to 2.16; I2 = 63%; 10 studies; 6596 participants; moderate-certainty). LVRD versus SVRD in a PDS setting When we compared LVRD versus SVRD following surgery, the estimates were attenuated compared to NMRD comparisons. All analyses showed an overall survival benefit in women who had RD < 1 cm after surgery (HR 1.22, 95% CI 1.13 to 1.32; I2 = 0%; 5 studies; 6000 participants; moderate-certainty). The results were robust to analyses of progression-free survival. SVRD and LVRD versus NMRD in an IDS setting The one study that defined the categories as NMRD, SVRD and LVRD showed that women who had SVRD and LVRD after IDS had more than twice the risk of death compared to women who had NMRD (HR 2.09, 95% CI 1.20 to 3.66; 310 participants; I2 = 56%, and HR 2.23, 95% CI 1.49 to 3.34; 343 participants; I2 = 35%; very low-certainty, for SVRD versus NMRD and LVRD versus NMRD, respectively). LVRD versus SVRD + NMRD in an IDS setting Meta-analysis found that women who had LVRD had a greater risk of death and disease progression compared to women who had either SVRD or NMRD (HR 1.60, 95% CI 1.21 to 2.11; 6 studies; 1572 participants; I2 = 58% for overall survival and HR 1.76, 95% CI 1.23 to 2.52; 1145 participants; I2 = 60% for progression-free survival; very low-certainty). However, this result is biased as in all but one study it was not possible to distinguish NMRD within the < 1 cm thresholds. Only one study separated NMRD from SVRD; all others included NMRD in the SVRD group, which may create bias when comparing with LVRD, making interpretation challenging. MRD versus NMRD in an IDS setting Women who had any amount of MRD after IDS had more than twice the risk of death compared to women with NMRD (HR 2.11, 95% CI 1.35 to 3.29, I2 = 81%; 906 participants; very low-certainty). AUTHORS' CONCLUSIONS In a PDS setting, there is moderate-certainty evidence that the amount of RD after primary surgery is a prognostic factor for overall and progression-free survival in women with advanced ovarian cancer. We separated our analysis into three distinct categories for the survival outcome including NMRD, SVRD and LVRD. After IDS, there may be only two categories required, although this is based on very low-certainty evidence, as all but one study included NMRD in the SVRD category. The one study that separated NMRD from SVRD showed no improved survival outcome in the SVRD category, compared to LVRD. Further low-certainty evidence also supported restricting to two categories, where women who had any amount of MRD after IDS had a significantly greater risk of death compared to women with NMRD. Therefore, the evidence presented in this review cannot conclude that using three categories applies in an IDS setting (very low-certainty evidence), as was supported for PDS (which has convincing moderate-certainty evidence).
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Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Patience T Kunonga
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ketankumar Gajjar
- Department of Gynaecological Oncology, 1st Floor Maternity Unit, City Hospital Campus, Nottingham, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Brett A Winter-Roach
- The Department of Surgery, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Ahmed Elattar
- City Hospital & Birmingham Treatment Centre, Birmingham, UK
| | - Raj Naik
- Gynaecological Oncology, Northern Gynaecological Oncology Centre, Gateshead, UK
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46
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Boria F, Chiva L, Carbonell M, Gutierrez M, Sancho L, Alcazar A, Coronado M, Hernández Gutiérrez A, Zapardiel I. 18F-fluorodeoxyglucose positron emission tomography/computed tomography ( 18F-FDG PET/CT) predictive score for complete resection in primary cytoreductive surgery. Int J Gynecol Cancer 2022; 32:ijgc-2022-003883. [PMID: 36137576 DOI: 10.1136/ijgc-2022-003883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the value of preoperative 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) scan, combined with clinical variables, in predicting complete cytoreduction in selected patients with advanced ovarian cancer. METHODS We carried out a multicenter, observational, retrospective study evaluating patients who underwent primary cytoreductive surgery for advanced ovarian cancer in two Spanish centers between January 2017 and January 2022. Inclusion criteria were histological confirmation of invasive epithelial ovarian carcinoma; preoperative International Federation of Gynecology and Obstetrics (FIGO) stage III or IV; upfront cytoreductive surgery; and 18F-FDG PET/CT performed 1 month prior to surgery. A modified 18F-FDG PET/CT peritoneal cancer index score was calculated for all patients. Clinical variables and preoperative 18F-FDG PET/CT findings were analyzed and a multivariate model was constructed. A predictive score based on the odds ratio of the variables was calculated to determine patient selection. RESULTS A total of 45 patients underwent primary cytoreductive surgery. Complete resection was achieved in 36 (80%) patients. On multivariate analysis, two clinical variables (age ≥58 years and American Society of Anesthesiology score ≥3) and two preoperative 18F-FDG PET/CT scan findings (presence of extra-abdominal lymph node involvement and modified peritoneal cancer index value of 6 or more) were associated with gross residual disease. For this multivariate model predictive of non-complete cytoreduction, the area under the curve was 0.881. A predictive value of ≥5 was the most predictive cut-off for gross residual disease. Complete resection rate was 91.7% in patients with a score of ≤4 and 33.3% in patients with a score of ≥5 points on the predictive score. CONCLUSIONS In selected patients, a predictive score value ≥5 may be consider as a cut-off point for triaging patients to diagnostic laparoscopy before the primary surgery or neoadjuvant chemotherapy.
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Affiliation(s)
- Felix Boria
- Clinica Universidad de Navarra Departamento de Ginecologia y Obstetricia, Madrid, Spain
| | - Luis Chiva
- Obstetrics and Gynecology, Clinica Universidad de Navarra, Madrid, Spain
| | - Maria Carbonell
- Gynecologic Oncology, La Paz University Hospital, Madrid, Spain
| | | | - Lidia Sancho
- Nuclear Medicine, Clinica Universidad de Navarra, Madrid, Spain
| | - Andres Alcazar
- Radiology Department, Clinica Universidad de Navarra, Madrid, Spain
| | - Monica Coronado
- Nuclear Medicine, La Paz University Hospital, Madrid, University, Spain
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47
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Farrell R, Liauw WS, Morris DL. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer in an Australian institution: lessons from 20 years' experience. BMC Surg 2022; 22:338. [PMID: 36096791 PMCID: PMC9469563 DOI: 10.1186/s12893-022-01786-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 08/31/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives We report the 20-year experience of the largest Australian unit performing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer and reflect on learning opportunities. Methods A retrospective review of all cases of CRS for ovarian cancer at St George Peritonectomy Unit from Jan 1998 to Jan 2018 was performed. Prospectively collected data include age, stage, histology, disease extent (PCI), completeness of cytoreduction (CC score), HIPEC regime, 30-day surgical morbidity, disease recurrence, and death. Survival was computed using Kaplan–Meier method and analysed using log-rank tests and Cox-proportional hazards models. Results Forty-one women with advanced ovarian cancer (11 primary stage III/IV, 30 recurrent) underwent CRS, 29 (71%) with HIPEC. Most (68%) had high-volume disease (PCI > 15). In 98%, CC0/CC1 (residual < 2.5 mm) was achieved. Fourteen (34%) had grade 3/4 complications, 1 patient (2%) died within 30 days and 2 patients (5%) died within 90 days. Progression-free and median overall survival was 30.0 and 67.0 months for primary cancer, and 6.7 and 18.1 months for recurrent cancer. Survival was associated with platinum-sensitivity, PCI ≤ 15, and CC score 0, but not HIPEC. Conclusion This study reports outcomes for patients with advanced ovarian cancer patients treated in an Australian centre offering CRS and HIPEC. Whilst survival and morbidity outcomes were good for primary disease, they were poorer than predicted from the literature for cases of recurrent disease. The incorporation of evidence-based predictors of survival and multidisciplinary input are essential to achieve the best survival outcomes.
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Affiliation(s)
- R Farrell
- Chris O'Brien Lifehouse Hospital, Camperdown, Sydney, NSW, 2050, Australia. .,The University of Sydney, Sydney, NSW, 2006, Australia. .,Department of Surgery, UNSW, Sydney, NSW, 2033, Australia. .,Prince of Wales Private Hospital, Suite 30, Level 7, Randwick Sydney, 2031, Australia.
| | - W S Liauw
- Department of Surgery, UNSW, Sydney, NSW, 2033, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, 2217, Australia
| | - D L Morris
- Department of Surgery, UNSW, Sydney, NSW, 2033, Australia.,Cancer Care Centre, St George Hospital, Kogarah, NSW, 2217, Australia
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48
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Ueno S, Sudo T, Saya H, Sugihara E. Pigment epithelium-derived factor promotes peritoneal dissemination of ovarian cancer through induction of immunosuppressive macrophages. Commun Biol 2022; 5:904. [PMID: 36056141 PMCID: PMC9440245 DOI: 10.1038/s42003-022-03837-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 08/12/2022] [Indexed: 11/24/2022] Open
Abstract
Peritoneal dissemination of ovarian cancer (OC) correlates with poor prognosis, but the mechanisms underlying the escape of OC cells from the intraperitoneal immune system have remained unknown. We here identify pigment epithelium–derived factor (PEDF) as a promoting factor of OC dissemination, which functions through induction of CD206+ Interleukin-10 (IL-10)–producing macrophages. High PEDF gene expression in tumors is associated with poor prognosis in OC patients. Concentrations of PEDF in ascites and serum are significantly higher in OC patients than those with more benign tumors and correlated with early recurrence of OC patients, suggesting that PEDF might serve as a prognostic biomarker. Bromodomain and extraterminal (BET) inhibitors reduce PEDF expression and limit both OC cell survival and CD206+ macrophage induction in the peritoneal cavity. Our results thus implicate PEDF as a driver of OC dissemination and identify a BET protein–PEDF–IL-10 axis as a promising therapeutic target for OC. Endogenously expressed pigment epithelium–derived factor (PEDF) promotes increased survival of ovarian cancer cells in the peritoneal cavity by inducing IL-10 expression in CD206 + peritoneal macrophages.
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Affiliation(s)
- Sayaka Ueno
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan.,Section of Translational Research, Hyogo Cancer Center, Hyogo, Japan
| | - Tamotsu Sudo
- Section of Translational Research, Hyogo Cancer Center, Hyogo, Japan
| | - Hideyuki Saya
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan. .,Division of Gene Regulation, Cancer Center, Research Promotion Headquarters, Fujita Health University School of Medicine, Aichi, Japan.
| | - Eiji Sugihara
- Division of Gene Regulation, Institute for Advanced Medical Research, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan. .,Division of Gene Regulation, Cancer Center, Research Promotion Headquarters, Fujita Health University School of Medicine, Aichi, Japan.
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49
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Zhang H, Yan T, Zhong A, Guo L, Lu R. COPS5 Conferred the Platinum Resistance in Epithelial Ovarian Cancer. Curr Issues Mol Biol 2022; 44:3948-3958. [PMID: 36135183 PMCID: PMC9498275 DOI: 10.3390/cimb44090271] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/23/2022] [Accepted: 08/31/2022] [Indexed: 11/16/2022] Open
Abstract
Development of platinum resistance is one of the major causes of epithelial ovarian cancer (EOC) treatment failure. COP9 signalosome subunit 5 (COPS5) was found to take part in the progression of EOC in our previous study. Herein, we aim to uncover the potential utility of COPS5 in EOC chemoresistance. COPS5 levels were analyzed to define clinic pathologic correlates using a matched tissue microarray and online datasets. The effect of COPS5 inhibition by the lentivirus-mediated short hairpin RNA on cell viability, proliferation and migration was accessed in vitro and in vivo. Results showed that COPS5 was upregulated in patients after platinum resistance. Kaplan–Meier survival curves revealed that COPS5 overexpression was correlated with shorter PFS and OS. COPS5 downregulation inhibited the cell proliferation, migration, and reduced the sensitivity of EOC to platinum. Overall, our data indicated that COPS5 inhibition might represent a new therapeutic strategy for overcoming platinum resistance in patients with EOC.
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Affiliation(s)
- Hongqin Zhang
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong’An Road, Xuhui District, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Tianqing Yan
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong’An Road, Xuhui District, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
- Qingdao Institute, Fudan University, 699 Jingshatan Road, Qingdao 266500, China
| | - Ailing Zhong
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong’An Road, Xuhui District, Shanghai 200032, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai 200032, China
| | - Lin Guo
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong’An Road, Xuhui District, Shanghai 200032, China
| | - Renquan Lu
- Department of Clinical Laboratory, Fudan University Shanghai Cancer Center, No. 270, Dong’An Road, Xuhui District, Shanghai 200032, China
- Correspondence:
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50
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Caruso G, Palaia I, Bogani G, Tomao F, Perniola G, Benedetti Panici P, Muzii L, Di Donato V. Systematic lymph node dissection during interval debulking surgery for advanced epithelial ovarian cancer: a systematic review and meta-analysis. J Gynecol Oncol 2022; 33:e69. [PMID: 35882606 PMCID: PMC9428300 DOI: 10.3802/jgo.2022.33.e69] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/27/2022] [Accepted: 06/21/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy and safety of systematic lymph node dissection (SyLND) at the time of interval debulking surgery (IDS) for advanced epithelial ovarian cancer (AEOC). METHODS Systematic literature review of studies including AEOC patients undergoing SyLND versus selective lymph node dissection (SeLND) or no lymph node dissection (NoLND) after neoadjuvant chemotherapy (NACT). Primary endpoints included progression-free survival (PFS) and overall survival (OS). Secondary endpoints included severe postoperative complications, lymphocele, lymphedema, blood loss, blood transfusions, operative time, and hospital stay. RESULTS Nine retrospective studies met the eligibility criteria, involving a total of 1,660 patients: 827 (49.8%) SyLND, 490 (29.5%) SeLND, and 343 (20.7%) NoLND. The pooled estimated hazard ratios (HR) for PFS and OS were, respectively, 0.88 (95% confidence interval [CI]=0.65-1.20; p=0.43) and 0.80 (95% CI=0.50-1.30; p=0.37). The pooled estimated odds ratios (ORs) for severe postoperative complications, lymphocele, lymphedema, and blood transfusions were, respectively, 1.83 (95% CI=1.19-2.82; p=0.006), 3.38 (95% CI=1.71-6.70; p<0.001), 7.23 (95% CI=3.40-15.36; p<0.0001), and 1.22 (95% CI=0.50-2.96; p=0.67). CONCLUSION Despite the heterogeneity in the study designs, SyLND after NACT failed to demonstrate a significant improvement in PFS and OS and resulted in a higher risk of severe postoperative complications. TRIAL REGISTRATION PROSPERO Identifier: CRD42022303577.
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Affiliation(s)
- Giuseppe Caruso
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy.
| | - Innocenza Palaia
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giorgio Bogani
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Federica Tomao
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giorgia Perniola
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Pierluigi Benedetti Panici
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Ludovico Muzii
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Violante Di Donato
- Department of Maternal and Child Health and Urological Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
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