Primary debulking surgery versus neoadjuvant chemotherapy in stage IV ovarian cancer

Prognostic value of histological type in stage IV ovarian carcinoma: a retrospective analysis of 223 patients

Background:

Patients with FIGO stage IV epithelial ovarian carcinoma have a poor but non-uniform prognosis. This study aimed to compare the survival of patients with serous or endometrioid tumours (S/E) and clear cell or mucinous tumours (non-S/E).

Methods:

Data for 223 patients who underwent surgery between 1987 and 2010 and were diagnosed by centralized pathology review and were retrospectively analysed. The patients included 169 with S/E tumours and 54 with non-S/E tumours.

Results:

The median overall survivals (OSs) of the S/E and non-S/E groups were 3.1 and 0.9 years, respectively (P<0.001). Six patients (2.7%), all with non-S/E tumours, died within 6 weeks after the initial surgery. Multivariate OS analysis revealed that performance status, residual tumor, metastatic sites, no debulking surgery, and non-S/E tumours were independent poor prognostic factors. For patients with non-S/E tumours, prognosis was more favourable for single-organ metastasis, except for liver or distant lymph nodes, no residual tumor, and resection of metastasis (median OS: 4.1, 4.6, and 2.6 years, respectively).

Conclusions:

In stage IV ovarian carcinoma, non-S/E tumours are associated with a significantly poorer prognosis and higher rates of early mortality compared to S/E tumours. Therefore, careful management and development of new strategies are required.

Neoadjuvant chemotherapy in advanced ovarian cancer: latest results and place in therapy

Approximately 70% of women with epithelial ovarian cancer (EOC) are diagnosed with advanced stage disease, which is associated with high morbidity and mortality. The standard approach to treating patients with advanced EOC remains primary debulking surgery (PDS) followed by chemotherapy. EOC is one of the most sensitive of all solid tumors to cytotoxic drugs, with over 80% of women showing a response to standard chemotherapy combined with taxane and platinum. Furthermore, residual disease is a major prognostic factor for survival. On the basis of the clinical features, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) is considered to be an alternative treatment option to standard treatment in patients unable to undergo complete resection during PDS. Noninferiority of NACT-IDS to PDS has been demonstrated in some randomized controlled trials and meta-analyses. NACT would also lead to improved quality of life (QOL) of patients, however there are still problems to be solved in the treatment strategy. The uncertainty of perioperative visual assessment of tumor dissemination after NACT has been reported. In addition, several papers have shown the possibility that NACT induces platinum resistance. Furthermore, a notable risk associated with NACT is that patients with significant side effects and refractory disease will lose the opportunity for debulking surgery. Appropriate selection of the patient cohort for NACT is an important issue. Bevacizumab (Bev) is active in patients with advanced EOC. However, the use of Bev is not recommended in the neoadjuvant setting. Bev has a specific adverse event profile that needs to be considered, especially for surgical management, such as gastrointestinal perforation, hemorrhage, and thromboembolic events. NACT could be an alternative treatment option in patients with stage III or IV EOC. However, further studies are needed to clarify the precise role of NACT in the management of advanced EOC.

Anesthetic selection and disease-free survival following optimal primary cytoreductive surgery for stage III epithelial ovarian cancer

BACKGROUND

Previous studies have offered conflicting results regarding an association between perioperative epidural analgesia and disease-free survival (DFS) following optimal primary cytoreductive surgery for stage III epithelial ovarian cancer. A possible separate role for inhalational anesthetics has not been assessed.

METHODS

We conducted a historical cohort study of all women undergoing optimal primary cytoreduction (<1 cm residual disease) for Stage III epithelial ovarian cancer between January 1, 2007, and December 31, 2011, at Brigham and Women's Hospital. Cohorts were defined by exposure to perioperative epidural analgesia or exposure to specific volatile anesthetics. The primary outcome was DFS.

RESULTS

A total of 194 patients met study inclusion criteria. Addition of epidural analgesia was associated with a lower overall rate of ovarian cancer recurrence compared with general anesthesia alone (72 vs. 85 %, p = 0.028). Longer median DFS was associated with more than 48 h of epidural use (14.9 months) compared with fewer than 24 h (10.9 months) or 24-48 h of epidural use (10.0 months; p = 0.025). Use of desflurane was associated with a lower overall rate of ovarian cancer recurrence compared with sevoflurane (63 vs. 84 %, p = 0.01). In multivariate analysis, use of desflurane was independently associated with improved DFS (hazards ratio 0.563; 95% confidence interval 0.33-0.962).

CONCLUSIONS

For patients with Stage III ovarian cancer, use of desflurane is associated with improved DFS following primary cytoreductive surgery compared with other volatile anesthetics. If epidural analgesia offers additional benefit, this effect appears limited to patients with more than 48 h of postoperative epidural use.

What is the optimal treatment for obese patients with advanced ovarian carcinoma?

OBJECTIVE

The purpose of this study was to compare primary debulking surgery (PDS) vs neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) among obese patients.

STUDY DESIGN

Medical records of patients with a body mass index (BMI) of ≥30 kg/m(2) with ovarian/fallopian tube/primary peritoneal carcinoma between January 2005 and December 2010 were reviewed. Patients were separated by PDS or NACT-IDS. Preoperative characteristics, surgical procedures, and postoperative and oncologic outcomes were compared.

RESULTS

Of 117 patients, 95 women (81.2%) underwent PDS, and 22 women (18.8%) underwent NACT-IDS. Patients who underwent NACT-IDS were more likely to have stage IV disease (63.6% vs 26.3%; P = .001) and a low surgical complexity score (n = 14; 63.6%). There were no other differences between groups with respect to preoperative characteristics or postoperative morbidity. Compared with the NACT-IDS group, the PDS group had an improved progression-free survival (PFS; 15 vs 11 months; P = .006) and overall survival (OS; 53 vs 32 months; P = .036). Seventy-eight patients (66.7%) had a BMI of 30-34.9 kg/m(2). Within this subset of obese patients, the PDS group had an improved PFS (15 vs 10 months; P = .011) and OS (58 vs 32 months; P = .033), compared with the NACT-IDS group. Among patients with a BMI of ≥35 kg/m(2), there was no difference in PFS (14 vs 12 months; P = .316) or OS (38 vs 32 months; P = .640) when the PDS and NACT-IDS groups were compared.

CONCLUSION

Patients with a BMI of 30-34.9 kg/m(2) who undergo PDS have improved oncologic outcomes, compared with those women who undergo NACT-IDS. Patients with a BMI of ≥35 kg/m(2) who undergo PDS have similar oncologic outcomes to those who undergo NACT-IDS. Complication rates were similar at all BMIs, regardless of treatment approach.

Does neoadjuvant chemotherapy impair long-term survival for ovarian cancer patients? A nationwide Danish study

OBJECTIVE

In Denmark, the proportion of women with ovarian cancer treated with neoadjuvant chemotherapy (NACT) has increased, and the use of NACT varies among center hospitals. We aimed to evaluate the impact of first-line treatment on surgical outcome and median overall survival (MOS).

METHODS

All patients treated in Danish referral centers with stage IIIC or IV epithelial ovarian cancer from January 2005 to October 2011 were included. Data were obtained from the Danish Gynecological Cancer Database, the Danish National Patient Register and medical records.

RESULTS

Of the 1677 eligible patients, 990 (59%) were treated with primary debulking surgery (PDS), 515 (31%) with NACT, and 172 (10%) received palliative treatment. Of the patients referred to NACT, 335 (65%) received interval debulking surgery (IDS). Patients treated with NACT-IDS had shorter operation times, less blood loss, less extensive surgery, fewer intraoperative complications and a lower frequency of residual tumor (p < 0.05 for all). No difference in MOS was found between patients treated with PDS (31.9 months) and patients treated with NACT-IDS (29.4 months), p = 0.099. Patients without residual tumor after surgery had better MOS when treated with PDS compared with NACT-IDS (55.5 and 36.7 months, respectively, p = 0.002). In a multivariate analysis, NACT-IDS was associated with increased risk of death after two years of follow-up (HR: 1.81; CI: 1.39-2.35).

CONCLUSIONS

No difference in MOS was observed between PDS and NACT-IDS. However, patients without residual tumor had superior MOS when treated with PDS, and NACT-IDS could be associated with increased risk of death after two years of follow-up.

Primary debulking surgery or neoadjuvant chemotherapy followed by interval debulking surgery for patients with advanced ovarian cancer

OBJECTIVES

To compare the survival and perioperative morbidity between primary debulking surgery (PDS) and neoadjuvant chemotherapy followed by interval debulking surgery (NAC/IDS) in treating patients with advanced epithelial ovarian cancer (EOC).

METHODS

We retrospectively reviewed 67 patients with stage IIIC or IV EOC treated at Peking University Cancer Hospital from January 2006 to June 2009. Wherein, 37 and 30 patients underwent PDS and NAC/IDS, respectively.

RESULTS

No difference in overall survival (OS) or progression-free survival (PFS) was observed between NAC/IDS group and PDS group (OS: 41.2 vs. 39.1 months, P=0.23; PFS: 27.1 vs. 24.3 months, P=0.37). The optimal debulking rate was 60% in the NAC/IDS group, which was significantly higher than that in the PDS group (32.4%) (P=0.024). The NAC/IDS group had significantly less intraoperative estimated blood loss and transfusion, lower nasogastric intubation rate, and earlier ambulation and recovery of intestinal function than the PDS group (P<0.05).

CONCLUSIONS

NAC/IDS is less invasive than PDS, and offers the advantages regarding optimal cytoreduction rate, intraoperative blood loss, and postoperative recovery, without significantly impairing the survival compared with PDS in treating patients with stage IIIC or IV EOC. Therefore, NAC/IDS may be a valuable treatment alternative for EOC patients.

Update on first-line treatment of advanced ovarian carcinoma

Despite the high response rate to first-line treatment of advanced ovarian cancer, the vast majority of patients relapse. Maximal debulking surgery and chemotherapy with a platinum doublet have remained the standard of care for many years and new approaches are imperative. Recent clinical trials have given grounds for hope. Neoadjuvant chemotherapy, intraperitoneal delivery, and dose-dense strategies have all shown promising results, as has the targeting of angiogenesis. A greater understanding of the molecular landscape of ovarian cancer is helping to identify new treatment options. In this review, we will highlight the key trials and recent progress in these areas.

Platinum resistance after neoadjuvant chemotherapy compared to primary surgery in patients with advanced epithelial ovarian carcinoma

OBJECTIVE

Primary debulking surgery (PDS) has historically been the standard treatment for advanced ovarian cancer. Recent data appear to support a paradigm shift toward neoadjuvant chemotherapy with interval debulking surgery (NACT-IDS) for a subset of women with advanced ovarian cancer. It remains unresolved whether NACT-IDS increases the risk of platinum resistance. We compared response to chemotherapy in patients that received NACT-IDS vs. PDS.

METHODS

From our Cancer Registry database we identified patients with stages IIIC and IV epithelial ovarian cancer who underwent treatment from January, 2005 to December, 2010. Standard univariate analyses were performed, as were multivariable analysis with logistic regression. The Kaplan-Meier method was used to generate survival data.

RESULTS

The study population consisted of 425 patients, 95 (22.3%) underwent NACT-IDS and 330 (77.6%) PDS. After the initial platinum-based chemotherapy, 42 (44.2%) women in the NACT-IDS group were considered to have platinum resistant disease, compared to 103 (31.2%) in the PDS group (P=0.01). When multivariate logistic regression was used to control for factors independently associated with platinum resistance, NACT-IDS was no longer associated with an initial increased risk. However, in women that had a recurrence and were retreated with platinum-based chemotherapy, 32 (88.8%) in the NACT-IDS group had developed a recurrence within six months and were considered platinum resistant, compared to 62 (55.3%) in the PDS (P<0.001).

CONCLUSION

In women with EOC that have a recurrence and are treated again with platinum-based chemotherapy, NACT-IDS appears to increase the risk of platinum resistance.

Evaluation of serum levels of sCD30L ligand in patients with ovarian cancer in terms of selected clinico-pathological factors

AIM OF THE STUDY

The CD30L ligand is a membrane-associated glycoprotein expressed by activated CD4(+)Th cells, macrophages, dendritic cells, and B lymphocytes. It binds to the CD30 receptor carried on activated and helper Th cells, inducing the immune response and apoptosis. The aim of this retrospective study was to determine the level of sCD30L in the serum of patients at diagnosis of ovarian cancer and at relapse and to assess the potential association of this ligand with selected clinico-pathologic factors.

MATERIAL AND METHODS

We studied 69 patients with ovarian cancer allocated to two groups: A - ovarian cancer at diagnosis, B - relapse of ovarian cancer and active growth of the tumor.

RESULTS

We found high levels of sCD30L in ovarian cancer patients. Levels at relapse (21.48 ng/ml) were significantly higher than at diagnosis (11.81 ng/ml). Poor response to first-line chemotherapy was accompanied by higher levels of sCD30L and by several other findings: resistance to platinum analogs was common, neoadjuvant chemotherapy was needed, relapse and death during two-year follow-up were frequent.

CONCLUSIONS

Our present study might initially suggest that elevated concentration of sCD30L can be an important finding prognosticating a poor prognosis and is associated with platinum resistant and refractory cases of ovarian cancer. However, studies are needed on larger groups of patients.