A critique of surgical cytoreduction in advanced ovarian cancer

What is the role of conservative primary surgical management of epithelial ovarian cancer: the United States experience and debate

Certification in Gynecologic Oncology and creation of the Society of Gynecologic Oncologists in the United States have led to the development of a specialty with individuals capable of performing complex abdominal and pelvic operations in the management of epithelial ovarian carcinoma. These operations can be divided into two types. 1) A staging operation to assess the extent of disease through careful palpation, histologic and cytologic assessment of all peritoneal surfaces along with removal of the uterus, ovaries and fallopian tubes, omentum, together with a bilateral pelvic and aortic lymphadenectomy. Such information allows the clinician to determine prognosis and if postoperative adjuvant therapy is indicated. 2) A debulking operation designed to resect or reduce the size of metastatic lesions as well as to remove the primary tumor including a bilateral salpingo-oophorectomy. This operation is designed to improve survival and cure. In spite of this apparently clear paradigm, there has been a steady debate as to the apparent justification of these operations, especially when the former is performed in a women who has not completed her childbearing and especially when the latter requires "ultraradical" procedures. Many feel that the pendulum is now swinging toward fertility-sparing surgery among young women with early invasive cancers and toward either neoadjuvant chemotherapy or less than ultraradical debulking among women with advanced ovarian cancer. The purpose of this study is not to provide an exhaustive review but rather to outline this debate and focus on the American experience with conservative surgery in the management of epithelial ovarian carcinoma.

Androgen mediation of thrombocytosis in epithelial ovarian cancer biology

PURPOSE

Preoperative thrombocytosis (platelet count > 400 x 10(9)/L) at initial exploration for epithelial ovarian carcinoma is associated with decreased surgical cytoreducibility and poor survival. Platelets express androgen receptor (AR), which contains a polymorphic CAG trinucleotide repeat sequence of which the length inversely correlates with AR transactivation function. We hypothesized that androgen-mediated thrombocytosis promotes aggressive ovarian cancer biology.

EXPERIMENTAL DESIGN

Sixty-three patients with epithelial ovarian carcinoma underwent genotype analysis of the CAG repeat polymorphism in AR. Medical records were reviewed to assess preoperative thrombocytosis, surgical findings, and survival. Data were examined using the Fisher's exact, logistic regression, and Kaplan-Meier analyses.

RESULTS

AR CAG repeat lengths ranged from 8 to 27, with a median of 23. Fifteen of 63 patients (23.8%) showed preoperative thrombocytosis. Short AR allelotype (< or = 20 CAG repeats) was associated with a higher incidence of thrombocytosis (P = 0.04). The combination of short AR allelotype and thrombocytosis was the only significant factor that predicted inability to achieve optimal surgical cytoreduction (P = 0.02). Women with short AR allelotype and thrombocytosis showed statistically decreased progression-free survival (13 versus 37 months, P = 0.01) and overall survival (37 versus 65 months, P = 0.02) when compared with women with long AR allelotype and normal platelet counts. On multivariate analyses, suboptimal cytoreduction was the only significant factor predictive of disease-specific overall survival (P = 0.0002) but the combination of short AR allelotype and thrombocytosis approached statistical significance (P = 0.08).

CONCLUSIONS

Androgen modulation of thrombocytosis may promote aggressive epithelial ovarian cancer biology.

A retrospective analysis of neoadjuvant platinum-based chemotherapy versus up-front surgery in advanced ovarian cancer

The objective of this study is to compare progression-free survival (PFS) and overall survival (OS) of ovarian cancer patients treated with neoadjuvant chemotherapy and surgery to primary surgery and postoperative chemotherapy. Retrospective analysis from 1998 to 2003 of 116 patients with ovarian cancer was performed. Fifty women diagnosed by positive cytology received three cycles of carboplatin and paclitaxel. Thirty-six patients subsequently underwent cytoreductive surgery and completed three further cycles postoperatively. The OS and PFS were compared in 66 women treated with primary surgery and postoperative chemotherapy. A statistically significant difference was observed for OS (P= 0.03, HR = 1.85, CI = 1.06-3.23) and PFS (P= 0.04, HR = 1.61, CI = 1.03-2.53) favoring the primary surgery group. Due to the small numbers, age, grade, stage, pleural effusions, and histologic cell type were controlled for separately in the bivariate analyses. Controlling for stage made the results weaker. A matched subgroup survival analysis was performed on patients who had surgery following neoadjuvant chemotherapy. After matching for stage and grade and controlling age and pleural effusions (N= 28 matched pairs), there was no statistical difference for OS (P= 0.95, HR = 1.04, CI = 0.33-3.30) or PFS (P= 0.79, HR = 1.11, CI = 0.98-1.04). It is concluded that primary surgery should be considered in all patients. Neoadjuvant chemotherapy may be an alternative in a subset of women with the intent to also perform interval debulking.

Is there a role for neoadjuvant chemotherapy in the treatment of stage IV serous endometrial carcinoma?

Serous endometrial carcinoma (SEC) is an uncommon variant of endometrial carcinoma that is notorious for its aggressive clinical course. Similar to its ovarian counterpart, it has a propensity for early intraabdominal and lymphatic spread. We present two cases of advanced SEC, who were left with no residual tumor after neoadjuvant chemotherapy. After three courses of chemotherapy, both patients underwent interval debulking surgery, resulting in no residual disease. The documentation of chemosensitivity might enable the clinician to select a subpopulation of patients with widespread SEC that might benefit from interval debulking surgery.

Gynaecological cancer surgery

Cancers of the female genital tract account for a significant proportion of cancers in women. Surgery plays a major role in the management of these patients. As a single modality, it provides definitive treatment for early-stage cancers and contributes to the management of patients with advanced cancers as part of multimodality treatment. Surgery can involve relatively simple procedures, such as wide local excision for microinvasive lesions of the vulva. However, for more advanced cancers, such as metastatic ovarian cancer, surgery can be very complex indeed, at times requiring resection of non-gynaecological organs, such as small or large bowel. Extensive surgical training and experience is needed to successfully manage patients with these challenging conditions, and this has resulted in the development of the subspecialty of gynaecological oncology. This chapter discusses the place of surgery in the treatment of individual gynaecological cancers.

Primary peritoneal carcinoma--Uterine involvement and hysterectomy

OBJECTIVE

To assess the frequency of uterine involvement in primary peritoneal carcinoma (PPC) and to describe selected clinical characteristics in patients with and without hysterectomy.

METHODS

All incident cases of histologically confirmed cancer of the ovary or peritoneum, diagnosed in Israeli Jewish women between March 1 1994 and June 30, 1999, were identified within the framework of a nationwide epidemiological study of these neoplasms. The study population was accrued through an active search of all newly diagnosed patients in all the departments of gynecology in Israel. The data of 81 PPC patients included in the present study were abstracted from medical records.

RESULTS

Hysterectomy was performed in 48 patients. These patients had a lower mean age (62.4 +/- 9.4 vs. 66.9 +/- 10.4; P = 0.05) at diagnosis and a higher rate of < or =2 cm residual disease (54.2% vs.24.2%; P = 0.02). Of those with hysterectomy, microscopic involvement was verified in all those with macroscopic involvement. Overall microscopic involvement was present in 28 (58.3%) of the patients who underwent hysterectomy. In the majority of them, only the serosa was involved. Macroscopic uterine involvement was present in 27 (33.3%) patients but in only 12% it was >2 cm. The median survival in patients with hysterectomy was 36 months and in those without hysterectomy 29 months, this difference was statistically not significant (P = 0.2).

CONCLUSIONS

Our study indicates that in an unselected group of PPC patients 33% have any macroscopic uterine involvement. The therapeutic value of routine hysterectomy at the initial operation for PPC should be further investigated.

Splenectomy in the context of primary cytoreductive operations for advanced epithelial ovarian cancer

OBJECTIVE

To determine if the need to perform splenectomy due to metastatic disease in the context of complete primary cytoreduction for ovarian cancer diminishes the prognosis for survival.

METHODS

Between 1990 and 2004, 356 stage IIIC epithelial ovarian cancer patients underwent resection of all visible disease before systemic platinum-based combination chemotherapy. Forty-nine (13.8%) required a splenectomy due to metastatic disease. Survival was analyzed (log rank) on the basis of whether splenectomy was necessary. The frequency of performing other procedures, operative time, blood loss, transfusion rate, and hospitalization, was compared (Chi-square test; discrete and binomial data, t test; continuous data) on the basis of whether a splenectomy was required.

RESULTS

Survival was not influenced (log rank) by the requirement of splenectomy (required; median 56.4 months, estimated 5-year survival of 48% vs. not required; median 76.8 months, estimated 5-year survival of 58% P = 0.4). The splenectomy subgroup more commonly required en-bloc resection of reproductive organs with rectosigmoid (89.8% vs. 55.7%, P < 0.001), diaphragm stripping (63.3% vs. 33.6%, <0.001)), full-thickness diaphragm resection (28.6% vs. 9.4%, P < 0.001), and resection of grossly positive retroperitoneal nodes (67.3% vs. 46.3%, P = 0.006). The splenectomy group had a longer operative time (238 min vs. 192 min, P = 0.004), estimated blood loss (1663 ml vs. 1167 ml, P = 0.001), transfusion rate (5.3 units prbc vs. 3.2 units prbc, P = 0.002), and hospitalization (16.1 vs. 12.2 days P = 0.001).

CONCLUSIONS

The need for splenectomy to achieve complete cytoreduction is a reflection of advanced disease but is not a manifestation of tumor biology precluding long-term survival.

Primary chemotherapy and adjuvant tumor debulking in the management of advanced-stage epithelial ovarian cancer

The aim of this article was to review the experience with neoadjuvant chemotherapy and interval surgical debulking in patients with metastatic epithelial ovarian cancer. A retrospective chart review was carried out to identify patients treated with neoadjuvant platinum/Taxol chemotherapy and interval debulking. Cox regression modeling was used to identify significant predictors of progression-free interval. The Kaplan-Meier method was used to estimate the survival statistic for the study group. Sixty-one patients were identified after being treated with neoadjuvant chemotherapy and interval debulking surgeries. All surgeries were performed after three cycles of platinum/Taxol combination chemotherapy. Eighty percent of patients had a residual disease status of 2 cm or less after surgery. Suboptimal debulking was statistically associated with tumor involvement of the upper abdominal organs (P < 0.001) and non-normalization of CA125 before surgery (P= 0.03). The perioperative complication rate was 7%. At a mean follow-up time of 19 months, 77% of patients were still alive. Cox regression modeling identified the microscopic tumor residual status as the only significant predictor of progression-free interval. The estimated median survival for the group was 41.70 months (95% confidence interval = 13.84-69.56 months). Neoadjuvant chemotherapy with interval debulking surgery appeared to be safe and feasible in patients with metastatic epithelial ovarian carcinoma.

Who should operate on patients with ovarian cancer? An evidence-based review

OBJECTIVE

To evaluate the relationship between surgical specialty and survival in patients receiving initial surgical management for ovarian epithelial cancer.

STUDY METHODS

An analytic framework was constructed to address the principle question 'does the type of surgeon operating on patients with newly diagnosed ovarian epithelial cancer influence survival?' A literature search addressing the components of this analytic framework was carried out using the Cochrane Library, Medline, EMBASE, and HealthSTAR databases. Relevant articles were selected and graded using U.S. Preventive Services Task Force and Canadian Task Force guidelines. Results were summarized by quality as well as level of evidence.

RESULTS

Eighteen studies were reviewed. The quality of evidence was good in 3, fair in 8, and poor in 7 of the studies. The most common study flaws encountered were 'failure to account for confounders' and 'incompleteness of data'. In studies focusing on advanced disease, there was good quality evidence to support a 6- to 9-month median survival benefit for patients operated on by gynecologic oncologists rather than general gynecologists and/or general surgeons (P values 0.009 to 0.01). Studies focusing on early stage disease found gynecologic oncologists more likely to carry out optimal staging (P values 0.001 to 0.01). Increased survival could be explained by improved identification of true stage I patients.

CONCLUSION

Patients receiving initial surgical management for ovarian epithelial cancer should be operated on by gynecologic oncologists.

Discordance between beliefs and recommendations of gynecologic oncologists in ovarian cancer management

PURPOSE

The purpose of this study was to determine how physician experts make decisions for clinical scenarios in ovarian cancer and describe a profile of factors reported to influence treatment decisions.

METHODS

A questionnaire was sent to Full Members of the Society of Gynecologic Oncologists regarding surgery and chemotherapy for scenarios of primary and recurrent ovarian cancer.

RESULTS

In a scenario of primary presentation, 94% of respondents chose a treatment of tumor resection over chemotherapy. Despite the preference for surgery in a clinical scenario, 50% agreed with a statement that neoadjuvant chemotherapy is equivalent to primary surgery. In a scenario of recurrent disease, a comparable number of respondents chose a treatment of secondary cytoreductive surgery (45%) versus direct retreatment with chemotherapy (49%). Those choosing surgery responded that they believed in extensive surgery to achieve optimal cytoreduction. Most (62%) respondents described themselves as collaborative in treatment planning, yet only 24% reported that patient preference strongly influences their decision making.

CONCLUSIONS

Although a plan for primary cytoreduction is favored, in specific scenarios, views were divided for the role of neoadjuvant chemotherapy. For a recurrent disease scenario, support was divided between secondary cytoreductive surgery and direct retreatment with chemotherapy. Further clinical research is necessary to minimize the discordance between physician beliefs and recommendations.

Response of combination platinum and gemcitabine chemotherapy for recurrent epithelial ovarian carcinoma

OBJECTIVE

It has been postulated that gemcitabine inhibits DNA repair, and platinum resistance is due to increased DNA repair activity. The addition of gemcitabine to platinum-based agents may have synergistic tumoricidal activity.

METHODS

Retrospective chart review of all patients with recurrent, persistent, or progressive fallopian tube or ovarian carcinoma treated with a platinum-based compound and gemcitabine from 2001 to present was performed.

RESULTS

Twenty-nine patients on second to eight line chemotherapy met inclusion criteria. The median age was 53 years. Twenty-two patients received cisplatin and gemcitabine, and 7 patients received carboplatin and gemcitabine based on results of chemoresistance assays or prior chemorelated toxicities. The intent to treat was with six cycles of gemcitabine (1000 mg/m(2)) and either cisplatin (75 mg/m(2)) or carboplatin (AUC 5) day 1 and gemcitabine only on day 8 of a 21-day cycle. The median number of cycles administered was six. There were 20 grade 3 and 4 toxicities and 63% of patients by cycle 6 needed erythropoietin marrow support and 19% needed GCSF support by cycle 4. Twenty-one patients required discontinuation of day 8 that most commonly occurred at cycle 4. Eleven (38%) had CR, 5 (17%) had PR, 6 (21%) had SD, and 7 (24%) had PD, which is a 55% overall response. Nineteen of 29 patients (66%) showed platinum resistance to initial therapy. Of those, four (21%) had CR, four (21%) had PR, six (32%) had SD, and five (26%) with PD, which demonstrates a 42% overall response rate for this particular subset of patients.

CONCLUSIONS

Adjuvant combination platinum-based agent with gemcitabine is a very effective and well-tolerated treatment for recurrent fallopian tube or ovarian carcinoma; even in those who exhibit initial platinum resistance.

Factors associated with cytoreducibility among women with ovarian carcinoma

OBJECTIVES

The aim of the current study is to investigate the clinical and molecular factors associated with cytoreduction among women with advanced stage epithelial ovarian carcinoma EOC.

METHODS

Seventy-two women with FIGO stage III and IV EOC or primary peritoneal carcinoma (PPC) underwent similar attempt at surgical cytoreduction, mostly by the same surgeon. The histologic material of these patients was reviewed and the histologic subtype and grade were assigned. Immunohistochemical tests were performed for expression of molecular regulators of apoptosis (p53, p21, Bcl(2), Bcl(x), Bax) and chemoresistance (PGP, MRP, LRP, GST). The following factors were assessed for their association with complete (no residual tumor) and optimal (residual tumor < 1 cm) cytoreduction: type of carcinoma (EOC versus PPC), stage, CA-125 values, ascites, histology, tumor grade, and p53, p21, Bcl(2), Bcl(x), Bax, PGP, MRP, LRP, GST expression using the odds ratio and associated 95% confidence intervals. Significant univariate odds ratios were assessed jointly in a multivariate logistic regression model. Receiver operating characteristic curve analysis was performed to determine the CA-125 level with the maximal cytoreduction prognostic power.

RESULTS

Twenty-three (31.9%) women had no residual tumor, 35 (48.6%) had <or=1 cm residual tumor and 14 (19.4%) had residual tumor >1 cm. Factors with significant univariate associations with complete cytoreduction included stage, CA-125 level, ascites, histology, and p53. p53 expression was the only factor which remained significant in the multivariate analysis (odds ratio 7.2, 95% CI 1.5, 34.9). A preoperative CA-125 value of <or=500 IU/ml best determined complete cytoreducibility.

CONCLUSIONS

Innate tumor characteristics determine cytoreducibility of women with ovarian carcinoma. Pre-operative evaluation of p53 expression may be of value in predicting the outcome of cytoreductive surgery in women with advanced stage EOC.

A rationale for neoadjuvant systemic treatment followed by surgical assessment and intraperitoneal chemotherapy in patients presenting with non-surgically resectable ovarian or primary peritoneal cancers

PURPOSE

Optimal management of patients with advanced ovarian or primary peritoneal cancers who have received, and achieved an excellent response to, neoadjuvant chemotherapy remains undefined.

METHODS

Five patients are briefly presented who were found to have extensive intra-abdominal carcinomatosis from ovarian/peritoneal cancers and were initially treated with a carboplatin/paclitaxel-based neoadjuvant chemotherapy program. Following major objective and subjective responses each patient underwent a surgical re-assessment and subsequently received single-agent intraperitoneal platinum (cisplatin or carboplatin).

RESULTS AND CONCLUSION

In the absence of definitive data from randomized phase-3 trials defining optimal management in this setting, a rational argument can be provided supporting the use of this multi-modality management strategy (neoadjuvant chemotherapy followed by surgery and regional chemotherapy) in carefully selected patients presenting with extensive ovarian or primary peritoneal cancers.

Analysis of cytogenetic alterations in stage III serous ovarian adenocarcinoma reveals a heterogeneous group regarding survival, surgical outcome, and substage

Ovarian cancer is the leading cause of death among patients with gynecological cancers, but the biology of these tumors is still among the least understood of all major human malignancies. In this study, comparative genomic hybridization was used to determine chromosomal alterations in 98 stage III serous papillary adenocarcinomas. The tumors were grouped according to survival and the main prognostic factors stage and surgical outcome. There were chromosomal imbalances that were significantly more common in tumors from patients who died than in tumors from patients who survived: gains of 1q24-qter and losses of 4p, 4q31.1-qter, 5q12-q22, 8p, 16q, and X. Furthermore, we observed that gains of 8q23-8q24.2 and losses of 4p, 4q13-4q26, 4q31.1-qter, 5q12-q22, 8p, and 16q were significantly more common in tumors from patients with macroscopic residual tumor after primary surgery, compared to tumors from those who had undergone radical surgery. Gains of 3q13.3-qter, 6p, 7q21-q31, and 11q13-q23 and losses of 4q31.1-qter and 16q were more common in stage IIIc tumors than in stage IIIa+b tumors. On the basis of our results, we suggest that there are biological differences among the groups mentioned above and that absence of chromosomal aberrations in specific regions predicts a good clinical outcome for individual patients.

Management of peritoneal surface component of ovarian cancer

Primary surgery followed by systemic platinum-based chemotherapy is the cornerstone of management for ovarian cancer. However, the majority of patients have an advanced disease (stage III/IV) at the time of diagnosis rendering the optimal primary cytoreduction feasible in only a small percentage of cases. A large tumor bulk limits the success of subsequent antiblastic therapy. There are two alternatives to overcome this unfavorable situation: (1) employment of ultra-radical interventions such as peritonectomy procedures, to increase the optimal cytoreduction rate; or (2) neoadjuvant chemotherapy. Whether such strategies would have an influence on the final outcome of patients is an issue to be defined in further prospective randomized studies. For second-line therapies no consensus regarding treatment has emerged. When previous effective drug combinations fail, there is virtually no chance of inducing a significant response with second-line treatment. The combination of secondary CRS and intraperitoneal hyperthermic perfusion constitutes a feasible and potential option for this subset of patients based on phase II studies. A randomized trial will be conducted to test the effectiveness of this strategy in patients with cisplatin-resistant disease. The indication for second-line treatment is macroscopic residual or relapse within 6 months after the completion of first line chemotherapy.

The potential role of neoadjuvant chemotherapy in advanced ovarian cancer

There is a multitude of evidence from retrospective analyses and meta-analyses showing that the amount of residual tumor after debulking surgery and before chemotherapy is one of the most powerful prognostic determinants in advanced ovarian cancer. This supports the important role of maximum cytoreductive surgery as one of the cornerstones in the treatment of this disease. These same analyses, however, do not suggest that patients whose tumors cannot be debulked optimally derive a significant survival benefit from upfront surgery. For these patients and those who have a poor performance status or other morbidity, making comprehensive upfront surgery contraindicated, different therapeutic approaches have to be explored. One possible way to go is to change the timing of the different therapeutic modalities: upfront chemical cytoreduction, followed by a maximal surgical effort, in turn followed by the remainder of the first-line chemotherapy or neoadjuvant chemotherapy and interval or delayed debulking surgery. The potential role of this approach and the experience with it thus far are discussed.

Relative influences of tumor volume before surgery and the cytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study

OBJECTIVE

The purpose of this study was to determine the relative influences of the extent of disease present before surgery and completeness of cytoreduction on survival for patients with advanced ovarian cancer.

METHODS

Patients (408) with stage IIIC epithelial ovarian cancer had cytoreductive surgery before systemic platinum-based combination chemotherapy. A ranking system (0-3) was devised to prospectively quantify the extent of disease involving: (1) right upper quadrant (diaphragm/hepatic, and adjacent peritoneal surfaces), (2) left upper quadrant (omentum/gastro-colic ligament, spleen, stomach, transverse colon, splenic flexure of colon), (3) pelvis (reproductive organs, recto-sigmoid, pelvic peritoneum), (4) retroperitoneum (pelvic/aortic nodes), and (5) central abdomen (small bowel, ascending/descending colon, mesentery, anterior abdominal wall, pericolic gutters). Survival was analyzed (log rank and Cox regression) on the basis of the rankings at these anatomic regions, the sum of intraabdominal rankings, and the cytoreductive outcome.

RESULTS

Overall median and estimated 5-year survivals were 58.2 months and 49%. On univariate analysis, the central abdominal (P = 0.008) and left upper quadrant (P = 0.03) rankings, the sum of rankings (P = 0.01), and the cytoreductive outcome (P </= 0.0001) influenced survival (log rank). Survival was independently (stepwise Cox model) influenced by the sum of rankings (0-5, RR 1.00; 6-10, RR 1.24; 11-15, RR 1.44; P = 0.05), and completeness of cytoreduction (visibly disease-free, RR 1.00; </=1 cm residual, RR 2.32; >1 cm residual, RR 2.98; P = 0.001).

CONCLUSIONS

Cytoreduction to a visibly disease-free outcome has a more significant influence on survival than the extent of metastatic disease present before surgery. Operative efforts should not be abbreviated on the hypothesis that extensive disease at specific anatomic regions precludes long-term survival.

Neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy in patients with primarily unresectable, advanced-stage ovarian cancer

OBJECTIVE

The aim of this review is to report our experience and the feasibility of neoadjuvant chemotherapy in patients with advanced-stage ovarian cancer.

METHODS

Forty-five patients with primarily unresectable advanced-stage epithelial ovarian cancer were treated in our center between 1995 and 2002 by platinum-based neoadjuvant chemotherapy followed by surgery and adjuvant chemotherapy. Their files were reviewed retrospectively.

RESULTS

At the end of neoadjuvant chemotherapy, according to RECIST criteria, 1 patient (2.2%) had achieved a clinical complete response (CR), 33 (73.4%) a partial response (PR), and 8 (17.8%) had stable disease (SD). Only 3 (6.6%) patients showed disease progression (PD). Surgery was performed in patients with objective response or SD after a median number of 4 courses (range: 2-6) of induction chemotherapy. A complete macroscopic debulking was achieved in 24 (53.3%) out of 39 patients in whom cytoreductive surgery was performed. For the entire group, median overall survival was 29 months. Survival was significantly improved in patients with optimal debulking compared to patients with persistent tumor after surgery: 41 months versus 23 months (P = 0.0062). Median survival for patients responding to neoadjuvant chemotherapy (CR and PR) was 44 months compared to 27 months for patients with SD or PD after initial chemotherapy (P = 0.01). Neither treatment-related deaths nor significant toxicities were observed.

CONCLUSION

Neoadjuvant chemotherapy followed by optimal debulking may be a safe and valuable treatment alternative in patients with primarily unresectable advanced-stage bulky ovarian cancer. Patients with an objective response to chemotherapy or absence of macroscopic residual tumor after surgery have a better outcome. This approach is currently being tested in large, prospective randomized clinical trials.

Hemorrhagic Peritoneal Carcinomatosis Treated with a Weekly Schedule of Carboplatin and Paclitaxel. A Case Report

Ovarian carcinomas are chemosensitive tumors. Chemotherapy plays a pivotal role also in advanced disease, and the response to chemotherapy appears to be predictive of prolonged survival. Only performance status seems to limit therapy administration and affect patient survival.

Here we report on a 66-year-old patient with a clinical status heavily compromised by peritoneal carcinomatosis associated with bloody effusion, which required increasingly frequent paracentesis and transfusions. The clinical conditions worsened under carboplatin monochemotherapy. A further attempt with carboplatin and paclitaxel in a weekly schedule resulted in a clinical response in terms of reduced need for paracentesis and blood support and improved performance status. This case confirms that treatment is the only chance to improve clinical status even in patients with very advanced ovarian cancer and an extensive tumor load. In our opinion, the modified schedule adopted in the case presented here may be worthwhile for future phase II studies in a selected patient population.

Ovarian cancer in Western Australia (1982-1998): trends in surgical intervention and relative survival

OBJECTIVES

We aimed to review the utilisation and trends in surgical procedures for the primary management of ovarian cancer and the survival outcomes of patients surgically treated in Western Australia.

METHODS

The population-based Western Australia Data Linkage System was used to link hospital morbidity and mortality data for all women diagnosed with malignant primary ovarian cancer in the State Cancer Registry in the period 1982-1998. Poisson regression was used to analyse trends in surgical procedure rates. Logistic regression examined the likelihood of having a surgical procedure in the periods 1988-1993 and 1994-1998 compared with 1982-1987. Relative survival was used to adjust survival estimates for other causes of death occurring in the general female population.

RESULTS

There were 1,126 women who underwent a primary surgical procedure for ovarian cancer in Western Australia in the period 1982-1998. Women were more likely to undergo surgery in 1994-1998 (87.8%) compared with 1988-1993 (76.8%), but there was no difference when compared to 1982-1987 (89.2%) (P = 0.62). The likelihood of using specific surgical procedures to treat ovarian cancer increased for all but total abdominal hysterectomy. Bilateral salpingo-oophorectomy was 3.7 times more likely to be performed and omentectomy 5 times more likely to be performed in 1994-1998 compared with 1982-1987. The median length of hospital stay decreased from 15 to 12 days and emergency admissions decreased from 26.5 to 15.4% over the three time periods. Thirty-two percent of women were readmitted within 30 days of separation from their primary surgery, 23% of which were for the same-day treatment with either chemotherapy or radiotherapy. A 15% increase in relative survival was observed between the periods 1982-1997 (38.8%) and 1994-1998 (53.5%).Conclusion.

CONCLUSION

Surgery remains a cornerstone in the primary management of ovarian cancer. There have been dramatic shifts in surgical practice in Western Australia, with more women undergoing certain surgical procedures today than they were 20 years ago. Coupling the increasing surgical trends are improved outcomes. Fewer women are presenting as an emergency, the length of hospital stay has been reduced, and survival outcomes have shown a significant improvement.

Quality of life in women treated with neoadjuvant chemotherapy for advanced ovarian cancer: a prospective longitudinal study

OBJECTIVE

The purpose was to examine the outcomes of patients with advanced ovarian cancer treated with neoadjuvant chemotherapy, with a special emphasis on the patients' quality of life (QOL).

METHODS

Seventeen patients with advanced ovarian cancer were treated with neoadjuvant chemotherapy based on the extent of disease on computer tomography. All patients received combined platinum/paclitaxel chemotherapy. Debulking surgery was performed after three cycles or six cycles of chemotherapy, depending on the response to the chemotherapy. Patients' QOL was studied over time using European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and was then compared with that of patients treated with conventional treatment in the previous cohort.

RESULTS

The response rate to chemotherapy assessed at three cycles was 82.4%. The rate of optimum debulking to residual disease less than 2 cm after chemotherapy was 76.9%, and 38.5% had no gross residual disease after surgery. The median overall survival was 22.9 months. The median disease-free interval was 13.3 months. The overall QOL improved after chemotherapy and this continued to improve up to 12 months. The other functional scales also showed improvements over time, apart from the initial transient deterioration in the role functioning and cognitive functioning at 3 months after chemotherapy. Patients treated with neoadjuvant chemotherapy seem to have better but statistically insignificant difference in QOL parameters than patients treated conventionally.

CONCLUSION

Neoadjuvant chemotherapy is an alternative treatment for patients with advanced ovarian cancer in whom the chance of optimal cytoreduction is low. The patients' overall quality of life and functional status improve after neoadjuvant chemotherapy.

Reduction of blood loss during extensive pelvic procedures by aortic clamping--a preliminary report

OBJECTIVE

The aim was to determine the effect of intraoperative aortic clamping during extensive pelvic procedures on blood loss, operative time, and morbidity.

METHODS AND MATERIALS

Thirteen women with ovarian cancer, 1 with cervical cancer, and 1 with an extensive pelvic sarcoma had their aortas completely occluded with a vascular clamp before the pelvic phases of their operations. Heparin and protamine reversal were used.

RESULTS

Patients requiring en bloc excision of the internal reproductive organs, pelvic peritoneum, and recto-sigmoid colon in the context of a cytoreductive operation had a median estimated total blood loss of 650 ml (range 200 to 3500), a median of 2 units (range 0 to 8) of blood transfused, and a median total operative time of 155 min (range 90 to 280). There were no complications due to the aortic clamping.

CONCLUSION

Most procedures were completed with a less than anticipated blood loss and operative time. Clamping of the aorta may potentially diminish blood loss, operative time, and the incidence of transfusion-related morbidity associated with extensive pelvic operations. Intraoperative aortic clamping merits further investigation.

Interval debulking surgery in advanced epithelial ovarian cancer

Cytoreductive surgery and chemotherapy are the mainstay for the treatment of advanced epithelial ovarian cancer. In order to minimize the tumour burden before chemotherapy, cytoreductive surgery is usually performed first. The importance of the amount of residual disease as the main prognostic factor for patients suffering from advanced disease has been almost universally accepted even in the absence of prospective randomized trials addressing the benefit of cytoreductive surgery. In the last decade, the value of debulking surgery after induction chemotherapy - interval debulking surgery, IDS - has been widely debated, especially after the completion of a prospective randomized study from the EORTC addressing the introduction of a surgical procedure with debulking intent preceded and followed by cytoreductive chemotherapy. The rationale of such a strategy in the context of the primary treatment of advanced ovarian cancer lies in a higher cytoreductibility to the 'optimal' status forwarded, and possibly facilitated, by chemotherapy. The results demonstrated a prolongation of both progression-free survival and median survival in favour of patients randomized to IDS (5 and 6 months, respectively). Multivariate analysis revealed IDS to be an independent prognostic factor which reduced the risk of death by 33% at 3 years and by 48% in subsequent re-evaluation after more than 6 years of observation. Despite the above, results have been questioned by many, leading the GOG to perform a similar study which has been concluded very recently. Nevertheless, the main concern regarding the application of IDS in all instances relates to the morbidity of two major surgical procedures integrated within a short period during which cytotoxic chemotherapy is also administered. Neoadjuvant chemotherapy has been recently proposed to avoid a non-useful surgical procedure in patients considered 'optimally unresectable' after diagnosis of advanced ovarian cancer. Whether or not this newer approach will translate into a longer survival with a better quality of life is going to be addressed by a novel EORTC study. Finally, the concept of a 'chemical' cytoreduction preceding and facilitating a subsequent 'surgical' effort has been recently introduced also in the treatment of recurrent disease. The EORTC has recently initiated a prospective randomized study (LOROCSON - Late Onset Recurrent Ovarian Cancer: Surgery or Not) to validate the importance of such an approach to be balanced with medical treatment alone not only in terms of survival but also as far as quality of life is concerned.

Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis

PURPOSE

To evaluate the relative effect of percent maximal cytoreductive surgery and other prognostic variables on survival among cohorts of patients with advanced-stage ovarian carcinoma treated with platinum-based chemotherapy.

MATERIALS AND METHODS

Eighty-one cohorts of patients with stage III or IV ovarian carcinoma (6,885 patients) were identified from articles in MEDLINE (1989 through 1998). Linear regression models, with weighted correlation calculations, were used to assess the effects on log median survival time of the proportion of each cohort undergoing maximal cytoreduction, dose-intensity of the platinum compound administered, proportion of patients with stage IV disease, median age, and year of publication.

RESULTS

There was a statistically significant positive correlation between percent maximal cytoreduction and log median survival time, and this correlation remained significant after controlling for all other variables (P <.001). Each 10% increase in maximal cytoreduction was associated with a 5.5% increase in median survival time. When actuarial survival was estimated, cohorts with < or = 25% maximal cytoreduction had a mean weighted median survival time of 22.7 months, whereas cohorts with more than 75% maximal cytoreduction had a mean weighted median survival time of 33.9 months--an increase of 50%. The relationship between platinum dose-intensity and log median survival time was not statistically significant.

CONCLUSION

During the platinum era, maximal cytoreduction was one of the most powerful determinants of cohort survival among patients with stage III or IV ovarian carcinoma. Consistent referral of patients with apparent advanced ovarian cancer to expert centers for primary surgery may be the best means currently available for improving overall survival.

Procedures required to accomplish complete cytoreduction of ovarian cancer: is there a correlation with "biological aggressiveness" and survival?

OBJECTIVE

The aim of this study was to determine if the necessity of using specific procedures to attain complete cytoreduction in ovarian cancer correlates with innate biologic aggressiveness and independently influences survival.

METHODS

Between 1990 and 2000, 213 patients with Stage IIIC epithelial ovarian cancer underwent complete cytoreduction before initiation of systemic platinum-based combination chemotherapy. Survival was stratified and analyzed (log rank and Cox regression) on the basis of whether extrapelvic bowel resection, diaphragm stripping, full-thickness diaphragm resection, modified posterior pelvic exenteration, peritoneal implant ablation and/or aspiration, and excision of grossly involved retroperitoneal lymph nodes were necessary to attain a visibly disease-free cytoreductive outcome.

RESULTS

The median and estimated 5-year survival for the cohort were 75.8 months and 54%, respectively. Survival was influenced (log rank) by the requirement of diaphragm stripping (required, median 42 months vs not required, median 79 months; P = 0.03) and the extent of mesenteric and serosal implants that required removal (none, median not reached, vs 1-50 implants, median not reached, vs >50 implants, median 40 months; P = 0.002). Survival was independently influenced (Cox regression) only by the extent of peritoneal metastatic implants that required removal (P = 0.01). The other investigated procedures and type of chemotherapy used did not influence survival.

CONCLUSIONS

The need to remove a large number of peritoneal implants correlates with biological aggressiveness and diminished survival, but not significantly enough to preclude long-term survival or justify abbreviation of the operative effort. The need to use the other investigated procedures had minimal or no observed influence on survival.

What are the current surgical objectives, strategies, and technical capabilities of gynecologic oncologists treating advanced epithelial ovarian cancer?

OBJECTIVE

The purpose of this survey was to determine the range of surgical objectives, strategies, and outcomes of primary cytoreductive operations performed by gynecologic oncologists.

METHODS

A survey addressing the definition of "optimal" cytoreduction, the use of neoadjuvant chemotherapy, disease sites precluding optimal cytoreduction, reasons optimal cytoreduction or cytoreduction to a visibly disease-free outcome is or is not accomplished, the use of 15 specific operative procedures, and attitude toward postfellowship training in the surgical management of advanced stage epithelial ovarian cancer was mailed to candidate and full members of the Society of Gynecologic Oncologists. Analysis of discrete and binomial data utilized the chi(2) and independent samples t tests. Logistic regression confirmed relationships between responses and both the definition of optimal cytoreduction and the attitudes toward postfellowship training.

RESULTS

Three hundred ninety-three (61.4%) of 640 physicians provided utilizable data. A median of 95% of patients were reported to be operated on primarily and 5% were treated with neoadjuvant chemotherapy (P < 0.0001). A median of 9 (range 0-15) of the surveyed procedures were utilized. Forty-seven (12.0%) respondents defined optimal cytoreduction as no residual disease, 54 (13.7%) used a 5-mm threshold, 239 (60.8%) used a 1-cm threshold, and 48 (12.6%) utilized a 1.5- to 2.0-cm threshold. Small dimensions of residual disease (0-5 mm versus 1-2 cm) defined optimal cytoreduction for physicians indicating that fewer disease sites precluded optimal cytoreduction (P = 0.02), using a larger number of the surveyed procedures (P = 0.04), and in practice longer (P = 0.001). Three hundred seventeen (83.9%) of 378 respondents favored development of postfellowship training in cytoreductive surgery. Physicians against postfellowship training used fewer of the surveyed procedures because of concerns about efficacy (P = 0.01). More recent fellowship graduates favored postfellowship training (P = 0.01).

CONCLUSIONS

A range of surgical objectives, strategies, procedures used, and outcomes exists among gynecologic oncologists. Confirmation of the efficacy of cytoreductive surgery may cultivate a consensus about the most appropriate therapeutic objective and strategy for advanced ovarian cancer. Cooperative efforts should be undertaken to offer postfellowship training.