Meta-analysis of surgery in advanced ovarian carcinoma: is maximum cytoreductive surgery an independent determinant of prognosis?

Doxorubicin-melphalan with and without cisplatin in advanced ovarian cancer--ten-year survival results from a prospective randomized study by the Swedish Cooperative Ovarian Cancer Study Group

In a controlled prospective randomized study the regimen doxorubicin (A) 40 mg/m2 + melphalan (M) 0.4 mg/kg was compared with A + M + cisplatin (C) 50 mg/m2 given every four weeks in advanced ovarian cancer, FIGO stage III or IV and with serous or anaplastic histology. From 1981 to 1983, 300 patients entered the study and 295 patients were evaluable for response, toxicity and long-term survival. All patients were followed for at least 10 years. The majority of patients had large residual tumours >2 cm. Patients treated with MAC had a higher response rate compared with patients treated with MA (76% vs. 50%, p < 0.01) and treatment with MAC resulted in significantly more pathological complete responders than MA. There was a significant difference in median duration of response (19 months vs. 13 months, p < 0.006) and in median survival time (26 months vs. 19 months, p = 0.05). After 5- and 10 years a significant difference in progression-free and overall survival was found. The independent prognostic factors in this study were residual tumour after primary surgery, treatment with MAC, tumour grade, ascites, and stage. Objective and subjective side effects were significantly worse with MAC, although tolerable. In conclusion, this study shows that incorporating C into MA improves the duration of progression-free survival and overall survival in women with incompletely resected Stage III or Stage IV ovarian epithelial cancer. A 5- and 10-year survival of 25% and 18%, respectively, is impressive.

Prospective randomized trials on cytoreduction in ovarian cancer

Ovarian cancer remains the main cause of death from gynaecological malignancy in England and Wales. Since the reports by Griffiths et al. in the 1970s that optimal cytoreduction to less than or equal to 1.5 cm is associated with an increase in survival there has been a gradual trend towards more radical surgery aimed at maximal tumour reduction. Since these first reports many others have made similar observations, so that now maximal surgical endeavour aimed at cytoreduction is almost standard practice. However, the majority of these reports are based on retrospective analysis, small numbers, poor standardization of treatment and other methodological inconsistencies. To date, no prospective randomized trials have been completed to confirm Griffiths's findings. The authors propose the case for a randomized trial before accepting a new and potentially morbid procedure as standard practice.

Primary surgery in ovarian cancer: current opinions

There have been no controlled clinical trials supporting the use of primary cytoreductive surgery. The question remains as to whether the observed survival benefits for patients subjected to primary cytoreductive surgery are an effect of surgical skill or tumour biology. The proponents of tumour biology claim that cytoreductive surgery is a selective procedure, choosing patients with better prognosis. This paper discusses indirect evidence in the literature in support of, or in contradiction to, this hypothesis.

Long term survival by cytoreductive surgery to less than 1 cm, induction weekly cisplatin and monthly cisplatin, doxorubicin, and cyclophosphamide therapy in advanced ovarian adenocarcinoma

BACKGROUND

Survival rates for patients with advanced epithelial ovarian cancer remain low despite improved chemotherapy regimens and cytoreductive surgery.

METHODS

One hundred thirty-six patients with Stage III or IV ovarian cancer were treated with primary cytoreductive surgery followed by cisplatin induction, 1 mg/kg weekly x 4 followed by 10 cycles of cisplatin (50 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (750 mg/m2). Second-look surgery was performed on those patients who were clinically without evidence of disease at the end of the planned chemotherapy course. Survival and progression-free survival were calculated, and prognostic factors regarding survival and progression-free survival were evaluated by both univariate and multivariate analyses.

RESULTS

Cytoreductive surgery to less than or equal to 2 cm was performed on 83% of patients and to less than 1 cm in 40%. A surgical complete response (SCR) rate of 34.9% and surgical partial response (SPR) rate of 47.6% were noted. Of the SCRs, recurrences developed in 52.7% of the patients. Estimated 5- and 8-year survival for all 136 patients was 31.2% and 21.5%, and 5- and 8-year progression-free survival was 23.9% and 20.6%, respectively. Those patients with less than 1-cm residual disease after primary surgery had significantly improved survival compared with those with 1-2 cm or greater than 2 cm (P < 0.001). Multivariate analysis identified residual disease status and age as the most significant prognostic factors associated with survival and progression-free survival.

CONCLUSION

Compared with those patients with greater than 1-cm residuum after initial surgery, a statistically significant improvement in long term survival was noted for those patients whose cancers were cytoreduced to less than 1-cm residuum.

Surgical management of ovarian cancer

Although several surgical approaches to the diagnosis and management of epithelial ovarian cancer are now standard, surprisingly few prospective data exist to support many of these procedures. However, retrospective data have accumulated over the past decade, much of it very recent, which allow clinicians to make informed decisions regarding most of the commonly performed procedures. This review is an attempt to critically evaluate the best available data regarding the following procedures: primary surgical staging, primary cytoreductive surgery, second look laparotomy and secondary cytoreductive surgery, and palliative surgery for relief of bowel obstruction. We conclude that there is evidence to support the continued use of primary surgical staging and primary cytoreductive surgery. However, data in support of second look laparotomy and secondary cytoreductive surgery are lacking, and we recommend that these procedures not be performed on a routine basis. Finally, we conclude that palliative surgery is hazardous at best and results in questionable benefits for most patients.

A randomised study of cisplatin versus thiotepa as induction chemotherapy in advanced ovarian carcinoma

Between 1980 and 1984, a total of 171 patients with advanced epithelial ovarian carcinoma and residual tumour after surgery were randomly assigned to treatment groups receiving either cisplatin or thiotepa. The objective of the study was to evaluate the regimes with regard to response and survival. The two groups were well balanced with respect to age, FIGO stage, histology, grade and residual tumour after surgery. In the cisplatin group, 66% responsed to treatment compared to 38% in the thiotepa group (P < 0.00005). The median progression-free survival was 10.5 months and 6.3 months, respectively. The corrected survival was somewhat, but non-significantly, higher in the cisplatin group than in the thiotepa group, with an 8-year corrected survival of 10.6 and 7.4%, respectively. In a multivariate analysis, based on progression-free survival with FIGO stage, residual tumour after surgery, histological type and grade as covariables, treatment with thiotepa had a relative risk of 1.64 compared to cisplatin (95% confidence interval 1.17-2.30, P = 0.004).

Neoadjuvant carboplatin and ifosfamide chemotherapy for inoperable FIGO stage III and IV ovarian carcinoma

Thirty patients aged 34-69 years (median 56) with previously untreated FIGO Stage III and IV ovarian carcinoma were given carboplatin (400 mg/m2) and ifosfamide (5 g/m2) with mesna every 28 days for a median of 3 cycles, followed, where possible, by laparotomy. Objective responses were observed in 13 (43%) patients, 11 of whom proceeded to laparotomy. Nine were successfully debulked, and two of these had removal of all macroscopic disease. Three cycles of chemotherapy were found to achieve the optimum response for the least toxicity. After a minimum follow-up of 32 months, two patients who had had debulking surgery remain alive. The median response duration was 13.9 months in the debulked group compared with 3 months in those who remained inoperable, while the corresponding median survivals were 23.4 and 6.4 months. This study suggests that neoadjuvant chemotherapy given over 8 weeks may render debulking surgery feasible in a proportion of patients presenting with unresectable ovarian cancer and can result in an improved median survival.

Advanced ovarian cancer. An overview of multi-variate analyses of prognostic variables with special reference to the role of cytoreductive surgery

BACKGROUND

Cytoreductive surgery is still widely believed to be a cornerstone in the management of advanced ovarian cancer. In the absence of data from prospective randomized trials, multi-variate analysis can assist in evaluating the role of optimal surgical cytoreduction relative to other possible prognostic variables.

MATERIALS AND METHODS

Published analyses of prognostic variables have been reviewed and the consistency and reproducibility of variables have been considered.

RESULTS

When reviewing the most recent literature it is obvious that there is a need to develop a consensus as to the most important patient characteristics which should be reported. Furthermore, these characteristics need to be standardized as do definitions such as toxicity, grading, and response criteria and duration. Subjective variables such as performance status, histological grading and typing, present a special problem as these lack reproducibility. The overview of multi-variate analyses for prognostic variables such as residual tumour size, tumour size prior to cytoreductive surgery, cisplatin therapy, grade, stage, histology, and performance status demonstrates that the impact of individual prognosticators depends on the indicators included in the analysis and that the importance of these variables could change as new technologies and treatments are introduced.

CONCLUSIONS

The collection of a single data base including all known variables reported for each patient with appropriate attention to the careful evaluation of subjective indicators should be undertaken, with a view to establishing a prognostic index. This would allow the relative risk for individual patients to be assessed.

The prognostic value of nuclear roundness and neopterin in ovarian cancer

The prognostic value of clinical factors, morphometric features and neopterin, a marker for macrophage activation, was investigated retrospectively in 68 ovarian carcinoma patients. Nuclear roundness was a good predictor of patient survival. About 50% of our patients showed neopterin concentrations above the cut-off level of 275 mumol/mol creatinine. Interestingly, those patients with elevated urinary neopterin concentration, and thus displaying a sign of activation of cell-mediated immunity, had a shorter survival than those with normal concentration. Applying a multivariate Cox regression analysis, the only independent parameters predicting patient survival were FIGO stage, residual disease, nuclear roundness and neopterin.