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Kim SR, Parbhakar A, Li X, Bernardini MQ, Hogen L, May T. Primary cytoreductive surgery compared with neoadjuvant chemotherapy in patients with BRCA mutated advanced high grade serous ovarian cancer: 10 year survival analysis. Int J Gynecol Cancer 2024; 34:879-885. [PMID: 38548312 DOI: 10.1136/ijgc-2023-005065] [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: 06/05/2024] Open
Abstract
OBJECTIVES Given the high response to platinum based chemotherapy in BRCA 1/2 mutated high grade serous ovarian cancers, there is uncertainty about the relative benefits of primary cytoreductive surgery versus neoadjuvant chemotherapy in this population. We aimed to compare the survival outcomes for women with BRCA 1/2 mutated high grade serous ovarian cancers undergoing either primary cytoreductive surgery or neoadjuvant chemotherapy. METHODS We conducted a retrospective cohort study of all stage III/IV BRCA mutated high grade serous ovarian cancers treated with primary cytoreductive surgery or neoadjuvant chemotherapy at a single tertiary cancer center between 1991 and 2020. Baseline demographics, initial disease burden, surgical complexity, and survival outcomes were examined. RESULTS Of 314 women with germline or somatic BRCA mutations, 194 (62%) underwent primary cytoreductive surgery and 120 (38%) underwent neoadjuvant chemotherapy followed by interval cytoreductive surgery. Those undergoing primary cytoreductive surgery were younger (median age 53 years (range 47-59) vs 59 years (50-65), p<0.001), but there were no differences in functional status or underlying comorbidities. The initial disease burden was lower (disease score high (40% vs 44%; p<0.001) but surgical complexity was higher (surgical complexity score high (18% vs 3%; p<0.001) in the primary cytoreductive surgery cohort. The rate of optimal or complete cytoreduction was similar in both groups (89% vs 90%; p=0.23) as well as the rate of poly (ADP-ribose) polymerase inhibitor use (62% vs 68%; p=0.3). The 10 year overall survival and recurrence free survival were superior in the primary cytoreductive surgery cohort (overall survival 49% vs 25%, p<0.001 and progression free survival 25% vs 10%, p<0.001). After controlling for confounders, primary cytoreductive surgery remained a significant predictor of improved overall survival (hazard ratio (HR) 0.45; 95% confidence interval (CI) 0.27 to 0.74; p=0.002) and recurrence free survival (HR 0.55; 95% CI 0.37 to 0.80; p=0.002). CONCLUSIONS Primary cytoreductive surgery was associated with improved survival in women with stage III/IV BRCA mutated high grade serous ovarian cancers compared with neoadjuvant chemotherapy.
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Affiliation(s)
- Soyoun Rachel Kim
- Division of Gynaecologic Oncology, Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | | | - Xuan Li
- Department of Biostatistics, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Marcus Q Bernardini
- Princess Margaret Cancer Centre/University Health Network/Sinai Health Systems, Princess Margaret Hospital, Toronto, Ontario, Canada
| | - Liat Hogen
- Gynaecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Taymaa May
- Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto, Ontario, Canada
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Costales AB, Crane EK, Chambers L, Yao M, Chau D, Naumann WR, Debernardo R, Ricci S, Rose PG, Michener CM. Laparoscopic predictability of minimally invasive interval debulking in advanced ovarian cancer: The MIID-SOC trial. Gynecol Oncol 2024; 185:143-147. [PMID: 38417209 DOI: 10.1016/j.ygyno.2024.02.019] [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: 11/07/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 03/01/2024]
Abstract
BACKGROUND We sought to create a laparoscopic-based model to predict the ability to perform a minimally invasive (MIS) cytoreductive surgery in advanced epithelial ovarian cancer patients who have received neoadjuvant chemotherapy (NACT). METHODS Fifty women were enrolled in a multi-institutional prospective pilot study (NCT03378128). Each patient underwent laparoscopic evaluation of 43 abdominopelvic sites followed by surgeon dictated surgical approach, either continue MIS or laparotomically. However, if the procedure continued MIS, the placement of a hand-assist port for manual palpation was mandated to emulate a laparotomic approach and all 43 sites were re-evaluated. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each site to predict MIS resectability. Each parameter was assigned a numeric value based on the strength of statistical association and a total predictive index score (PIV) was assigned for each patient. Receiver operating characteristic curve analysis was used to assess the ability of the model to predict the MIS approach. RESULTS Twenty-seven patients (61%) underwent MIS surgery. The following abdominopelvic sites were selected for inclusion in the model: gastrosplenic ligament, rectum, left mesocolon, transverse colon, right colon, cecum, appendix, liver capsule, intrahepatic fossa/gallbladder, ileum/jejunum. Using the PIV, a ROC was generated with an AUC = 0.695. In the final model, a PIV <2 identified patients able to undergo an optimal MIS cytoreductive surgery with an accuracy of 68.2%. The specificity, or the ability to identify patients who would not be able to undergo an optimal MIS interval cytoreductive surgery, was 66.7%. CONCLUSION This predictive index model may help to guide future inclusion criteria in randomized studies evaluating the MIS approach in advanced epithelial ovarian cancer.
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Affiliation(s)
- Anthony B Costales
- Gynecologic Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, United States of America.
| | - Erin K Crane
- Gynecologic Oncology, Levine Cancer Institute, Atrium Health System, United States of America
| | - Laura Chambers
- Gynecologic Oncology, Taussig Comprehensive Cancer Center, Cleveland Clinic, United States of America
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic, United States of America
| | - Danielle Chau
- Gynecologic Oncology, Taussig Comprehensive Cancer Center, Cleveland Clinic, United States of America
| | - Wendel R Naumann
- Gynecologic Oncology, Levine Cancer Institute, Atrium Health System, United States of America
| | - Robert Debernardo
- Gynecologic Oncology, Taussig Comprehensive Cancer Center, Cleveland Clinic, United States of America
| | - Stephanie Ricci
- Gynecologic Oncology, Taussig Comprehensive Cancer Center, Cleveland Clinic, United States of America
| | - Peter G Rose
- Gynecologic Oncology, Taussig Comprehensive Cancer Center, Cleveland Clinic, United States of America
| | - Chad M Michener
- Gynecologic Oncology, Taussig Comprehensive Cancer Center, Cleveland Clinic, United States of America
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Ejaredar M, Ruzycki SM, Glazer TS, Trudeau P, Jim B, Nelson G, Cameron A. Implementation of a surgical site infection prevention bundle in gynecologic oncology patients: An enhanced recovery after surgery initiative. Gynecol Oncol 2024; 185:173-179. [PMID: 38430815 DOI: 10.1016/j.ygyno.2024.02.023] [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: 09/26/2023] [Revised: 02/10/2024] [Accepted: 02/17/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE To evaluate the clinical outcomes pre- and post-implementation of an evidence-informed surgical site infection prevention bundle (SSIPB) in gynecologic oncology patients within an Enhanced Recovery After Surgery (ERAS) care pathway. METHODS Patients undergoing laparotomy for a gynecologic oncology surgery between January-June 2017 (pre-SSIPB) and between January 2018-December 2020 (post-SSIPB) were compared using t-tests and chi-square. Patient characteristics, surgical factors, and ERAS process measures and outcomes were abstracted from the ERAS® Interactive Audit System (EIAS). The primary outcomes were incidence of surgical site infections (SSI) during post-operative hospital admission and at 30-days post-surgery. Secondary outcomes included total postoperative infections, length of stay, and any surgical complications. Multivariate models were used to adjust for potential confounding factors. RESULTS Patient and surgical characteristics were similar in the pre- and post-implementation periods. Evaluation of implementation suggested that preoperative and intraoperative components of the intervention were most consistently used. Infectious complications within 30 days of surgery decreased from 42.1% to 24.4% after implementation of the SSIPB (p < 0.001), including reductions in wound infections (17.0% to 10.8%, p = 0.02), urinary tract infections (UTI) (12.7% to 4.5%, p < 0.001), and intra-abdominal abscesses (5.4% to 2.5%, p = 0.05). These reductions were associated with a decrease in median length of stay from 3 to 2 days (p = 0.001). In multivariate analysis, these SSI reductions remained statistically significant after adjustment for potential confounders. CONCLUSION Implementation of SSIPB was associated with a reduction in SSIs and infectious complications, as well as a shorter length of stay in gynecologic oncology patients.
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Affiliation(s)
- Maede Ejaredar
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shannon M Ruzycki
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tali Sara Glazer
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Pat Trudeau
- Surgery Strategic Clinical Network TM, Alberta Health Services, Edmonton, Alberta, Canada
| | - Brent Jim
- Department of Oncology & Department of Obstetrics and Gynecology, University of Saskatchewan, Regina, Saskatchewan, Canada
| | - Gregg Nelson
- Department of Oncology and Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Anna Cameron
- Department of Oncology and Department of Obstetrics & Gynecology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Li C, Cui Q, Wang X, Yao S, Tu H, Chen M. CA-125 elimination rate constant K (KELIM) as a promising predictor of complete cytoreduction after neoadjuvant chemotherapy in advanced ovarian cancer patients: a retrospective study from two Chinese hospitals. BMC Cancer 2024; 24:609. [PMID: 38769484 PMCID: PMC11107035 DOI: 10.1186/s12885-024-12252-3] [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: 01/03/2024] [Accepted: 04/11/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND The modeled CA-125 elimination constant K (KELIM) is a potential marker of tumor chemosensitivity in ovarian cancer patients treated with neoadjuvant chemotherapy (NACT) before interval surgery. The objective of this study was to externally validate the KELIM (rate of elimination of CA-125) score in patients with high-grade serous ovarian cancer (HGSC) undergoing NACT and explore its relation to the completeness of IDS and survival. METHODS The study was based on a retrospective cohort of 133 patients treated for advanced HGSC, International Federation of Gynecology and Obstetrics (FIGO) stages III-IV, with neoadjuvant chemotherapy, folllowed by interval surgery, in two centres in China. CA-125 concentrations at baseline and during neoadjuvant chemotherapy were collected. We used standardized (std) KELIM for subsequent analysis. Clinicopathologic parameters were collected, and Kaplan‒Meier survival analyses were performed for PFS and OS. RESULTS KELIM was an independent predictor of the probability of complete surgery and survival in our cohort. The median std KELIM score of patients with complete surgery was significantly higher than that of patients with incomplete IDS (1.20 vs. 0.71, P < 0.001). Multivariate analysis showed that a std KELIM score ≥0.925 was an independent predictive factor for achieving complete resection (OR = 5.480; 95% CI, 2.409-12.466, P < 0.001) and better PFS (HR = 0.544; 95% CI: 0.349-0.849, P = 0.007) and OS (HR = 0.484; 95% CI: 0.251-0.930, P = 0.030). CONCLUSIONS The tumor-primary tumor chemosensitivity, assessed by the modeled CA-125 KELIM, calculated during NACT, is a major parameter to consider for decision-making regarding IDS attempts and predicting patient survival.
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Affiliation(s)
- Cheng Li
- Department of Gynaecology, Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan Second Road 1, 510080, Guangzhou, Guangdong, China
| | - Qiulin Cui
- Department of Gynaecology, Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan Second Road 1, 510080, Guangzhou, Guangdong, China
| | - Xuanhui Wang
- Department of Gynaecology, Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan Second Road 1, 510080, Guangzhou, Guangdong, China
| | - Shuzhong Yao
- Department of Gynaecology, Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan Second Road 1, 510080, Guangzhou, Guangdong, China
| | - Hua Tu
- Department of Gynecologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China.
| | - Ming Chen
- Department of Gynaecology, Guangdong Provincial Clinical Research Center for Obstetrical and Gynecological Diseases, The First Affiliated Hospital of Sun Yat-sen University, Zhongshan Second Road 1, 510080, Guangzhou, Guangdong, China.
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Filippova OT, Boecking K, Broach V, Gardner GJ, Sonoda Y, Chi DS, Zivanovic O, Long Roche K. Trends in specific procedures performed at the time of cytoreduction for ovarian cancer: Is interval debulking surgery truly less radical? A Memorial Sloan Kettering Cancer Center Team Ovary study. Gynecol Oncol 2024; 187:80-84. [PMID: 38735143 DOI: 10.1016/j.ygyno.2024.05.009] [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: 12/15/2023] [Revised: 05/03/2024] [Accepted: 05/07/2024] [Indexed: 05/14/2024]
Abstract
OBJECTIVES To evaluate procedures performed during primary debulking surgery (PDS) and interval debulking surgery (IDS) for ovarian cancer. METHODS Patients surgically treated at our institution for newly diagnosed stage IIIC/IV epithelial ovarian cancer between 6/1/2015-12/31/2021 were identified using a prospectively collected database. Patients were triaged to PDS or neoadjuvant chemotherapy (NACT) followed by IDS using an institutional algorithm. Data on specific procedures performed, including consultants called, were collected from operative and pathology reports. Appropriate statistical analyses were applied. RESULTS Overall, 467 patients underwent PDS and 434 underwent IDS; 76% (PDS) and 71% (IDS) of cases achieved complete gross resection. Comparing PDS vs IDS cohorts, median age was 63 years (range, 23-86) vs 67 years (range, 35-95), 79% vs 86% of patients had high-grade serous histology, and 38% vs 70% had stage IV disease. Most procedures (except ostomy, distal pancreatectomy) were more common during PDS (P < .05). Bowel surgery was performed during 65% of PDS and 33% of IDS, and upper abdominal surgery during 72% of PDS and 52% of IDS; both were more common during PDS (P < .001). Estimated blood loss (median, 500 mL [PDS] vs 300 mL [IDS]) and operative time (median, 362 min [PDS] vs 267 min [IDS]) were higher for PDS (P < .001). A consulting surgeon was utilized during 31% of PDS and 18% of IDS, with hepatopancreaticobiliary as the most commonly called service (61% and 65%, respectively). CONCLUSIONS In our study of patients with advanced-stage ovarian cancer, while most procedures were more often performed during PDS, NACT did not obviate the need for radical surgical resection. Thus, advanced surgical skills remain essential.
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Affiliation(s)
- Olga T Filippova
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Katherine Boecking
- Department of OB/GYN, Ochsner Clinic Foundation, New Orleans, LA, United States of America
| | - Vance Broach
- 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
| | - 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
| | - 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
| | - 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.
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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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Zhao M, Gao Y, Yang J, He H, Su M, Wan S, Feng X, Wang H, Cai H. Predictive value of the Adult Comorbidity Evaluation 27 on adverse surgical outcomes and survival in elderly with advanced epithelial ovarian cancer undergoing cytoreductive surgery. Eur J Med Res 2024; 29:179. [PMID: 38494480 PMCID: PMC10946157 DOI: 10.1186/s40001-024-01666-1] [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: 04/18/2023] [Accepted: 01/12/2024] [Indexed: 03/19/2024] Open
Abstract
OBJECTIVE We aimed to evaluate the ability of Adult Comorbidity Evaluation 27 (ACE-27) to predict perioperative outcomes and survival in elderly women with advanced epithelial ovarian cancer (AEOC) undergoing cytoreductive surgery. METHODS We collected patients with AEOC in our hospital between January 1, 2012 and January 1, 2021. Patients younger than 65 years old or those with non-epithelial ovarian cancer were excluded. ACE-27 was applied retrospectively to assess comorbidities in the selected patients, who were then classified into two groups based on their ACE-27 scores: low ACE-27 score group (none to mild) and high ACE-27 score group (moderate to severe). RESULTS A total of 222 elderly women with AEOC were included, of whom 164 patients accepted debulking surgery. Among those who have undergone surgery, Clavien-Dindo grade III + perioperative complications or unintended intensive care unit (ICU) admission occurred more often in patients of high ACE-27 score group, with statistically significant difference (odds ratio [OR]: 4.21, 95% confidence interval [CI], 1.28-14.35, p = 0.018). Further stratified analyses by age, BMI, FIGO stage and pathology also prove that OS of patients graded severe was shorter than patients graded none to moderate in cohort of age < 70, BMI < 25 kg/m2, FIGO III stage and pathology of serous, respectively. Kaplan-Meier survival curves analyzed by log-rank test showed that the overall survival (OS) of patients with severe comorbidities were shorter than with none to moderate (HR 3.25, 95%CI 1.55-6.79, p = 0.002). CONCLUSIONS Our findings demonstrate the ability of ACE-27 to predict grade III + perioperative complications or unintended ICU admission and survival in elderly patients with AEOC. This highlights the possibility for ACE-27 to play an instrumental role in identifying AEOC patients who are more susceptible to adverse surgical outcomes and have a poor survival rate and assisting in decisions regarding treatment.
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Affiliation(s)
- Mengna Zhao
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Yang Gao
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Junyuan Yang
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Hao He
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Min Su
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Shimeng Wan
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Xiaoye Feng
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Hua Wang
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China
| | - Hongbing Cai
- Department of Gynecological Oncology, Hubei Clinical Cancer Study Center, Hubei Key Laboratory of Tumor Biological Behaviors, Zhongnan Hospital of Wuhan University, No. 169 East Lake Road, Wuhan, 430071, People's Republic of China.
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Tortorella L, Cappuccio S, Giannarelli D, Nero C, Marchetti C, Gallotta V, Costantini B, Pasciuto T, Minucci A, Fagotti A, Scambia G. Distribution and prognostic role of BRCA status in elderly ovarian cancer patients. Gynecol Oncol 2024; 182:57-62. [PMID: 38262239 DOI: 10.1016/j.ygyno.2023.12.022] [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: 10/17/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/25/2024]
Abstract
OBJECTIVE In the era of target therapy and personalized medicine, BRCA mutational status has a major influence on survival in ovarian cancer patients. Our aim is to verify if the poorer prognosis of elderly ovarian cancer patients can be related to the biology of the tumor beyond their own morbidities and/or suboptimal treatments. METHODS This is a retrospective single-institution study evaluating prognosis of patients with a diagnosis of ovarian cancer and known BRCA status. We collected clinical and surgical characteristics and the distribution of BRCA mutational status according to age groups. RESULTS 1840 patients were included in the analysis. The rate of BRCA mutated decreased over age-range from 49.7% in patients aged <50 years to 18.8% in ≥80 years old women. The prognostic role of BRCA status on survival is maintained when focusing on the elderly population, with improved Disease Free Survival (27.2 months vs 16.5 months for BRCA mutated and wild type respectively, p = 0.001) and Cancer Specific Survival (117.6 months vs 43.1 months for BRCA mutated and wild type respectively, p = 0.001) for BRCAmut compared to BRCAwt patients. In the multivariable analysis, among elderly women, upfront surgery and BRCA mutation are independent factors affecting survival. CONCLUSIONS Elderly patients experiment a poorer prognosis due to multiple factors that include both their medical condition and comorbidities, under-treatment and most importantly disease characteristics. We found that beyond disparities, BRCA mutation is still the strongest independent prognostic factor affecting both the risk of recurrence and death due to disease.
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Affiliation(s)
- Lucia Tortorella
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Serena Cappuccio
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Diana Giannarelli
- Epidemiology and Biostatistics Facility G-STeP Generator Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Camilla Nero
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Claudia Marchetti
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Valerio Gallotta
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Barbara Costantini
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Unicamillus, International Medical University, Via di Sant'Alessandro 8, 00131 Rome, Italy
| | - Tina Pasciuto
- Epidemiology and Biostatistics Facility G-STeP Generator Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy
| | - Angelo Minucci
- Genomics Core Facility, Gemelli Science and Technology Park (G-STeP), Fondazione Policlinico Universitario Agostino Gemelli IRCCS, L.go A. Gemelli, 00167 Roma, Italy
| | - Anna Fagotti
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00167 Rome, Italy.
| | - Giovanni Scambia
- Department of Woman and Child Health and Public Health Sciences, Gynercologic Oncology Unit Fondazione Policlinico Universitario A. Gemelli, IRCCS, L.go A. Gemelli 8, 00167 Rome, Italy; Faculty of Medicine and Surgery, Università Cattolica del Sacro Cuore, L.go A. Gemelli 8, 00167 Rome, Italy
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9
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Huepenbecker SP, Iniesta MD, Wang XS, Cain KE, Zorrilla-Vaca A, Shen SE, Basabe MS, Suki T, Garcia Lopez JE, Mena GE, Lasala JD, Williams LA, Ramirez PT, Meyer LA. Longitudinal perioperative patient-reported outcomes in open compared with minimally invasive hysterectomy. Am J Obstet Gynecol 2024; 230:241.e1-241.e18. [PMID: 37827271 DOI: 10.1016/j.ajog.2023.10.012] [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: 07/25/2023] [Revised: 10/05/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND There are few prospective studies in the gynecologic surgical literature that compared patient-reported outcomes between open and minimally invasive hysterectomies within enhanced recovery after surgery pathways. OBJECTIVE This study aimed to compare prospectively collected perioperative patient-reported symptom burden and interference measures in open compared with minimally invasive hysterectomy cohorts within enhanced recovery after surgery pathways. STUDY DESIGN We compared patient-reported symptom burden and functional interference in 646 patients who underwent a hysterectomy (254 underwent open surgery and 392 underwent minimally invasive surgery) for benign and malignant indications under enhanced recovery after surgery protocols. Outcomes were prospectively measured using the validated MD Anderson Symptom Inventory, which was administered perioperatively up to 8 weeks after surgery. Cohorts were compared using Fisher exact and chi-squared tests, adjusted longitudinal generalized linear mixed modeling, and Kaplan Meier curves to model return to no or mild symptoms. RESULTS The open cohort had significantly worse preoperative physical functional interference (P=.001). At the time of hospital discharge postoperatively, the open cohort reported significantly higher mean symptom severity scores and more moderate or severe scores for overall (P<.001) and abdominal pain (P<.001), fatigue (P=.001), lack of appetite (P<.001), bloating (P=.041), and constipation (P<.001) when compared with the minimally invasive cohort. The open cohort also had significantly higher interference in physical functioning (score 5.0 vs 2.7; P<.001) than the minimally invasive cohort at the time of discharge with no differences in affective interference between the 2 groups. In mixed modeling analysis of the first 7 postoperative days, both cohorts reported improved symptom burden and functional interference over time with generally slower recovery in the open cohort. From 1 to 8 postoperative weeks, the open cohort had worse mean scores for all evaluated symptoms and interference measures except for pain with urination, although scores indicated mild symptomatic burden and interference in both cohorts. The time to return to no or mild symptoms was significantly longer in the open cohort for overall pain (14 vs 4 days; P<.001), fatigue (8 vs 4 days; P<.001), disturbed sleep (2 vs 2 days; P<.001), and appetite (1.5 vs 1 days; P<.001) but was significantly longer in the minimally invasive cohort for abdominal pain (42 vs 28 days; P<.001) and bloating (42 vs 8 days; P<.001). The median time to return to no or mild functional interference was longer in the open than in the minimally invasive hysterectomy cohort for physical functioning (36 vs 32 days; P<.001) with no difference in compositive affective functioning (5 vs 5 days; P=.07) between the groups. CONCLUSION Open hysterectomy was associated with increased symptom burden in the immediate postoperative period and longer time to return to no or mild symptom burden and interference with physical functioning. However, all patient-reported measures improved within days to weeks of both open and minimally invasive surgery and differences were not always clinically significant.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Maria D Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xin S Wang
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Katherine E Cain
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Andres Zorrilla-Vaca
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Shu-En Shen
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - M Sol Basabe
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tina Suki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Juan E Garcia Lopez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Gabriel E Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Javier D Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Loretta A Williams
- Department of Symptom Research, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
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10
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Kostov S, Selçuk I, Watrowski R, Dineva S, Kornovski Y, Slavchev S, Ivanova Y, Yordanov A. Neglected Anatomical Areas in Ovarian Cancer: Significance for Optimal Debulking Surgery. Cancers (Basel) 2024; 16:285. [PMID: 38254777 PMCID: PMC10813817 DOI: 10.3390/cancers16020285] [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: 12/05/2023] [Revised: 12/31/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024] Open
Abstract
Ovarian cancer (OC), the most lethal gynecological malignancy, usually presents in advanced stages. Characterized by peritoneal and lymphatic dissemination, OC necessitates a complex surgical approach usually involving the upper abdomen with the aim of achieving optimal cytoreduction without visible macroscopic disease (R0). Failures in optimal cytoreduction, essential for prognosis, often stem from overlooking anatomical neglected sites that harbor residual tumor. Concealed OC metastases may be found in anatomical locations such as the omental bursa; Morison's pouch; the base of the round ligament and hepatic bridge; the splenic hilum; and suprarenal, retrocrural, cardiophrenic and inguinal lymph nodes. Hence, mastery of anatomy is crucial, given the necessity for maneuvers like liver mobilization, diaphragmatic peritonectomy and splenectomy, as well as dissection of suprarenal, celiac, and cardiophrenic lymph nodes in most cases. This article provides a meticulous anatomical description of neglected anatomical areas during OC surgery and describes surgical steps essential for the dissection of these "neglected" areas. This knowledge should equip clinicians with the tools needed for safe and complete cytoreduction in OC patients.
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Affiliation(s)
- Stoyan Kostov
- Research Institute, Medical University Pleven, 5800 Pleven, Bulgaria;
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Ilker Selçuk
- Department of Gynecologic Oncology, Ankara Bilkent City Hospital, Maternity Hospital, 06800 Ankara, Turkey;
| | - Rafał Watrowski
- Department of Obstetrics and Gynecology, Helios Hospital Müllheim, 79379 Müllheim, Germany;
- Faculty Associate, Medical Center, University of Freiburg, 79106 Freiburg, Germany
| | - Svetla Dineva
- Diagnostic Imaging Department, Medical University of Sofia, 1431 Sofia, Bulgaria;
- National Cardiology Hospital, 1309 Sofia, Bulgaria
| | - Yavor Kornovski
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Stanislav Slavchev
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Yonka Ivanova
- Department of Gynecology, Hospital “Saint Anna”, Medical University—“Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; (Y.K.); (S.S.)
| | - Angel Yordanov
- Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria
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11
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Laios A, Kalampokis E, Mamalis ME, Thangavelu A, Tan YS, Hutson R, Munot S, Broadhead T, Nugent D, Theophilou G, Jackson RE, De Jong D. Explaining the Elusive Nature of a Well-Defined Threshold for Blood Transfusion in Advanced Epithelial Ovarian Cancer Cytoreductive Surgery. Diagnostics (Basel) 2023; 14:94. [PMID: 38201403 PMCID: PMC10795734 DOI: 10.3390/diagnostics14010094] [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: 10/26/2023] [Revised: 12/18/2023] [Accepted: 12/29/2023] [Indexed: 01/12/2024] Open
Abstract
There is no well-defined threshold for intra-operative blood transfusion (BT) in advanced epithelial ovarian cancer (EOC) surgery. To address this, we devised a Machine Learning (ML)-driven prediction algorithm aimed at prompting and elucidating a communication alert for BT based on anticipated peri-operative events independent of existing BT policies. We analyzed data from 403 EOC patients who underwent cytoreductive surgery between 2014 and 2019. The estimated blood volume (EBV), calculated using the formula EBV = weight × 80, served for setting a 10% EBV threshold for individual intervention. Based on known estimated blood loss (EBL), we identified two distinct groups. The Receiver operating characteristic (ROC) curves revealed satisfactory results for predicting events above the established threshold (AUC 0.823, 95% CI 0.76-0.88). Operative time (OT) was the most significant factor influencing predictions. Intra-operative blood loss exceeding 10% EBV was associated with OT > 250 min, primary surgery, serous histology, performance status 0, R2 resection and surgical complexity score > 4. Certain sub-procedures including large bowel resection, stoma formation, ileocecal resection/right hemicolectomy, mesenteric resection, bladder and upper abdominal peritonectomy demonstrated clear associations with an elevated interventional risk. Our findings emphasize the importance of obtaining a rough estimate of OT in advance for precise prediction of blood requirements.
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Affiliation(s)
- Alexandros Laios
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Evangelos Kalampokis
- Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece; (E.K.); (M.-E.M.)
- Center for Research & Technology HELLAS (CERTH), 6th km Charilaou-Thermi Rd, 57001 Thessaloniki, Greece
| | - Marios-Evangelos Mamalis
- Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece; (E.K.); (M.-E.M.)
| | - Amudha Thangavelu
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Yong Sheng Tan
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Richard Hutson
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Sarika Munot
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Tim Broadhead
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - David Nugent
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | - Georgios Theophilou
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
| | | | - Diederick De Jong
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (Y.S.T.); (R.H.); (S.M.); (T.B.); (D.N.); (G.T.); (D.D.J.)
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12
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Laios A, Kalampokis E, Mamalis ME, Thangavelu A, Hutson R, Broadhead T, Nugent D, De Jong D. Exploring the Potential Role of Upper Abdominal Peritonectomy in Advanced Ovarian Cancer Cytoreductive Surgery Using Explainable Artificial Intelligence. Cancers (Basel) 2023; 15:5386. [PMID: 38001646 PMCID: PMC10670755 DOI: 10.3390/cancers15225386] [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: 09/17/2023] [Revised: 11/02/2023] [Accepted: 11/07/2023] [Indexed: 11/26/2023] Open
Abstract
The Surgical Complexity Score (SCS) has been widely used to describe the surgical effort during advanced stage epithelial ovarian cancer (EOC) cytoreduction. Referring to a variety of multi-visceral resections, it best combines the numbers with the complexity of the sub-procedures. Nevertheless, not all potential surgical procedures are described by this score. Lately, the European Society for Gynaecological Oncology (ESGO) has established standard outcome quality indicators pertinent to achieving complete cytoreduction (CC0). There is a need to define what weight all these surgical sub-procedures comprising CC0 would be given. Prospectively collected data from 560 surgically cytoreduced advanced stage EOC patients were analysed at a UK tertiary referral centre.We adapted the structured ESGO ovarian cancer report template. We employed the eXtreme Gradient Boosting (XGBoost) algorithm to model a long list of surgical sub-procedures. We applied the Shapley Additive explanations (SHAP) framework to provide global (cohort) explainability. We used Cox regression for survival analysis and constructed Kaplan-Meier curves. The XGBoost model predicted CC0 with an acceptable accuracy (area under curve [AUC] = 0.70; 95% confidence interval [CI] = 0.63-0.76). Visual quantification of the feature importance for the prediction of CC0 identified upper abdominal peritonectomy (UAP) as the most important feature, followed by regional lymphadenectomies. The UAP best correlated with bladder peritonectomy and diaphragmatic stripping (Pearson's correlations > 0.5). Clear inflection points were shown by pelvic and para-aortic lymph node dissection and ileocecal resection/right hemicolectomy, which increased the probability for CC0. When UAP was solely added to a composite model comprising of engineered features, it substantially enhanced its predictive value (AUC = 0.80, CI = 0.75-0.84). The UAP was predictive of poorer progression-free survival (HR = 1.76, CI 1.14-2.70, P: 0.01) but not overall survival (HR = 1.06, CI 0.56-1.99, P: 0.86). The SCS did not have significant survival impact. Machine Learning allows for operational feature selection by weighting the relative importance of those surgical sub-procedures that appear to be more predictive of CC0. Our study identifies UAP as the most important procedural predictor of CC0 in surgically cytoreduced advanced-stage EOC women. The classification model presented here can potentially be trained with a larger number of samples to generate a robust digital surgical reference in high output tertiary centres. The upper abdominal quadrants should be thoroughly inspected to ensure that CC0 is achievable.
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Affiliation(s)
- Alexandros Laios
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (R.H.); (T.B.); (D.N.); (D.D.J.)
| | - Evangelos Kalampokis
- Information Systems Lab, Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece; (E.K.); (M.E.M.)
- Center for Research & Technology HELLAS (CERTH), 6th km Charilaou-Thermi Rd, 57001 Thessaloniki, Greece
| | - Marios Evangelos Mamalis
- Information Systems Lab, Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece; (E.K.); (M.E.M.)
| | - Amudha Thangavelu
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (R.H.); (T.B.); (D.N.); (D.D.J.)
| | - Richard Hutson
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (R.H.); (T.B.); (D.N.); (D.D.J.)
| | - Tim Broadhead
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (R.H.); (T.B.); (D.N.); (D.D.J.)
| | - David Nugent
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (R.H.); (T.B.); (D.N.); (D.D.J.)
| | - Diederick De Jong
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK; (A.T.); (R.H.); (T.B.); (D.N.); (D.D.J.)
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13
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de Jong D, Thangavelu A, Broadhead T, Chen I, Burke D, Hutson R, Johnson R, Kaufmann A, Lodge P, Nugent D, Quyn A, Theophilou G, Laios A. Prerequisites to improve surgical cytoreduction in FIGO stage III/IV epithelial ovarian cancer and subsequent clinical ramifications. J Ovarian Res 2023; 16:214. [PMID: 37951927 PMCID: PMC10638711 DOI: 10.1186/s13048-023-01303-1] [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: 01/26/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND No residual disease (CC 0) following cytoreductive surgery is pivotal for the prognosis of women with advanced stage epithelial ovarian cancer (EOC). Improving CC 0 resection rates without increasing morbidity and no delay in subsequent chemotherapy favors a better outcome in these women. Prerequisites to facilitate this surgical paradigm shift and subsequent ramifications need to be addressed. This quality improvement study assessed 559 women with advanced EOC who had cytoreductive surgery between January 2014 and December 2019 in our tertiary referral centre. Following implementation of the Enhanced Recovery After Surgery (ERAS) pathway and prehabilitation protocols, the surgical management paradigm in advanced EOC patients shifted towards maximal surgical effort cytoreduction in 2016. Surgical outcome parameters before, during, and after this paradigm shift were compared. The primary outcome measure was residual disease (RD). The secondary outcome parameters were postoperative morbidity, operative time (OT), length of stay (LOS) and progression-free-survival (PFS). RESULTS R0 resection rate in patients with advanced EOC increased from 57.3% to 74.4% after the paradigm shift in surgical management whilst peri-operative morbidity and delays in adjuvant chemotherapy were unchanged. The mean OT increased from 133 + 55 min to 197 + 85 min, and postoperative high dependency/intensive care unit (HDU/ICU) admissions increased from 8.1% to 33.1%. The subsequent mean LOS increased from 7.0 + 2.6 to 8.4 + 4.9 days. The median PFS was 33 months. There was no difference for PFS in the three time frames but a trend towards improvement was observed. CONCLUSIONS Improved CC 0 surgical cytoreduction rates without compromising morbidity in advanced EOC is achievable owing to the right conditions. Maximal effort cytoreductive surgery should solely be carried out in high output tertiary referral centres due to the associated substantial prerequisites and ramifications.
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Affiliation(s)
- Diederick de Jong
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Amudha Thangavelu
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Timothy Broadhead
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Inga Chen
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Dermot Burke
- Department of Surgery, Colorectal Surgery Service, St. James's University Hospital LTHT, Leeds, UK
| | - Richard Hutson
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Racheal Johnson
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Angelika Kaufmann
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Peter Lodge
- Department of Surgery, Hepatobilliary Surgery and Liver Transplant Service, St. James's University Hospital LTHT, Leeds, UK
| | - David Nugent
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Aaron Quyn
- Department of Surgery, Hepatobilliary Surgery and Liver Transplant Service, St. James's University Hospital LTHT, Leeds, UK
| | - Georgios Theophilou
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK
| | - Alexandros Laios
- Department of Gynaecological Oncology, ESGO Centre of Excellence in advanced ovarian cancer surgery, St. James's University Hospital, LTHT, Beckett Street, Leeds, LS9 7TF, UK.
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14
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Odajima S, Tanabe H, Koike Y, Onishi J, Ichikawa T, Yokosu K, Takaneka S, Okamoto A. Short- and long-term morbidity of total parietal peritonectomy for advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:1771-1777. [PMID: 37875321 DOI: 10.1136/ijgc-2023-004742] [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: 10/26/2023] Open
Abstract
OBJECTIVE Total parietal peritonectomy is gradually being recognized as a surgical option for advanced ovarian cancer; however, evidence regarding its efficacy and safety remains insufficient. Herein, we aimed to assess the short- and long-term post-operative safety profiles of total parietal peritonectomy. METHODS We reviewed the medical records of post-operative morbidity and mortality of patients who underwent cytoreductive surgery with total parietal peritonectomy for stage III and IV ovarian cancer between April 2018 and January 2023. RESULTS Fifty patients were enrolled in the study: 31 who underwent primary cytoreductive surgery and 19 who underwent interval cytoreductive surgery. The median age of all patients was 57 (range, 23-74) years. The median follow-up period was 22 (range, 3-59) months. Of 44 patients (88%) with stage IIIC/IV, 38 patients (76%) had high-grade serous carcinoma. The complete resection rates were 94%, 91%, and 100% in all patients, the primary cytoreductive surgery group, and the interval cytoreductive surgery group, respectively. There were 63 post-operative complication events overall, including 17 (27%) major complication events in 15 patients within 1 year post-operatively. Ten major complications occurred within 30 days of surgery, mainly in the primary cytoreductive surgery group (9 cases). Regarding complication type, the most frequent major event was pleural effusion (3 cases, 7%). After 30 days, there were a total of 17 all-grade complication events, of which ileus and hydronephrosis were major complications in 3 cases each (18%). There were no mortalities related to cytoreductive surgery. The scheduled adjuvant chemotherapy could be completed in 96% of patients. CONCLUSIONS Total parietal peritonectomy is a feasible procedure for managing advanced ovarian cancer. Short- and long-term complications may include pleural effusion and ileus/hydronephrosis, respectively.
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Affiliation(s)
- Suguru Odajima
- Department of Gynecology, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Hiroshi Tanabe
- Department of Gynecology, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Yuki Koike
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Junki Onishi
- Department of Gynecology, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Teppei Ichikawa
- Department of Gynecology, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Kota Yokosu
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
| | - Shin Takaneka
- Department of Gynecology, National Cancer Center-Hospital East, Kashiwa, Chiba, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
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15
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Fagan PJ, Gomes N, Heath OM, Chandrasekaran D, Yao SE, Satchwell L, George A, Banerjee S, Sohaib A, Barton DP, Nobbenhuis M, Ind T, Butler J. The peritoneal cancer index as a predictor of complete cytoreduction at primary and interval cytoreductive surgery in advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:1757-1763. [PMID: 37890875 DOI: 10.1136/ijgc-2022-004093] [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: 10/29/2023] Open
Abstract
OBJECTIVE The peritoneal cancer index quantitatively assesses cancer distribution and tumor burden in the peritoneal cavity. The aim of this study is to evaluate the association between the peritoneal cancer index and completeness of surgical cytoreduction for ovarian cancer and to identify a cut-off above which complete cytoreduction is unlikely. METHODS This is a single-center prospective cohort observational study. A total of 100 consecutive patients who underwent ovarian cancer surgery were included. Peritoneal cancer index scores prior to and after surgery were calculated, and a cut-off value for incomplete cytoreduction was identified using a receiver operator characteristic (ROC) curve. Surgical complexity, blood loss, length of surgery, and complications were analyzed and associations with the peritoneal cancer index score were evaluated. RESULTS The overall median peritoneal cancer index score was 9.5 (range 0-36). The median age of the patients was 61 years (range 24-85). The most common stage was III (13% stage II, 53% stage III, 34% stage IV) and the most common histologic sub-type was high-grade serous (76% high-grade serous, 8% low-grade serous, 5% clear cell, 4% serous borderline, 2% endometrioid, 2% adult granulosa cell, 2% adenocarcinoma, 1% carcinosarcoma). Complete cytoreduction was achieved in 82% of patients, with a median score of 9 (range 0-30). The remaining 18% had a median score of 28.5 (range 0-36). The best predictor of incomplete cytoreduction was the peritoneal cancer index score, with an area under the curve (AUC) of 0.928 (95% CI 0.85 to 1.00). ROC curve analysis determined a peritoneal cancer index cut-off score of 20. Major complications occurred in 15% of patients with peritoneal cancer index scores >20 and in 2.5% of patients with scores ≤20, which was statistically significant (p=0.014). CONCLUSIONS In our study we found that a peritoneal cancer index score of ≤20 was associated with a high likelihood of complete cytoreduction. Incorporating the peritoneal cancer index into routine surgical practice and research may impact treatment plans.
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Affiliation(s)
- Paula J Fagan
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- Gynaecological Cancer Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Nana Gomes
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research (ICR), London, UK
| | - Owen M Heath
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Dhivya Chandrasekaran
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- Department of Gynaecological Oncology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Shih-Ern Yao
- Department of Gynaecological Oncology, Monash Cancer Centre, Bentleigh East, Victoria, Australia
| | - Laura Satchwell
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Angela George
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research (ICR), London, UK
| | - Susana Banerjee
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- The Institute of Cancer Research (ICR), London, UK
| | - Aslam Sohaib
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Desmond P Barton
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- Gynaecological Cancer Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Marielle Nobbenhuis
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
| | - Thomas Ind
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
- St George's University of London, London, UK
| | - John Butler
- Department of Gynaecological Oncology, The Royal Marsden NHS Foundation Trust, London, UK
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Black KA, Nelson G, Goucher N, Foley J, Pin S, Chong M, Ghosh S, Bisch SP. Effect of transversus abdominis plane block on postoperative outcomes in gynecologic oncology patients managed on an Enhanced Recovery After Surgery pathway. Gynecol Oncol 2023; 178:1-7. [PMID: 37729808 DOI: 10.1016/j.ygyno.2023.09.003] [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: 07/23/2023] [Revised: 09/04/2023] [Accepted: 09/08/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVES To characterize the effect of transversus abdominis plane (TAP) blocks on post-operative outcomes in patients undergoing laparotomy for gynecologic malignancy. METHODS This retrospective cohort study assessed patients undergoing laparotomy in 2016-2017 and 2020 in Alberta, Canada. The primary outcome was opioid consumption in oral morphine milligram equivalent (MME). Secondary outcomes included maximum pain scores, length of stay, and patient-controlled analgesia (PCA) use. Outcomes were compared using t-test with subgroup analysis by NSAID use. Multivariate regression modelling was performed for potential confounders. RESULTS Data was collected on 956 patients; 828 received a TAP block, 128 did not. Opioid use in the first 24 h was lower in the TAP block group (35.9 mg MME vs 44.5 mg MME, p = 0.0294), without any increase in pain scores, this did not remain significant after regression analysis. Patients with TAP blocks had significant reduced mean length of stay (3.2 days vs. 5.0 days, p < 0.0001), and PCA use (19.9% vs. 56.25%, p < 0.0001). On subgroup analysis of patients that did not receive NSAIDs (n = 160), mean opioid use was decreased in those patients with TAP blocks compared to those without TAP blocks in the first 24 h (36.1 mg vs. 61.2 mg, p = 0.0017), and at 24 to 48 h (16.3 mg vs. 51.0 mg, p < 0.0001). CONCLUSIONS Surgeon-administered TAP blocks were associated with decreased length of stay and post-operative opioid use in patients not receiving scheduled NSAIDs. This decrease in opioid use was not associated with any increase in average or maximum pain scores.
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Affiliation(s)
- Kristin A Black
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada.
| | - Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
| | - Natalie Goucher
- Department of Anesthesia, Memorial University, St. John's, Newfoundland, Canada
| | - Joshua Foley
- Department of Anesthesia, University of Alberta, Edmonton, Alberta, Canada
| | - Sophia Pin
- Division of Gynecologic Oncology, Cross Cancer Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Michael Chong
- Department of Anesthesia, University of Calgary, Calgary, Alberta, Canada
| | - Sunita Ghosh
- Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Steven P Bisch
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, University of Calgary, Calgary, Alberta, Canada
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Wohrer H, Koual M, Bentivegna E, Benoit L, Metairie M, Bolze PA, Kerbage Y, Raimond E, Akladios C, Carcopino X, Canlorbe G, Uzan J, Lavoue V, Mimoun C, Huchon C, Koskas M, Costaz H, Margueritte F, Dabi Y, Touboul C, Bendifallah S, Ouldamer L, Delanoy N, Nguyen-Xuan HT, Bats AS, Azaïs H. Prognostic impact of cytoreductive surgery conducted with primary intent, versus cytoreductive surgery after neoadjuvant chemotherapy, in the management of patients with advanced epithelial ovarian cancers: a multicentre, propensity score-matched study from the FRANCOGYN group. BJOG 2023; 130:1511-1520. [PMID: 37165717 DOI: 10.1111/1471-0528.17524] [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: 02/10/2023] [Revised: 04/05/2023] [Accepted: 04/15/2023] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To compare survival and morbidity rates between primary cytoreductive surgery (pCRS) and interval cytoreductive surgery (iCRS) for epithelial ovarian cancer (EOC), using a propensity score. DESIGN We conducted a propensity score-matched cohort study, using data from the FRANCOGYN cohort. SETTING Retrospective, multicentre study of data from patients followed in 15 French department specialized in the treatment of ovarian cancer. SAMPLE Patients included were those with International Federation of Gynaecology and Obstetrics (FIGO) stage III or IV EOC, with peritoneal carcinomatosis, having undergone CRS. METHODS The propensity score was designed using pre-therapeutic variables associated with both treatment allocation and overall survival (OS). MAIN OUTCOME MEASURES The primary outcome was OS. Secondary outcomes included recurrence-free survival (RFS), quality of CRS and other variables related to surgical morbidity. RESULTS A total of 513 patients were included. Among these, 334 could be matched, forming 167 pairs. No difference in OS was found (hazard ratio, HR = 0.8, p = 0.32). There was also no difference in RFS (median = 26 months in both groups) nor in the rate of CRS leaving no macroscopic residual disease (pCRS 85%, iCRS 81.4%, p = 0.76). The rates of gastrointestinal tract resections, stoma, postoperative complications and hospital stay were significantly higher in the pCRS group. CONCLUSIONS Analysis of groups of patients made comparable by propensity score matching showed no difference in survival, but lower postoperative morbidity in patients treated with iCRS.
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Affiliation(s)
- Henri Wohrer
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
| | - Meriem Koual
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
- INSERM UMR-S 1124, University of Paris Cité, Centre Universitaire des Saint-Père, Paris, France
| | - Enrica Bentivegna
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
| | - Louise Benoit
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
- INSERM UMR-S 1124, University of Paris Cité, Centre Universitaire des Saint-Père, Paris, France
| | - Marie Metairie
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
| | - Pierre-Adrien Bolze
- Department of Gynecologic and Oncologic Surgery and Obstetrics, Lyon Sud University Hospital, Hospices Civils de Lyon, Université Lyon 1, Lyon, France
| | - Yohan Kerbage
- CHU Lille, Service de Chirurgie Gynécologique, Université Lille, Lille, France
| | - Emilie Raimond
- Department of Obstetrics and Gynaecology, Institute Alix de Champagne University Hospital, Reims, France
| | - Cherif Akladios
- Department of Gynaecology, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Xavier Carcopino
- Department of Obstetrics and Gynaecology, Hôpital Nord, APHM, Aix-Marseille University (AMU), Univ Avignon, CNRS, IRD, IMBE UMR 7263, Marseille, France
| | - Geoffroy Canlorbe
- Department of Gynecological and Breast Surgery and Oncology, Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), University Hospital, Paris, France
- Centre de Recherche Saint-Antoine (CRSA), INSERM UMR_S_938, Cancer Biology and Therapeutics, Sorbonne University, Paris, France
- University Institute of Cancer, Sorbonne University, Paris, France
| | - Jennifer Uzan
- Department of Obstetrics Gynecology and Reproductive Medicine, University Paris Est Créteil, Centre Hospitalier Inter-Communal de Créteil, Creteil, France
| | - Vincent Lavoue
- Service de Gynécologie, INSERM 1242, Oncogenesis, Stress and Signaling, CRLC Eugène Marquis, Université de Rennes 1, Hopital Sud, CHU de Rennes, Rennes, France
| | - Camille Mimoun
- Service de Chirurgie Gynécologique - Université de Paris, Hôpital Lariboisière, Paris, France
| | - Cyrille Huchon
- Service de Chirurgie Gynécologique - Université de Paris, Hôpital Lariboisière, Paris, France
| | - Martin Koskas
- Division of Gynaecologic Oncology, Bichat University Hospital, Paris, France
| | - Hélène Costaz
- Department of Surgical Oncology, Georges-Francois Leclerc Centre, Dijon, France
| | - François Margueritte
- Department of Gynaecology, Centre Hospitalier Intercommunal de Poissy-Saint-Germain-en-Laye Site Hospitalier de Poissy, Poissy, France
| | - Yohann Dabi
- Department of Gynaecology and Obstetrics, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Cyril Touboul
- Department of Gynaecology and Obstetrics, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Lobna Ouldamer
- Department of Gynaecology, Hôpital Universitaire de Tours, Tours, France
| | - Nicolas Delanoy
- Institut du Cancer Paris CARPEM, Université de Paris Cité, Paris, France
- Department of Medical Oncology, AP-HP Centre, Hopital Européen Georges Pompidou, Paris, France
| | - Huyen-Thu Nguyen-Xuan
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
| | - Anne-Sophie Bats
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
- Institut du Cancer Paris CARPEM, Université de Paris Cité, Paris, France
- INSERM UMR-S 1147, Centre de Recherche des Cordeliers, University of Paris Cité, Paris, France
| | - Henri Azaïs
- Department of Gynaecological Oncological and Breast Surgery, Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpital Européen Georges-Pompidou, Paris, France
- Institut du Cancer Paris CARPEM, Université de Paris Cité, Paris, France
- INSERM UMR-S 1147, Centre de Recherche des Cordeliers, University of Paris Cité, Paris, France
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Boitano TKL, Gardner A, Chu DI, Leath CA, Straughn JM, Smith HJ. Use of a mobile health patient engagement technology improves perioperative outcomes in gynecologic oncology patients. Gynecol Oncol 2023; 178:23-26. [PMID: 37742507 PMCID: PMC10873082 DOI: 10.1016/j.ygyno.2023.09.008] [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: 06/20/2023] [Revised: 09/04/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVE To evaluate the impact of a mobile health patient engagement technology (PET) on postoperative outcomes in gynecologic oncology patients. METHODS All gynecologic oncology patients undergoing laparotomy on an enhanced recovery program (ERP) were approached from July 2019 to May 2021 to enroll in a PET, which can be accessed by computer, tablet, or smart phone. This platform provides enhanced pre- and postoperative patient education and remote patient monitoring. Patients who elected to participate were provided with targeted education based on their age and comorbidities and were asked to complete daily health checks during the postoperative period. Participants in the PET were compared to patients who opted out as well as to a historical cohort from prior to PET implementation. Patient and procedure-level factors were recorded. The primary outcomes were length of stay (LOS) and 30-day readmission rate. Analysis was performed using SPSS v.26. RESULTS 682 women met inclusion criteria during the study time; 347 in the PET group and 335 in the control group. Demographic and other factors including race, BMI (kg/m2), Charlson Comorbidity Index (CCI), surgical complexity, and insurance status were not different between the PET and control group; however, patients in the PET cohort were slightly younger (55.0 yo vs. 57.2 yo; p = 0.04). Patients in the PET group had a significantly shorter LOS (2.9 days vs. 3.6 days; p < 0.01) and lower readmission rate (4.3% vs. 8.6%; p < 0.01) when compared with the control group. CONCLUSIONS Use of a PET in our gynecologic oncology patients decreased LOS by nearly one day despite an absence of differences in other demographic and surgical factors other than age. Furthermore, there was a 50% reduction in readmission rates in the PET group. The use of a PET allows for healthcare professionals to engage, evaluate, and treat patients in a way that improves perioperative care.
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Affiliation(s)
- Teresa K L Boitano
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Birmingham, AL, USA.
| | - Austin Gardner
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel I Chu
- Department of Surgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Charles A Leath
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Birmingham, AL, USA
| | - J Michael Straughn
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Birmingham, AL, USA
| | - Haller J Smith
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham Birmingham, AL, USA
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Smits A, Agius CM, Blake D, Ang C, Kucukmetin A, van Ham M, Pijnenborg JMA, Knight J, Rundle S. Is Cardiopulmonary Exercise Testing Predictive of Surgical Complications in Patients Undergoing Surgery for Ovarian Cancer? Cancers (Basel) 2023; 15:5185. [PMID: 37958358 PMCID: PMC10648080 DOI: 10.3390/cancers15215185] [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: 09/15/2023] [Revised: 10/16/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capability. In other intra-abdominal surgical specialties, CPET outcomes are predictive of operative morbidity. However, in ovarian cancer surgery, its predictive value remains unknown. In this study, we evaluated the association between CPET performance and surgical morbidity in ovarian cancer patients. Secondly, we assessed the association between CPET performance and other surgical outcomes (i.e., hospital stay, readmission and residual disease). This was a retrospective cohort study of patients undergoing primary surgery for ovarian cancer between 2020 and 2023. CPET performance included peak oxygen uptake (VO2 max), ventilatory efficiency (VE/VO2) and anaerobic threshold. Outcomes were operative morbidity and included intra- and postoperative complications (Clavien-Dindo), hospital stay, readmission within 30 days and residual disease. A total of 142 patients were included. A lower VO2 peak and a higher VE/VCO2 were both associated with the occurrence of postoperative complications, and a poorer anaerobic threshold was associated with more transfusions. VE/VCO2 remained significantly associated after multivariate analysis (p = 0.035). None of the CPET outcomes were associated with length of stay, readmission or residual disease. In conclusion, VE/VCO2 was significantly associated with an increased risk of all-cause postoperative complications in ovarian cancer patients undergoing primary surgery.
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Affiliation(s)
- Anke Smits
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
- Department of Gynaecological Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | - Claire-Marie Agius
- Department of Anaesthetics, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Dominic Blake
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Christine Ang
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Ali Kucukmetin
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Maaike van Ham
- Department of Gynaecological Oncology, Radboudumc, 6525 GA Nijmegen, The Netherlands
| | | | - Joanne Knight
- Department of Anaesthetics, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
| | - Stuart Rundle
- Northern Gynaecological Oncology Centre, Queen Elizabeth Hospital, Gateshead NE9 6SX, UK
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Shah R, Polen-De C, McGree M, Fought A, Kumar A. Re-Evaluating Chemotherapy Dosing Strategies for Ovarian Cancer: Impact of Sarcopenia. Curr Oncol 2023; 30:9501-9513. [PMID: 37999108 PMCID: PMC10670337 DOI: 10.3390/curroncol30110688] [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: 08/31/2023] [Revised: 10/20/2023] [Accepted: 10/24/2023] [Indexed: 11/25/2023] Open
Abstract
We investigated the impact of sarcopenia on adjuvant chemotherapy dosing in advanced epithelial ovarian cancer (EOC). The chemotherapy dosing and toxicity of 173 eligible patients who underwent cytoreductive surgery and adjuvant chemotherapy at a single institution were analyzed. Patients with a skeletal muscle index less than 39 cm2/m2 measured on a CT scan were considered sarcopenic. Sarcopenic and non-sarcopenic patients were compared with regard to relative dose intensity (RDI), completion of scheduled chemotherapy, toxicity, and survival. A total of 62 (35.8%) women were sarcopenic. Sarcopenic women were less likely to complete at least six cycles of chemotherapy (83.9% vs. 95.5%, p = 0.02). The mean RDI for both carboplatin (80.4% vs. 89.4%, p = 0.03) and paclitaxel (91.9% vs. 104.1%, p = 0.03) was lower in sarcopenic patients compared to non-sarcopenic patients. Despite these differences in chemotherapy, there was no difference in neutropenia or median overall survival (3.99 vs. 4.57 years, p = 0.62) between the sarcopenic and non-sarcopenic women, respectively. This study highlights the importance of considering lean body mass instead of body weight or surface area in chemotherapy dosing formulas for sarcopenic women with advanced EOC. Further research is needed to optimize chemotherapy strategies based on individual body composition, potentially leading to improved dosing strategies in this population.
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Affiliation(s)
- Rushi Shah
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN 55905, USA;
| | - Clarissa Polen-De
- Department of Gynecologic Oncology, Summa Health, Akron, OH 44304, USA;
| | - Michaela McGree
- Department of Quantitative Health Sciences, Division Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA; (M.M.); (A.F.)
| | - Angela Fought
- Department of Quantitative Health Sciences, Division Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN 55905, USA; (M.M.); (A.F.)
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecological Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Crestani A, Dabi Y, Bendifallah S, Kolanska K, Buffet NC, Thomassin-Naggara I, Darai E, Touboul C. ENDOGRADE: A four level classification to rate surgical complexity in endometriosis. J Gynecol Obstet Hum Reprod 2023; 52:102632. [PMID: 37473962 DOI: 10.1016/j.jogoh.2023.102632] [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: 04/25/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/22/2023]
Abstract
OBJECTIVES We studied a post operative classification of surgical complexity in endometriosis. STUDY DESIGN Retrospective monocentric observational study was conducted between January 2001 to December 2019 and included 764 women with DE that underwent surgery. We retrospectively graded surgical complexity through operative reports according to the ENDOGRADE classification, that grades the surgical complexity of DE in four progressive levels. RESULTS Operating time was longer for patients rated ENDOGRADE 3 (228±93 min) compared to patients rated ENDOGRADE 2 (120± 51 min) (p<10-3) and for patients rated ENDOGRADE 4 (301±99 min) compared to patients rated ENDOGRADE 3 (228±93 min), (p<10-3). Eighty percent (20/25) of peroperative complications were rated ENDOGRADE 3 or 4, 20% (5/25) were rated ENDOGRADE 1 or 2 (p = 0.01). Patients rated ENDOGRADE 2, 3 and 4 were 10.3 times (95CI=2.4-44.9, p = 2.10-3), 12.2 times (95CI=2.9-50.2, p = 5.10-4) and 38.3 times (95CI=9.1-162, p = 7.10-7) more likely to experience postoperative complications than those rated ENDOGRADE 1. According to multivariate analysis, only patients rated ENDOGRADE 2, 3, and 4 had a significantly higher risk of postoperative complications with an OR=16.0 (95CI=2.0-127.4, p = 9.10-3), OR=16.2 (95CI=1.6-159.7, p = 0.02) and OR=104.2 (95CI=24.6-440.5, p = 4.10-3), respectively. CONCLUSION ENDOGRADE classification of surgical complexity in DE is correlated to operating time, per- and post-operative complications.
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Affiliation(s)
- Adrien Crestani
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; UMRS 938, Centre de recherche Saint Antoine, Faculté de Médecine Sorbonne Université, Paris 75012, France.
| | - Yohann Dabi
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; Université de Médecine Paris Est Créteil (UPEC), Centre Hospitalier intercommunal de Créteil Service de Gynécologie Obstétrique
| | - Sofiane Bendifallah
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; Groupe de recherche clinique (GRC-6), Centre Expert En Endométriose (C3E), Assistance publique des hôpitaux de Paris, hôpital Tenon, Sorbonne Université, Paris 75020, France
| | - Kamila Kolanska
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; UMRS 938, Centre de recherche Saint Antoine, Faculté de Médecine Sorbonne Université, Paris 75012, France
| | - Nathalie Chabbert Buffet
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; UMRS 938, Centre de recherche Saint Antoine, Faculté de Médecine Sorbonne Université, Paris 75012, France
| | - Isabelle Thomassin-Naggara
- Department of Radiology, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France
| | - Emile Darai
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; UMRS 938, Centre de recherche Saint Antoine, Faculté de Médecine Sorbonne Université, Paris 75012, France; Groupe de recherche clinique (GRC-6), Centre Expert En Endométriose (C3E), Assistance publique des hôpitaux de Paris, hôpital Tenon, Sorbonne Université, Paris 75020, France
| | - Cyril Touboul
- Department of Gynaecology and Obstetrics, Tenon University Hospital, Assistance Publique des Hôpitaux de Paris (AP-HP), Sorbonne University, Paris 75020, France; UMRS 938, Centre de recherche Saint Antoine, Faculté de Médecine Sorbonne Université, Paris 75012, France; Groupe de recherche clinique (GRC-6), Centre Expert En Endométriose (C3E), Assistance publique des hôpitaux de Paris, hôpital Tenon, Sorbonne Université, Paris 75020, France
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Rousseau F, Ranchon F, Bardin C, Bakrin N, Lavoué V, Bengrine-Lefevre L, Falandry C. Ovarian cancer in the older patient: where are we now? What to do next? Ther Adv Med Oncol 2023; 15:17588359231192397. [PMID: 37724138 PMCID: PMC10505350 DOI: 10.1177/17588359231192397] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/19/2023] [Indexed: 09/20/2023] Open
Abstract
In recent years, major advances have been made toward the individualization of epithelial ovarian cancer care, leading to an overall improvement of patient outcomes. However, real-life data indicate that the oldest populations do not benefit from this, due to aspects related to cancer (more aggressive histopathological features), treatment (i.e. frequently suboptimal), and the host (increased toxicities in patients with lower physiological reserve). A specific risk-benefit perspective should therefore be taken when considering surgery, chemotherapy, and maintenance treatments: the decision for cytoreductive surgery should include geriatric vulnerability and surgical complexity, neo-adjuvant chemotherapy being an option when primary surgery appears at high risk; carboplatin paclitaxel association remains the standard even in vulnerable older patients; and bevacizumab and poly(ADP-ribose) polymerase inhibitors maintenance are interesting options provided they are prescribed according to their indications with a close monitoring of their toxicities. Future studies should aim to individualize care without limiting access of older patients to innovation. A specific focus is needed on age-specific translational analyses (focusing on tumor mutational burden and impaired biological pathways), a better patient stratification according to geriatric parameters, an adaptation of both oncological treatment and geriatric interventions, and treatment adaptations not a priori but according to formal pharmacokinetic data.
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Affiliation(s)
- Frédérique Rousseau
- Institut Paoli Calmettes Institute, Marseille, France
- Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Florence Ranchon
- Groupement Hospitalier Sud, Unité de Pharmacie Clinique Oncologique, Hospices Civils de Lyon, Pierre-Bénite, France
- CICLY Centre pour l’Innovation en Cancérologie de Lyon, Oullins, France
- Société Française de Pharmacie Oncologique (SFPO)
| | - Christophe Bardin
- Service de Pharmacie Clinique, Hôpital Cochin AP-HP Centre Université Paris Cité, Paris, France
- Société Française de Pharmacie Oncologique (SFPO)
| | - Naoual Bakrin
- Hospices Civils de Lyon, Service de Chirurgie Digestive, CHU Hôpital Lyon-Sud, Pierre-Bénite Cedex, France
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Vincent Lavoué
- Service de Gynécologie, CHU de Rennes, Hôpital Sud, Rennes, France
- UMR S1085, IRSET-INSERM, Université de Rennes, Rennes, France
- Groupe Français de chirurgie Oncologique et Gynécologique (FRANCOGYN)
| | - Leila Bengrine-Lefevre
- Département d’Oncologie Médicale, Centre Georges-Francois Leclerc, Dijon, France
- Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Claire Falandry
- Hospices Civils de Lyon, Unité de Gériatrie, Centre Hospitalier de la Croix Rousse, 103, Grande Rue de la Croix-Rousse, Lyon 69004, France
- Université de Lyon, CarMeN Laboratory, INSERM U.1060/Université Lyon 1/INRA U1397/INSA Lyon/Hospices Civils Lyon Bâtiment CENS-ELI 2D; Hôpital Lyon Sud Secteur 2; Pierre-Bénite 69310, France
- Université Claude Bernard Lyon 1, Pierre-Bénite 69310, France Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
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23
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Bang YJ, Lee EK, Kim CS, Hahm TS, Jeong H, Cho YJ, Noh JJ, Lee YY, Choi CH, Lee JW, Jeong JS. The Effect of Intrathecal Morphine on Postoperative Opioid Consumption in Patients Undergoing Abdominal Surgery for Gynecologic Malignancy: A Randomized Sham-Controlled Trial. Anesth Analg 2023; 137:525-533. [PMID: 36727850 DOI: 10.1213/ane.0000000000006358] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgery for gynecologic malignancy via midline-laparotomy leads to severe postoperative pain. Adequate pain control while sparing opioid consumption does offer benefits in postoperative complications and recovery. Intrathecal morphine (ITM) provides simple and effective analgesia. In this randomized trial, we compared postoperative opioid consumption in patients who received either ITM or a sham procedure. METHODS We enrolled 68 adult patients undergoing open gynecologic oncology surgery from June 2021 to November 2021. They were randomly allocated to the ITM group (ITM; 200 μg injection) or sham group (sham procedure) to achieve a final 1:1 ratio between groups. We compared opioid consumption and pain severity during 72 hours after surgery. The variables regarding postoperative recovery and patient-centered outcomes were collected. The primary outcome is cumulative intravenous (IV) opioid consumption 24 hours after surgery. RESULTS The median (interquartile range) cumulative IV opioid consumption during 24 hours after surgery was 18 mg (12-29) in the ITM group and 36 mg (27-42) in the sham group (median difference, 13; 95% confidence interval, 7.2-20.7; P < .001). Patient satisfaction regarding pain control was statistically significantly higher in the ITM group than in the sham group at postoperative 24 and 48 hours ( P < .001 and P = .005, respectively). There were no significant differences in the variables associated with postoperative recovery and frequency of complications requiring treatment. CONCLUSIONS ITM is a safe and effective analgesic method after curative intent laparotomy for gynecologic malignancy. ITM provides better pain relief, reduces opioid consumption, and improves patient satisfaction without additional evident adverse events.
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Affiliation(s)
- Yu Jeong Bang
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun Kyung Lee
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chung Su Kim
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Soo Hahm
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Heejoon Jeong
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon Jee Cho
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joseph J Noh
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoo-Young Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chel Hun Choi
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jeong-Won Lee
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Seon Jeong
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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24
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Lindemann K, Heimisdottir Danbolt S, Ramberg L, Eyjólfsdóttir B, Wang YY, Heli-Haugestøl AG, Walcott SL, Mjåland O, Navestad GA, Hermanrud S, Juul-Hansen KE, Bragstad LK, Opheim R, Kleppe A, Kongsgaard U. Patient-reported nausea after implementation of an enhanced recovery after surgery protocol for gynae-oncology patients. Int J Gynecol Cancer 2023; 33:1287-1294. [PMID: 37451689 PMCID: PMC10423539 DOI: 10.1136/ijgc-2023-004356] [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: 02/12/2023] [Accepted: 06/02/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVES This study aimed to analyze the adherence to strategies to prevent post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) protocol for gynae-oncology patients. Patient-reported nausea before and after ERAS was also studied. METHODS This prospective observational study included all patients undergoing laparotomy for a suspicious pelvic mass or confirmed advanced ovarian cancer before (pre-ERAS) and after the implementation of ERAS (post-ERAS) at Oslo University Hospital, Norway. Patients were a priori stratified according to the planned extent of surgery into two cohorts (Cohort 1: Surgery of advanced disease; Cohort 2: Surgery for a suspicious pelvic tumor). Clinical data including baseline characteristics and outcome data were prospectively collected. RESULTS A total of 439 patients were included, 243 pre-ERAS and 196 post-ERAS. At baseline, 27% of the patients reported any grade of nausea. In the post-ERAS cohort, statistically significantly more patients received double post-operative nausea and vomiting prophylaxis (64% pre-ERAS vs 84% post-ERAS, p<0.0001). There was no difference in the need for rescue medication (82% pre-ERAS vs 79% post-ERAS; p=0.17) and no statistically significant difference between pre- and post-ERAS or between the surgical cohorts in patient-reported nausea of any grade on day 2. Patients who reported none/mild nausea on day 2 had significantly less peri-operative fluid administered during surgery than those who reported moderate or severe nausea (median 12.5 mL/kg/hour vs 16.5 mL/kg/hour, p=0.045) but, in multivariable analysis, fluid management did not remain significantly associated with nausea. CONCLUSION Implementation of an ERAS protocol increased the adherence to post-operative nausea and vomiting prevention guidelines. Nausea, both before and after laparotomy, remains an unmet clinical need of gynae-oncology patients also in an ERAS program. Patient-reported outcome measures warrant further investigation in the evaluation of ERAS.
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Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Svana Heimisdottir Danbolt
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Lene Ramberg
- Department of Gynecology and Obstetrics, Akershus University Hospital, Lørenskog, Norway
| | - Brynhildur Eyjólfsdóttir
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Yun Yong Wang
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Sara L Walcott
- Department of Clinical Service, Oslo University Hospital, Oslo, Norway
| | - Odd Mjåland
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Gerd Anita Navestad
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Division of Cancer Medicine, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Line K Bragstad
- Department of Public Health Science and CHARM Research Centre for Habilitation and Rehabilitation models & services, University of Oslo, Oslo, Norway
| | - Randi Opheim
- Department of Public Health, Institute of Health and Society, University of Oslo, Oslo, Norway
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Andreas Kleppe
- Institute of Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | - Ulf Kongsgaard
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
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25
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Lindemann K, Kleppe A, Eyjólfsdóttir B, Heimisdottir Danbolt S, Wang YY, Heli-Haugestøl AG, Walcott SL, Mjåland O, Navestad GA, Hermanrud S, Juul-Hansen KE, Kongsgaard U. Prospective evaluation of an enhanced recovery after surgery (ERAS) pathway in a Norwegian cohort of patients with suspected or advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:1279-1286. [PMID: 37451690 PMCID: PMC10423533 DOI: 10.1136/ijgc-2023-004355] [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: 02/06/2023] [Accepted: 05/18/2023] [Indexed: 07/18/2023] Open
Abstract
OBJECTIVE This prospective cohort study evaluated the introduction of an enhanced recovery after surgery (ERAS) pathway in a tertiary gynecologic oncology referral center. Compliance and clinical outcomes were studied in two separate surgical cohorts. METHODS Patients undergoing laparotomy for suspected or verified advanced ovarian cancer at Oslo University Hospital were prospectively included in a pre- and post-implementation cohort. A priori, patients were stratified into: cohort 1, patients planned for surgery of advanced disease; and cohort 2, patients undergoing surgery for suspicious pelvic tumor. Baseline characteristics, adherence to the pathway, and clinical outcomes were assessed. RESULTS Of the 439 included patients, 235 (54%) underwent surgery for advanced ovarian cancer in cohort 1 and 204 (46%) in cohort 2. In cohort 1, 53% of the patients underwent surgery with an intermediate/high Aletti complexity score. Post-ERAS, median fasting times for solids (13.1 hours post-ERAS vs 16.0 hours pre-ERAS, p<0.001) and fluids (3.7 hours post-ERAS vs 11.0 hours pre-ERAS, p<0.001) were significantly reduced. Peri-operative fluid management varied less and was reduced from median 15.8 mL/kg/hour (IQR 10.8-22.5) to 11.5 mL/kg/hour (IQR 9.0-15.4) (p<0.001). In cohort 2 only there was a statistically significant reduction in length of stay (mean (SD) 4.3±1.5 post-ERAS vs 4.6±1.2 pre-ERAS, p=0.026). Despite stable readmission rates, there were significantly more serious complications reported in cohort 1 post-ERAS. CONCLUSIONS ERAS increased adherence to current standards in peri-operative management with significant reduction in fasting times for both solids and fluids, and peri-operative fluid administration. Length of stay was reduced in patients with suspicious pelvic tumor. Despite serious complications being common in patients with advanced disease undergoing debulking surgery, a causal relationship with the ERAS protocol could not be established. Implementing ERAS and continuous performance auditing are crucial to advancing peri-operative care of patients with ovarian cancer.
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Affiliation(s)
- Kristina Lindemann
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
| | - Andreas Kleppe
- Institute for Cancer Genetics and Informatics, Oslo University Hospital, Oslo, Norway
- Department of Informatics, University of Oslo, Oslo, Norway
| | | | | | - Yun Yong Wang
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | | | - Sara L Walcott
- Department of Clinical Service, Oslo University Hospital, Oslo, Norway
| | - Odd Mjåland
- Department of Gastroenterological Surgery, Oslo University Hospital, Oslo, Norway
| | - Gerd-Anita Navestad
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Silje Hermanrud
- Department of Gynecological Oncology, Oslo University Hospital, Oslo, Norway
| | - Knut Erling Juul-Hansen
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
| | - Ulf Kongsgaard
- Faculty of Medicine, Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Division of Emergencies and Critical Care, Oslo, Norway
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26
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Silberman JN, Bercow AS, Gockley AA, Eisenhauer EL, Sisodia R, Randall T, Del Carmen MG, Goodman A, Castro CM, Melamed A, Bregar AJ. Trends in the use of neoadjuvant chemotherapy for low-grade serous ovarian cancer in the United States. Gynecol Oncol 2023; 175:60-65. [PMID: 37327540 DOI: 10.1016/j.ygyno.2023.06.001] [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: 04/03/2023] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE To describe trends in neoadjuvant chemotherapy (NACT) use for low-grade serous ovarian carcinoma (LGSOC) and to quantify associations between NACT and extent of cytoreductive surgery. METHODS We identified women treated for stage III or IV serous ovarian cancer in a Commission on Cancer accredited program between January 2004-December 2020. Regression models were developed to evaluate trends in NACT use for LGSOC, to identify factors associated with receipt of NACT, and to quantify associations between NACT and bowel or urinary resection at the time of surgery. Demographic and clinical factors were used for confounder control. RESULTS We observed 3350 patients who received treatment for LGSOC during the study period. The proportion of patients who received NACT increased from 9.5% in 2004 to 25.9% in 2020, corresponding to an annual percent change of 7.2% (95% CI 5.6-8.9). Increasing age (rate ratio (RR) 1.15; 95% CI 1.07-1.24), and stage IV disease (RR 2.66; 95% CI 2.31-3.07) were associated with a higher likelihood of receiving NACT. For patients with high-grade disease, NACT was associated with a decrease in likelihood of bowel or urinary surgery (35.3% versus 23.9%; RR 0.68, 95% CI 0.65-0.71). For LGSOC, NACT was associated with a higher likelihood of these procedures (26.6% versus 32.2%; RR 1.24, 95% CI 1.08-1.42). CONCLUSION NACT use among patients with LGSOC has increased from 2004 to 2020. While NACT was associated with a lower rate of gastrointestinal and urinary surgery among patients with high-grade disease, patients with LGSOC receiving NACT were more likely to undergo these procedures.
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Affiliation(s)
- Jason N Silberman
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States.
| | - Alexandra S Bercow
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Allison A Gockley
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Eric L Eisenhauer
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Rachel Sisodia
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas Randall
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Marcela G Del Carmen
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Annekathryn Goodman
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States
| | - Cesar M Castro
- Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Department of Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Alexander Melamed
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Division of Gynecologic Oncology, Wentworth-Douglass Hospital, Dover, NH, United States
| | - Amy J Bregar
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, MA, United States; Harvard Medical School, Boston, MA, United States; Division of Gynecologic Oncology, Massachusetts General Hospital, Boston, MA, United States; Division of Gynecologic Oncology, Wentworth-Douglass Hospital, Dover, NH, United States
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27
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Peters ITA, Marchetti C, De Palma A, Giannarelli D, Carcagnì A, Scambia G, Fagotti A. Cytoreductive surgery for advanced epithelial ovarian cancer in the poly(ADP-ribose) polymerase inhibitors era-Is it time for a new paradigm shift? A systematic review and meta-analysis. Eur J Cancer 2023; 187:77-86. [PMID: 37130463 DOI: 10.1016/j.ejca.2023.03.035] [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: 01/29/2023] [Revised: 03/27/2023] [Accepted: 03/28/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION In patients with newly diagnosed advanced high-grade serous and endometrioid epithelial ovarian cancer (EOC) first-line maintenance therapy with poly(ADP-ribose) polymerase inhibitors (PARPi) tremendously improved progression-free survival (PFS). Yet, data on the effect of PARPi in proportion to postoperative residual disease status were lacking. MATERIAL AND METHODS A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items of Systematic reviews and Meta-Analysis (PRISMA) guidelines. We searched Medline/Pubmed, Embase and Cochrane databases as well as meeting abstracts until 18th March 2023. Hazard ratios (HRs) alongside their 95% confidence intervals (CIs) for PFS were extracted from the studies. A subgroup analysis was conducted to examine the effect of PARPi according to postoperative residual disease. RESULTS A total of six phase III randomised controlled trials were included and comprised SOLO 1, PAOLA 1, PRIMA, PRIME, ATHENA-MONO and VELIA. Patients who received PARPi following complete gross resection showed greatest PFS benefit. Compared with placebo, maintenance with PARPi significantly improved PFS in patients with macroscopic residual disease (pooled HR 0.55; 95% CI 0.44-0.68). This magnitude was comparable to that found in patients with complete gross resection (pooled HR 0.53; 95% CI 0.41-0.67). CONCLUSIONS Patients with macroscopic residual disease benefit from PARPi at the same extent as cases with complete gross resection. However, patients with complete gross resection who were treated with PARPi show the most favourable PFS rates. Hence, the pursuit of achieving complete cytoreduction remains valid in the PARPi era.
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Affiliation(s)
- Inge T A Peters
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Claudia Marchetti
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Antonella De Palma
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Diana Giannarelli
- Epidemiology and Biostatistics Facility, G-STeP Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonella Carcagnì
- Epidemiology and Biostatistics Facility, G-STeP Generator, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy
| | - Anna Fagotti
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy.
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28
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Pandraklakis A, Haidopoulos D, Lappas T, Stamatakis E, Oikonomou MD, Valsamidis D, Rodolakis A, Thomakos N. Enhanced Recovery After Surgery Protocols in Obese Gynecological Oncology Patients: A Single-Center Experience. Cureus 2023; 15:e40453. [PMID: 37456369 PMCID: PMC10349384 DOI: 10.7759/cureus.40453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2023] [Indexed: 07/18/2023] Open
Abstract
Objective The aim of this study is to present our experience and evaluate the safety and outcomes of the implementation of Enhanced Recovery After Surgery (ERAS) protocols in obese patients who underwent surgery for suspected or confirmed gynecological malignancies. Method From January 2020 to September 2021, 217 patients underwent laparotomy for a confirmed or suspected gynecological malignancy following a 19-element ERAS pathway. The patients were divided into two groups: obese (BMI ≥ 30 kg/m2, n = 104) and non-obese (BMI < 30, n = 113). Both groups were treated with a 19-element ERAS protocol. Results After dividing the 217 patients into two groups, significantly more comorbidities were observed in the obese group (diabetes mellitus: 23% vs. 8%, p = 0.004; ASA score grade 3: 25.0% vs. 6.2%, p < 0.001), as well as higher rates of endometrial cancer (51.9% vs. 17.7%, p < 0.001) compared to the non-obese group. The overall ERAS compliance rates when matched element by element were similar. Postoperatively, complication rates of all grades were significantly higher in the obese group (46.1% vs. 27.4%, p < 0.001) without differences in the length of stay, readmission, and reoperation rates. Conclusion In this retrospective study, we showed that obese gynecological oncology patients can be safely managed with ERAS protocols perioperatively while potentially minimizing the adverse outcomes in these otherwise high-risk patients.
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Affiliation(s)
- Anastasios Pandraklakis
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Dimitrios Haidopoulos
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Theodoros Lappas
- Department of Anaesthesiology, Alexandra General Hospital, Athens, GRC
| | | | - Maria D Oikonomou
- The Fertility Centre, Chelsea and Westminster Hospital NHS Foundation Trust, London, GBR
| | | | - Alexandros Rodolakis
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
| | - Nikolaos Thomakos
- Division of Gynaecologic Oncology, 1st Department of Obstetrics and Gynaecology, Alexandra Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, GRC
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29
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Feng Z, Fu Y, Li R, Li H, Lu J, Chen X, Ju X, Wu X, Wen H. Diffusion-weighted magnetic resonance imaging for the pre-operative evaluation of epithelial ovarian cancer patients. Gynecol Oncol 2023; 174:142-147. [PMID: 37207498 DOI: 10.1016/j.ygyno.2023.03.014] [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: 01/10/2023] [Revised: 03/12/2023] [Accepted: 03/19/2023] [Indexed: 05/21/2023]
Abstract
OBJECTIVE To investigate the value diffusion-weighted magnetic resonance imaging (DWI/MR) in the selection of ovarian cancer patients suitable for primary debulking surgery. METHODS Patients with suspected ovarian cancer who underwent pre-operative DWI/MR were enrolled between April 2020 and March 2022. All participants received preoperative clinic-radiological assessment according to the Suidan criteria for R0 resection with a predictive score. Data for patients with primary debulking surgery were prospectively recorded. The diagnostic value was calculated with ROC curves, and the cut-off value for the predictive score was also explored. RESULTS 80 patients with primary debulking surgery were included in the final analysis. The majority (97.5%) of patients were at advanced stage (III-IV), and 90.0% of patients had high-grade serous ovarian histology. 46 (57.5%) patients had no residual disease (R0), and 27 (33.8%) patients had optimal debulking surgery with zzmacroscopic disease less than or equal to 1 cm (R1). Patients with BRCA1 mutation had lower R0 resection rate, higher R1 resection rate compared with wild-type patients (42.9% vs 63.0%, 50.0% vs 29.6%, respectively). The median (range) predictive score was 4 (0-13), and the AUC for R0 resection was 0.742 (0.632-0.853). The R0 rates for patients with predictive score 0-2, 3-5, and ≥ 6 were 77.8%, 62.5% and 23.8%, respectively. CONCLUSION DWI/MR was a sufficient technique for pre-operative evaluation of ovarian cancer. Patients with predictive score 0-5 were suitable for primary debulking surgery at our institution.
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Affiliation(s)
- Zheng Feng
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi Fu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Ruimin Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Haiming Li
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jing Lu
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China; Department of Radiology, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Xiaojun Chen
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Xingzhu Ju
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Xiaohua Wu
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
| | - Hao Wen
- Department of Gynecological Oncology, Fudan University Shanghai Cancer Center, Shanghai, China; Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China.
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Polen-De C, Giri S, Fadadu P, Weaver A, Mcgree ME, Moynagh M, Takahashi N, Jatoi A, Lebrasseur NK, Cliby W, Williams G, Kumar A. Muscle loss during cancer therapy is associated with poor outcomes in advanced ovarian cancer. J Natl Cancer Inst Monogr 2023; 2023:43-48. [PMID: 37139982 DOI: 10.1093/jncimonographs/lgad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/02/2023] [Accepted: 02/06/2023] [Indexed: 05/05/2023] Open
Abstract
Data evaluating change in body composition during treatment of advanced cancer are limited. Here we evaluated computed tomography (CT)-based changes in muscle mass during treatment for advanced ovarian cancer (OC) and association with outcomes. We analyzed the preoperative and posttreatment skeletal muscle index (SMI), skeletal muscle area normalized for height of 109 patients with advanced OC who underwent primary surgery and platinum-based chemotherapy from 2006 to 2016. Based on an SMI less than 39 cm2/m2, 54.1% of patients were never sarcopenic, 24.8% were sarcopenic on both CT scans, and 21.1% were newly sarcopenic upon treatment completion. Patients who lost muscle during treatment had the worst survival of the 3 groups identified: median survival 2.6 years vs 4.6 years if sarcopenic on both CT scans and 4.8 years if never sarcopenic. Loss of muscle portends a poor prognosis among patients with OC. Additional research is needed to better understand and best mitigate these changes.
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Affiliation(s)
- Clarissa Polen-De
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Smith Giri
- Department of Medical Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama, Birmingham, AL, USA
| | - Priyal Fadadu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Amy Weaver
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | - Michaela E Mcgree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, USA
| | | | | | - Aminah Jatoi
- Department of Oncology, Mayo Clinic, Rochester, MN, USA
| | - Nathan K Lebrasseur
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN, USA
| | - William Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Grant Williams
- Department of Medical Oncology, Institute for Cancer Outcomes and Survivorship, University of Alabama, Birmingham, AL, USA
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, USA
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Piedimonte S, Bernardini MQ, Ding A, Laframboise S, Ferguson SE, Bouchard-Fortier G, Avery L, May T, Hogen L. Validation of the Integrated Prediction Model algorithm for outcome of cytoreduction in advanced ovarian cancer. Int J Gynecol Cancer 2023:ijgc-2022-004202. [PMID: 37015756 DOI: 10.1136/ijgc-2022-004202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND We previously developed the Integrated Prediction Model using a 4-step algorithm of unresectable stage IVB, patient factors, surgical resectability, and surgical complexity to predict outcome of <1 cm cytoreduction in advanced epithelial ovarian cancer, and triaged patients to neoadjuvant chemotherapy or primary cytoreductive surgery. OBJECTIVE To validate the Integrated Prediction Model on a retrospective cohort of patients. METHODS A retrospective cohort study of 107 patients with advanced ovarian cancer treated between January 2017 and September 2018 was carried out. The above mentioned 4-step algorithm determined cut-off points using the Youden Index. This validation study reports sensitivity, specificity, negative and positive predictive value on an external cohort. RESULTS Among 107 patients, 61 had primary surgery and 46 had neoadjuvant chemotherapy. Compared with primary surgery, patients treated with neoadjuvant chemotherapy were significantly older (63.5 vs 61, p=0.037), more likely to have stage IV disease (52% vs 18%, p<0.001), Eastern Cooperative Oncology Group (ECOG) score >1 (30% vs 11%, 0.045), lower pre-operative albumin (37 vs 40, p<0.001), and higher CA-125 (970 vs 227.5, p<0.001). They also had higher patient factors (2 vs 0, p=0.013), surgical resectability (4 vs 1, p<0.001), and anticipated surgical complexity (8 vs 5, p<0.001). There was no significant difference in outcome of cytoreduction (<1 cm residual disease: 85% for primary surgery vs 87% interval surgery, p=0.12)In this validation cohort, triaging patients with patient factors ≤2, surgical resectability score ≤5, and surgical complexity score ≤9 to primary surgery had a sensitivity of 91% for optimal cytoreduction <1 cm and a specificity of 81%. The positive predictive value, negative predictive value, and accuracy were 83%, 90%, and 86%, respectively. Application of the Integrated Prediction Model would have prevented five patients from receiving suboptimal cytoreduction and triaged them to neoadjuvant chemotherapy. CONCLUSIONS We validated the proposal that a triage algorithm integrating patient factors, surgical complexity, and surgical resectability in advanced ovarian cancer had high sensitivity and specificity to predict optimal cytoreduction <1 cm.
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Affiliation(s)
- Sabrina Piedimonte
- Division of Gynecologic Oncology, University of Toronto, Toronto, Ontario, Canada
| | | | - Avrilynn Ding
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Stephane Laframboise
- Department of Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | - Sarah Elizabeth Ferguson
- Department of Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | | | - Lisa Avery
- Department of Biostatistics, University of Toronto, Toronto, Ontario, Canada
| | - Taymaa May
- Department of Gynecologic Oncology, University Health Network, Toronto, Ontario, Canada
| | - Liat Hogen
- Department of Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
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So KA, Shim SH, Lee SJ, Kim TJ. Surgical Treatment Outcomes of Gynecologic Cancer in Older Patients: A Retrospective Study. J Clin Med 2023; 12:jcm12072518. [PMID: 37048601 PMCID: PMC10094859 DOI: 10.3390/jcm12072518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/15/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023] Open
Abstract
This study aimed to evaluate oncologic characteristics and surgical outcomes in older patients with gynecologic cancers. This retrospective study included patients aged ≥65 years who were diagnosed with gynecologic cancers and underwent surgical treatment between 2005 and 2020. We reviewed the medical records for age at diagnosis, body mass index, American Society of Anesthesiologists score, comorbidities, postoperative complications, cancer stage, histologic type, surgical treatment, postoperative outcome, and survival rate. Data were compared between groups according to the age at the time of diagnosis: <75 years (young-old) and ≥75 years (old-old). In total, 131 patients were identified: 53 (40.5%) with ovarian or primary peritoneal cancer (OC), 44 (33.6%) with endometrial cancer (EC), 30 (22.9%) with cervical cancer, and 4 (3.1%) with leiomyosarcoma. The patients’ mean age was 70 (range, 65–83) years; 106 (80.9%) were young-old and 25 (19.1%) were old-old. Postoperative complications occurred in 19 (14.5%) patients. Four patients died within six months after surgery, and three died because of disease progression. There was no difference in the survival rates between the two groups among those with OC and EC. Older patients with gynecologic cancers showed good surgical outcomes and tolerable postoperative complications. Therefore, we can safely offer surgical treatment to older patients.
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Warring SK, Narasimhulu DM, Kumar A, Langstraat CL, Weaver AL, McGree ME, Cliby WA. Next Steps Toward Reducing Surgical Morbidity After Complex Cytoreductive Surgery in Fit Surgical Patients. J Gynecol Surg 2023. [DOI: 10.1089/gyn.2022.0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Affiliation(s)
- Simrit K. Warring
- Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Amanika Kumar
- Division of Gynecologic Oncology, and Rochester, Minnesota, USA
| | | | - Amy L. Weaver
- Division of Clinical Trials and Biostatistics, Rochester, Minnesota, USA
| | - Michaela E. McGree
- Division of Clinical Trials and Biostatistics, Rochester, Minnesota, USA
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Kofoed NG, Falconer H, Vanky H, Johansson H, Abraham-Nordling M, Salehi S. Survival and chance of reversal after intestinal stoma formation during cytoreductive surgery for advanced ovarian cancer; a population-based cohort study. Gynecol Oncol 2023; 170:259-265. [PMID: 36738484 DOI: 10.1016/j.ygyno.2023.01.030] [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: 11/27/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Our objective was to examine oncologic outcome in women with advanced epithelial ovarian cancer (aEOC) receiving an intestinal stoma (IS) at the time of cytoreductive surgery (CRS), probability of stoma reversal (SR) and variables affecting odds of SR. METHODS This population-based cohort study included all women diagnosed with aEOC between 2009 and 2018 in the Stockholm/Gotland Region of Sweden. The association between IS formation at CRS and survival was analyzed with proportional hazards regression yielding hazard ratios (HR) with 95% confidence intervals (CI), adjusted for predefined confounders. Cumulative incidence functions, with death or recurrence as competing risk, were used to estimate chance of SR. The association between clinical factors and SR was analyzed with logistic regression yielding odds ratios (OR) with 95% CI. RESULTS The final analysis included 888 women undergoing CRS for aEOC. Of these, 129 (14,5%) received an IS of which 74% (n = 95) were defunctioning and 26% (n = 34) permanent. IS was associated with an increased hazard of death (HR 1.30, CI 95%, 1.05-1.61; p = 0.02) in the univariate analysis, however not in the adjusted analysis. The probability of SR of defunctioning IS within 2 years was 48% (95% CI, 38-58). Median time to SR was 10 months. High surgical complexity score (SCS) was associated with increased odds of reversal (OR 3.43, 95% CI, 1.06-11.05; p = 0.04). CONCLUSIONS IS formation does not seem to affect prognosis in women with aEOC. We could not identify any factor, known at time of CRS, that may predict the odds of SR except a high SCS.
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Affiliation(s)
- Nina Groes Kofoed
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden.
| | - Henrik Falconer
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Hanna Vanky
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Hemming Johansson
- Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Mirna Abraham-Nordling
- Department of Molecular medicine and Surgery Karolinska Institutet and Department of Pelvic Cancer, Theme Cancer Karolinska University Hospital, Stockholm, Sweden
| | - Sahar Salehi
- Department of Women's and Children's Health, Division of Obstetrics and Gynecology, Karolinska Institutet, and Department of Pelvic Cancer, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden; Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Sweden
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Piedimonte S, Erdman L, So D, Bernardini MQ, Ferguson SE, Laframboise S, Bouchard Fortier G, Cybulska P, May T, Hogen L. Using a machine learning algorithm to predict outcome of primary cytoreductive surgery in advanced ovarian cancer. J Surg Oncol 2023; 127:465-472. [PMID: 36350138 DOI: 10.1002/jso.27137] [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: 06/26/2022] [Revised: 09/11/2022] [Accepted: 10/21/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To develop a machine learning (ML) algorithm to predict outcome of primary cytoreductive surgery (PCS) in patients with advanced ovarian cancer (AOC) METHODS: This retrospective cohort study included patients with AOC undergoing PCS between January 2017 and February 2021. Using radiologic criteria, patient factors (age, CA-125, performance status, BRCA) and surgical complexity scores, we trained a random forest model to predict the dichotomous outcome of optimal cytoreduction (<1 cm) and no gross residual (RD = 0 mm) using JMP-Pro 15 (SAS). This model is available at https://ipm-ml.ccm.sickkids.ca. RESULTS One hundred and fifty-one patients underwent PCS and randomly assigned to train (n = 92), validate (n = 30), or test (n = 29) the model. The median age was 58 (27-83). Patients with suboptimal cytoreduction were more likely to have an Eastern Cooperative Oncology Group 3-4 (11% vs. 0.75%, p = 0.004), lower albumin (38 vs. 41, p = 0.02), and higher CA125 (1126 vs. 388, p = 0.012) than patients with optimal cytoreduction (n = 133). There were no significant differences in age, histology, stage, or BRCA status between groups. The bootstrap random forest model had AUCs of 99.8% (training), 89.6%(validation), and 89.0% (test). The top five contributors were CA125, albumin, diaphragmatic disease, age, and ascites. For RD = 0 mm, the AUCs were 94.4%, 52%, and 84%, respectively. CONCLUSION Our ML algorithm demonstrated high accuracy in predicting optimal cytoreduction in patients with AOC selected for PCS and may assist decision-making.
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Affiliation(s)
| | - Lauren Erdman
- Computer Science, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Delvin So
- Computer Science, The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Sarah E Ferguson
- Division of Gynecologic Oncology, Princess Margaret Hospital Cancer Centre, Toronto, Ontario, Canada
| | | | | | - Paulina Cybulska
- Obsterics and Gynecology, University of Toronto, Toronto, Ontario, Canada
| | - Taymaa May
- Obstetrics and Gynecology, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
| | - Liat Hogen
- Obsterics and Gynecology, University of Toronto, Toronto, Ontario, Canada
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Ronsini C, Pasanisi F, Greco P, Cobellis L, De Franciscis P, Cianci S. Mininvasive Cytoreduction Surgery plus HIPEC for Epithelial Ovarian Cancer: A Systematic Review. Medicina (B Aires) 2023; 59:medicina59030421. [PMID: 36984422 PMCID: PMC10055964 DOI: 10.3390/medicina59030421] [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: 01/05/2023] [Revised: 02/10/2023] [Accepted: 02/17/2023] [Indexed: 02/24/2023] Open
Abstract
Background and objectives: The Gold-Standard treatment for Advanced Epithelial Ovarian Cancer remains cytoreductive surgery followed by systemic chemotherapy. Surgery can be performed either by an open or minimally invasive approach (MIS), although the former remains the most widely used approach. Recently, Van Driel et al. proved that adding 100 mg/m2 of Cisplatin in Hyperthermic Intraperitoneal Chemotherapy (HIPEC) at Interval Debulking Surgery (IDS) gives a disease-free survival (DFS) advantage. Similarly, Gueli-Alletti et al. demonstrated how the MIS approach is feasible and safe in IDS. Moreover, Petrillo et al. reported pharmacokinetic profiles with a higher chemotherapy concentration in patients undergoing HIPEC after MIS compared with the open approach. Therefore, the following review investigates the oncological and clinical safety consequences of the association between MIS and HIPEC. Methods: Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, we systematically searched the PubMed and Scopus databases in April 2022. Studies containing data about oncological and safety outcomes were included. We registered the Review to the PROSPERO site for meta-analysis with protocol number CRD42022329503. Results: Five studies fulfilled inclusion criteria. 42 patients were included in the review from three different Gynecological Oncological referral centers. The systematic review highlighted a Recurrence Rate ranging between 0 and 100%, with a 3-year Platinum-Free Survival between 10 and 70%. The most common HIPEC drug was Cisplatin, used at concentrations between 75 and 100 mg/m2 and at an average temperature of 42 °C, for 60 to 90 min. Only 1 Acute Kidney Insufficiency has been reported. Conclusions: The scarcity of clinical trials focusing on a direct comparison between MIS and the open approach followed by HIPEC in EOC treatment does not make it possible to identify an oncological advantage between these two techniques. However, the safety profiles shown are highly reassuring.
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Affiliation(s)
- Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Francesca Pasanisi
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Pierfrancesco Greco
- Unit of Gynecologic Oncology, Department of Woman, Child and Public Health, A. Gemelli, IRCCS, University Hospital Foundation, 00198 Rome, Italy
| | - Luigi Cobellis
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania Luigi Vanvitelli, 80138 Naples, Italy
| | - Stefano Cianci
- Unit of Gynecology and Obstetrics, Department of Human Pathology of Adult and Childhood “G. Barresi”, University of Messina, 98122 Messina, Italy
- Correspondence:
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Huang D, Harrison R, Curtis E, Mirabadi N, Chen GY, Alexandridis R, Barroilhet L, Rose S, Hartenbach E, Al-Niami A. Beyond post-operative readmissions: analysis of the impact of unplanned readmissions during primary treatment of advanced-stage epithelial ovarian cancer on long-term oncology outcome. Int J Gynecol Cancer 2023; 33:741-748. [PMID: 36808044 DOI: 10.1136/ijgc-2022-003765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND Multiple studies have assessed post-operative readmissions in advanced ovarian cancer. OBJECTIVE To evaluate all unplanned readmissions during the primary treatment period of advanced epithelial ovarian cancer, and the impact of readmission on progression-free survival. METHODS This was a single institution retrospective study from January 2008 to October 2018. Χ2/Fisher's exact and t-test, or Kruskal-Wallis test were used. Multivariable Cox proportional hazard models were used to assess the effect of covariates in progression-free survival analysis. RESULTS A total of 484 patients (279 primary cytoreductive surgery, 205 neoadjuvant chemotherapy) were analyzed. In total, 272 of 484 (56%; 37% primary cytoreductive surgery, 32% neoadjuvant chemotherapy, p=0.29) patients were readmitted during the primary treatment period. Overall, 42.3% of the readmissions were surgery related, 47.8% were chemotherapy related, and 59.6% were cancer related but not related to surgery or chemotherapy, and each readmission could qualify for more than one reason. Readmitted patients had a higher rate of chronic kidney disease (4.1% vs 1.0%, p=0.038). Post-operative, chemotherapy, and cancer-related readmissions were similar between the two groups. However, the percentage of inpatient treatment days due to unplanned readmission was twice as high for primary cytoreductive surgery at 2.2% vs 1.3% for neoadjuvant chemotherapy (p<0.001). Despite longer readmissions in the primary cytoreductive surgery group, Cox regression analysis demonstrated that readmissions did not affect progression-free survival (HR=1.22, 95% CI 0.98 to 1.51; p=0.08). Primary cytoreductive surgery, higher modified Frailty Index, grade 3 disease, and optimal cytoreduction were associated with longer progression-free survival. CONCLUSIONS In this study, 35% of the women with advanced ovarian cancer had at least one unplanned readmission during the entire treatment time. Patients treated by primary cytoreductive surgery spent more days during readmission than those with neoadjuvant chemotherapy. Readmissions did not affect progression-free survival and may not be valuable as a quality metric.
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Affiliation(s)
- Dandi Huang
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA .,Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ross Harrison
- Division of Gynecologic Oncology, Department of Obstetrics & Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Erin Curtis
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Nina Mirabadi
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.,Department of General Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Grace Yi Chen
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Roxana Alexandridis
- Department of Biostatistics and Medical Informatics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Lisa Barroilhet
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Stephen Rose
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ellen Hartenbach
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ahmed Al-Niami
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
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Xia Y, Wang H, Zhang J, Wang Y. Prognostic value and adverse events of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in primary advanced and platinum-sensitive recurrent epithelial ovarian cancer: a systematic review and meta-analysis. Int J Hyperthermia 2023; 40:2165729. [PMID: 36775583 DOI: 10.1080/02656736.2023.2165729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023] Open
Abstract
BACKGROUND The original meta-analysis of hyperthermic intraperitoneal chemotherapy (HIPEC) is already outdated, owing to the latest trial results. This study aimed to clarify the efficacy and adverse events of cytoreductive surgery with HIPEC compared to conventional therapy for advanced and platinum-sensitive recurrent epithelial ovarian cancer (OC). METHODS In this meta-analysis, phase II/III controlled trials regarding 'HIPEC' and 'ovarian cancer' were searched for in electronic databases from inception to March 2022. RESULTS Twenty-one studies were included in the quantitative synthesis. The pooled hazard ratio [HR] in the HIPEC group for progression-free survival (PFS) (HR = 0.61, 95% confidence interval [CI]: 0.45-0.83, p = .002) and overall survival (OS) (HR = 0.65, 95% CI: 0.51-0.82, p < .001) were improved in the HIPEC group compared with the non-HIPEC group. For primary advanced disease, OS and PFS were significantly increased in patients receiving interval debulking surgery + HIPEC, whereas PFS was not significantly different between primary debulking surgery (PDS) + HIPEC and PDS alone. For platinum-sensitive recurrent disease, no correlation was observed for PFS and OS between the HIPEC and non-HIPEC groups (p < .05). The incidence of procedure-related complications was higher in the HIPEC group than in the non-HIPEC group (odds ratio = 1.93, 95% CI: 1.24-3.01, p < .01). The morbidity of leukopenia, neutropenia, nausea, hypoalbuminemia, and grades III-IV electrolyte disturbance was higher in the HIPEC group than in the non-HIPEC group. However, HIPEC administration reduced the risk of intra-abdominal bleeding and constipation. CONCLUSION HIPEC-based regimens improved the clinical prognosis for primary advanced OC, whereas no significant value was elicited for recurrent OC.
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Affiliation(s)
- Yu Xia
- School of Clinical Medical, Weifang Medical University, Weifang, China.,Department of Gynecology and Obstetrics, Beijing Jishuitan Hospital, Beijing, China
| | - He Wang
- Department of Gynecology and Obstetrics, Weifang People's Hospital, Weifang, China
| | - Jing Zhang
- Department of Gynecology and Obstetrics, Beijing Jishuitan Hospital, Beijing, China
| | - Yongjun Wang
- Department of Gynecology and Obstetrics, Beijing Jishuitan Hospital, Beijing, China
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Conte C, Marchetti C, Loverro M, Giudice MT, Rosati A, Gallotta V, Scambia G, Fagotti A. Role of minimally invasive secondary cytoreduction in patients with recurrent ovarian cancer. Int J Gynecol Cancer 2023; 33:137-144. [PMID: 36639195 DOI: 10.1136/ijgc-2022-003904] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVE Retrospective series have shown minimally invasive secondary cytoreductive surgery is a feasible approach in selected cases of recurrent ovarian cancer. However, no predictors of minimally invasive secondary cytoreductive surgery feasibility are currently available. This study aims to identify predictive factors of minimally invasive secondary cytoreductive surgery feasibility and to compare perioperative and survival outcomes in a matched series of recurrent ovarian cancer patients who underwent secondary cytoreduction via an open or minimally invasive surgical approach. METHODS We retrospectively identified all platinum-sensitive recurrent epithelial ovarian cancer patients who underwent minimally invasive or laparotomic secondary cytoreductive surgery between January 2013 and July 2020. Each patient underwent a preoperative positron emission tomography (PET) computerized tomography (CT) scan and diagnostic laparoscopy before secondary cytoreductive surgery. A 1:2 propensity score-matched analysis was performed to balance predictive factors of minimally invasive secondary cytoreductive surgery. RESULTS Overall, 276 patients were identified (62 minimally invasive and 214 open), and a complete gross resection was achieved in 262 (94.9%) patients. At multivariate analysis, predictive factors for minimally invasive secondary cytoreductive surgery were neoadjuvant chemotherapy at first diagnosis (p=0.007), site of recurrence (p=0.031), and number of lesions (p=0.001). In the 1:2 propensity-matched population (39 minimally invasive and 78 open), complete gross resection was similar for both groups (p=0.082). Early post-operative complications were significantly higher in the laparotomy (33.3%) than in the minimally invasive surgery (10.3%) group (p=0.004). Only one (2.6%) patient experienced a grade >3 early post-operative complication in the minimally invasive surgery group compared with 13 (16.7%) patients in the open cohort (p<0.001). The median follow-up period was 32 months (range: 1-92) in the propensity-matched population. The median post-recurrence survival was 81 months in the minimally invasive surgery group and was not reached in the open group (p=0.11). CONCLUSIONS Patients with single or oligometastatic recurrences can be offered minimally invasive secondary cytoreductive surgery, mainly if localized in the lymph-nodes, and/or if they received neoadjuvant chemotherapy at primary diagnosis. Minimally invasive secondary cytoreductive surgery is associated with favorable perioperative outcomes with no differences in terms of post-recurrence survival with respect to open approach.
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Affiliation(s)
- Carmine Conte
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Claudia Marchetti
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Matteo Loverro
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | | | - Andrea Rosati
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy .,Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Rome, Italy
| | - Anna Fagotti
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore Facoltà di Medicina e Chirurgia, Rome, Italy
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Laios A, Kalampokis E, Johnson R, Munot S, Thangavelu A, Hutson R, Broadhead T, Theophilou G, Nugent D, De Jong D. Development of a Novel Intra-Operative Score to Record Diseases' Anatomic Fingerprints (ANAFI Score) for the Prediction of Complete Cytoreduction in Advanced-Stage Ovarian Cancer by Using Machine Learning and Explainable Artificial Intelligence. Cancers (Basel) 2023; 15:cancers15030966. [PMID: 36765924 PMCID: PMC9913185 DOI: 10.3390/cancers15030966] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The Peritoneal Carcinomatosis Index (PCI) and the Intra-operative Mapping for Ovarian Cancer (IMO), to a lesser extent, have been universally validated in advanced-stage epithelial ovarian cancer (EOC) to describe the extent of peritoneal dissemination and are proven to be powerful predictors of the surgical outcome with an added sensitivity of assessment at laparotomy of around 70%. This leaves room for improvement because the two-dimensional anatomic scoring model fails to reflect the patient's real anatomy, as seen by a surgeon. We hypothesized that tumor dissemination in specific anatomic locations can be more predictive of complete cytoreduction (CC0) and survival than PCI and IMO tools in EOC patients. (2) Methods: We analyzed prospectively data collected from 508 patients with FIGO-stage IIIB-IVB EOC who underwent cytoreductive surgery between January 2014 and December 2019 at a UK tertiary center. We adapted the structured ESGO ovarian cancer report to provide detailed information on the patterns of tumor dissemination (cancer anatomic fingerprints). We employed the extreme gradient boost (XGBoost) to model only the variables referring to the EOC disseminated patterns, to create an intra-operative score and judge the predictive power of the score alone for complete cytoreduction (CC0). Receiver operating characteristic (ROC) curves were then used for performance comparison between the new score and the existing PCI and IMO tools. We applied the Shapley additive explanations (SHAP) framework to support the feature selection of the narrated cancer fingerprints and provide global and local explainability. Survival analysis was performed using Kaplan-Meier curves and Cox regression. (3) Results: An intra-operative disease score was developed based on specific weights assigned to the cancer anatomic fingerprints. The scores range from 0 to 24. The XGBoost predicted CC0 resection (area under curve (AUC) = 0.88 CI = 0.854-0.913) with high accuracy. Organ-specific dissemination on the small bowel mesentery, large bowel serosa, and diaphragmatic peritoneum were the most crucial features globally. When added to the composite model, the novel score slightly enhanced its predictive value (AUC = 0.91, CI = 0.849-0.963). We identified a "turning point", ≤5, that increased the probability of CC0. Using conventional logistic regression, the new score was superior to the PCI and IMO scores for the prediction of CC0 (AUC = 0.81 vs. 0.73 and 0.67, respectively). In multivariate Cox analysis, a 1-point increase in the new intra-operative score was associated with poorer progression-free (HR: 1.06; 95% CI: 1.03-1.09, p < 0.005) and overall survival (HR: 1.04; 95% CI: 1.01-1.07), by 4% and 6%, respectively. (4) Conclusions: The presence of cancer disseminated in specific anatomical sites, including small bowel mesentery, large bowel serosa, and diaphragmatic peritoneum, can be more predictive of CC0 and survival than the entire PCI and IMO scores. Early intra-operative assessment of these areas only may reveal whether CC0 is achievable. In contrast to the PCI and IMO scores, the novel score remains predictive of adverse survival outcomes.
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Affiliation(s)
- Alexandros Laios
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
- Correspondence:
| | - Evangelos Kalampokis
- Information Systems Lab, Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece
| | - Racheal Johnson
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Sarika Munot
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Amudha Thangavelu
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Richard Hutson
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Tim Broadhead
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Georgios Theophilou
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - David Nugent
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
| | - Diederick De Jong
- Department of Gynaecologic Oncology, St James’s University Hospital, Leeds LS9 7TF, UK
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Graham R, Kotsopoulos IC. A comparison of end-to-end and end-to-side anastomosis following rectosigmoid resection in ovarian cancer cytoreductive surgery. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2023; 49:468-474. [PMID: 36096854 DOI: 10.1016/j.ejso.2022.08.039] [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: 07/28/2022] [Revised: 08/17/2022] [Accepted: 08/31/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION A rectosigmoid resection with anastomosis is a common component of cytoreductive surgery for ovarian cancer. Evidence from colorectal studies suggests that end-to-side anastomoses may be associated with fewer complications than end-to-end approaches, but these have not previously been compared in an ovarian cancer patient cohort. MATERIALS AND METHODS Over a 51-month period, 239 patients underwent cytoreductive surgery for FIGO stage III/IV ovarian cancer. A rectosigmoid resection was performed in 79 (33.1%) with anastomosis in 59 (74.7%). Pre-operative and intra-operative factors associated with anastomotic leak, and post-operative complications were compared by anastomotic technique. RESULTS Anastomoses were end-to-end in 33 (55.9%) and end-to-side in 26 (44.1%) patients. There was a greater proportion of patients with a higher American Society of Anaesthesiologists score in the end-to-side group, but no other statistically significant differences in pre-or intra-operative factors between the groups. There were three (9.1%) cases of anastomotic leak in the end-to-end group, and no leaks in the end-to-side group, but the difference did not reach statistical significance. Both leaks were small, and successfully conservatively managed. There was no significant difference in rate of Clavien Dindo grade III/IV complications, although there was a higher rate of grade II complications following an end-to-side anastomosis (p = 0.036). There was no difference in length of stay, time to restarting chemotherapy, re-operation or 90-day mortality rate. CONCLUSION There was no significant difference in major morbidity following end-to-end or end-to-side anastomosis. Prospective randomised trials specifically focussed in ovarian cancer are needed.
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Affiliation(s)
- Radha Graham
- University College Hospital, 250 Euston Road, London, NW1 2PG, UK.
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Wood N, Morton M, Shah SN, Yao M, Barnard H, Tewari S, Suresh A, Kollikonda S, AlHilli MM. Association between CT-based body composition assessment and patient outcomes during neoadjuvant chemotherapy for epithelial ovarian cancer. Gynecol Oncol 2023; 169:55-63. [PMID: 36508759 DOI: 10.1016/j.ygyno.2022.11.024] [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] [Received: 07/30/2022] [Revised: 11/17/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The aim of this study was to characterize the body composition of patients undergoing neoadjuvant chemotherapy (NACT) for epithelial ovarian cancer (EOC), identify factors associated with sarcopenia at diagnosis, and evaluate the impact of pretreatment sarcopenia and changes in body composition parameters during therapy on perioperative and disease-related outcomes. METHODS Patients undergoing NACT for EOC between 2008 and 2020 were identified. Pre-treatment and post-treatment contrast-enhanced CT scans were reviewed to determine skeletal muscle index (SMI) and visceral adipose tissue (VAT) area at the mid-fourth lumbar vertebral level. SMI and VAT were analyzed for association with clinical and treatment variables. RESULTS 174 patients were identified. Mean pretreatment SMI and VAT were 38.3 cm2/m2 ± 7.9 and 51.2 cm2/m2 ± 34.3, respectively. Comparatively, mean post-treatment SMI and VAT were 37.8 cm2/m2 ± 7.9 and 43.7 cm2/m2 ± 29.7, respectively. Most patients exhibited an overall decrease in SMI from pretreatment to posttreatment scans. Caucasian race, older age, and lower body mass index at diagnosis were associated with lower pretreatment SMI. Lower pre-treatment SMI was associated with lower surgical complexity scores (p < 0.001) and estimated blood loss (p = 0.029). Decrease in SMI after NACT was associated with increased rates of ICU admissions and length of stay. While there was no association between SMI and overall survival (OS) or progression-free survival (PFS), >2% decrease per 100 days in VAT was significantly associated with worse OS. CONCLUSIONS Patients with lower pretreatment SMI tend to undergo less complex surgery than those with higher SMI despite NACT. Decrease in VAT may be a potential indicator of worse OS. Information on body composition can aid in clinical decision making in patients with EOC.
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Affiliation(s)
- Nicole Wood
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Molly Morton
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Shetal N Shah
- Department of Radiology, Cleveland Clinic, Cleveland, OH, United States of America
| | - Meng Yao
- Department of Qualitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States of America
| | - Hannah Barnard
- Department of Radiology, Cleveland Clinic, Cleveland, OH, United States of America
| | - Surabhi Tewari
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
| | - Abhilash Suresh
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University School of Medicine, Cleveland, OH, United States of America
| | - Swapna Kollikonda
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Mariam M AlHilli
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States of America; Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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Maximal Effort Cytoreduction in Epithelial Ovarian Cancer: Perioperative Complications and Survival Outcomes from a Retrospective Cohort. J Clin Med 2023; 12:jcm12020622. [PMID: 36675556 PMCID: PMC9865054 DOI: 10.3390/jcm12020622] [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: 12/27/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/15/2023] Open
Abstract
Background: Rates of maximal effort cytoreductive surgery in ovarian cancer patients increase gradually the last decade. The purpose of the present study is to evaluate factors that contribute to survival and morbidity outcomes in this group of patients. Methods: We retrospectively reviewed patient records of epithelial ovarian cancer patients with an intermediate and high Mayo Clinic surgical complexity score, operated between January 2010 and December 2018. Results: Overall, 107 patients were enrolled in the present study with a median age of 62 years (23-84) and a follow-up of 32 months (2-156). Thirteen Clavien-Dindo grade IIIa complications were documented in 10 patients (9.3%). Of all the investigated factors, only stage IVb (p = 0.027) and interval debulking surgery (p = 0.042) affected overall survival rates. Overall survival outcomes of patients operated on a primary setting started to differentiate compared to those that received neo-adjuvant chemotherapy after the 4th postoperative year. Conclusions: Maximal effort cytoreductive procedures should be considered feasible in the modern surgical era, as they are accompanied by acceptable rates of perioperative morbidity. Hence, every effort should be made to perform them in the primary setting, rather than following neoadjuvant chemotherapy as current evidence favor increased survival rates of patients that will likely surpass an interval of observation of more than 4 years.
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Diagnostic and Therapeutic Pathway of Advanced Ovarian Cancer with Peritoneal Metastases. Cancers (Basel) 2023; 15:cancers15020407. [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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Narasimhulu DM, Fagotti A, Scambia G, Weaver AL, McGree M, Quagliozzi L, Langstraat C, Kumar A, Cliby W. Validation of a risk-based algorithm to reduce poor operative outcomes after complex surgery for ovarian cancer. Int J Gynecol Cancer 2023; 33:83-88. [PMID: 36517075 PMCID: PMC9972179 DOI: 10.1136/ijgc-2022-003799] [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: 12/23/2022] Open
Abstract
OBJECTIVE We developed an algorithm that identifies patients at high risk of morbidity/mortality after cytoreductive surgery for advanced ovarian cancer. We have previously shown that the Mayo triage algorithm reduces operative mortality internally, followed by validation using an external low complexity national dataset. However, validation in a higher complexity surgical setting is required before widespread acceptance of this approach, and this was the goal of our study. METHODS We included patients who underwent debulking surgery (including primary or interval debulking surgery) for stage IIIC/IV ovarian cancer between October 2011 and November 2019 (SCORPION trial patients until May 2016 and non-trial patients thereafter) at Fondazione Policlinico A Gemelli, Italy. Using the algorithm, we classified patients as either high-risk or triage-appropriate and compared 30-day grade 3+ complications and 90-day mortality using a χ2 test or Fisher's exact test. RESULTS A total of 625 patients were included. The mean age was 58.7±11.4 years, 73.6% (n=460) were stage IIIC, and 63.0% (n=394) underwent primary debulking surgery. Surgical complexity was intermediate or high in 82.6% (n=516) of patients (95.7% (n=377) for primary surgery and 60.2% (n=139) for interval surgery), and 20.3% (n=127) were classified as high-risk. When compared with triage-appropriate patients, high-risk patients had (1) a threefold higher rate of 90-day mortality (6.3% vs 2.0%, p=0.02); (2) a higher likelihood of 90-day mortality following a grade 3+ complication (25.9% vs 10.0%, p=0.05); and (3) comparable rates of grade 3+ complications (21.3% vs 16.1%, p=0.17). CONCLUSION The evidence-based triage algorithm identifies patients at high risk of morbidity/mortality after cytoreductive surgery. Triage high-risk patients are poor candidates for surgery when complex surgery is required. This algorithm has been validated in heterogeneous settings (internal, national, and international) and degree of surgical complexity. Risk-based decision making should be standard of care when planning surgery for patients with advanced ovarian cancer, whether primary or interval surgery.
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Affiliation(s)
- Deepa Maheswari Narasimhulu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anna Fagotti
- Department of Gynecological Oncology, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Giovanni Scambia
- Department of Gynecological Oncology, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Amy L Weaver
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Lorena Quagliozzi
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Kim NK, Suh DH, Kim K, Kim YB, No JH. Feasibility of extended cycles of neoadjuvant chemotherapy in patients with advanced ovarian cancer in terms of prognosis and surgical outcomes. PLoS One 2023; 18:e0284753. [PMID: 37083873 PMCID: PMC10121047 DOI: 10.1371/journal.pone.0284753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 04/07/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVE We aimed to identify the effect of an extended number of neoadjuvant chemotherapy (NAC) cycles on prognosis and surgical morbidity after interval debulking surgery (IDS) in patients with newly diagnosed advanced ovarian cancer. METHODS Medical records of patients with advanced ovarian cancer treated with NAC and having undergone IDS were retrospectively reviewed. Clinicopathological factors were compared between two groups: conventional (≤4 cycles) and extended (≥5 cycles) NAC groups. Kaplan-Meier analysis was performed to evaluate progression-free survival (PFS) and overall survival (OS). RESULTS A total of 156 patients were included, 112 patients in the conventional group and 44 patients in the extended NAC group. The extended NAC group had a significantly higher frequency of cancer antigen (CA)-125 normalization after NAC (59.1% vs. 33.9%, P = 0.004), a lower rate of bowel surgery (18.2% vs. 34.8%, P = 0.042), and a lower rate of transfusion during or after IDS (36.4% vs. 59.8%, P = 0.008) as compared to the conventional group. The complete cytoreduction rate after IDS was similar between the groups. In multivariate Cox regression analysis for PFS, radiologically stable and progressive disease after NAC (Hazard ratio [HR], 1.983; 95% Confidence interval [CI], 1.141-3.446; P = 0.015) and gross residual tumor after IDS (HR, 2.054; 95% CI, 1.414-2.983; P < 0.001) were independent risk factors for poor PFS. However, extended NAC cycles were not significantly associated with poor PFS. The median PFS was 19.5 and 16.9 months (P = 0.830), and the 5-year OS was 71.4 and 63.2% (P = 0.677) in the conventional and extended NAC groups, respectively. CONCLUSION Our study showed that extended NAC cycles were not inferior to conventional NAC cycles in terms of survival in patients with advanced ovarian cancer and reduced surgical morbidity such as bowel surgery and transfusion during or after IDS.
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Affiliation(s)
- Nam Kyeong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong Hoon Suh
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Kidong Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Beom Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
| | - Jae Hong No
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
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Laios A, Kalampokis E, Mamalis ME, Tarabanis C, Nugent D, Thangavelu A, Theophilou G, De Jong D. RoBERTa-Assisted Outcome Prediction in Ovarian Cancer Cytoreductive Surgery Using Operative Notes. Cancer Control 2023; 30:10732748231209892. [PMID: 37915208 PMCID: PMC10624075 DOI: 10.1177/10732748231209892] [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: 06/15/2023] [Revised: 09/16/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023] Open
Abstract
INTRODUCTION Contemporary efforts to predict surgical outcomes focus on the associations between traditional discrete surgical risk factors. We aimed to determine whether natural language processing (NLP) of unstructured operative notes improves the prediction of residual disease in women with advanced epithelial ovarian cancer (EOC) following cytoreductive surgery. METHODS Electronic Health Records were queried to identify women with advanced EOC including their operative notes. The Term Frequency - Inverse Document Frequency (TF-IDF) score was used to quantify the discrimination capacity of sequences of words (n-grams) regarding the existence of residual disease. We employed the state-of-the-art RoBERTa-based classifier to process unstructured surgical notes. Discrimination was measured using standard performance metrics. An XGBoost model was then trained on the same dataset using both discrete and engineered clinical features along with the probabilities outputted by the RoBERTa classifier. RESULTS The cohort consisted of 555 cases of EOC cytoreduction performed by eight surgeons between January 2014 and December 2019. Discrete word clouds weighted by n-gram TF-IDF score difference between R0 and non-R0 resection were identified. The words 'adherent' and 'miliary disease' best discriminated between the two groups. The RoBERTa model reached high evaluation metrics (AUROC .86; AUPRC .87, precision, recall, and F1 score of .77 and accuracy of .81). Equally, it outperformed models that used discrete clinical and engineered features and outplayed the performance of other state-of-the-art NLP tools. When the probabilities from the RoBERTa classifier were combined with commonly used predictors in the XGBoost model, a marginal improvement in the overall model's performance was observed (AUROC and AUPRC of .91, with all other metrics the same). CONCLUSION/IMPLICATIONS We applied a sui generis approach to extract information from the abundant textual surgical data and demonstrated how it can be effectively used for classification prediction, outperforming models relying on conventional structured data. State-of-art NLP applications in biomedical texts can improve modern EOC care.
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Affiliation(s)
- Alexandros Laios
- Department of Gynaecologic Oncology, ESGO Center of Excellence for Ovarian Cancer Surgery, St James’s University Hospital, Leeds, UK
| | - Evangelos Kalampokis
- Information Systems Lab, Department of Business Administration, University of Macedonia, Thessaloniki, Greece
| | - Marios Evangelos Mamalis
- Information Systems Lab, Department of Business Administration, University of Macedonia, Thessaloniki, Greece
| | - Constantine Tarabanis
- Department of Internal Medicine, School of Medicine, New York University, New York, NY, USA
| | - David Nugent
- Department of Gynaecologic Oncology, ESGO Center of Excellence for Ovarian Cancer Surgery, St James’s University Hospital, Leeds, UK
| | - Amudha Thangavelu
- Department of Gynaecologic Oncology, ESGO Center of Excellence for Ovarian Cancer Surgery, St James’s University Hospital, Leeds, UK
| | - Georgios Theophilou
- Department of Gynaecologic Oncology, ESGO Center of Excellence for Ovarian Cancer Surgery, St James’s University Hospital, Leeds, UK
| | - Diederick De Jong
- Department of Gynaecologic Oncology, ESGO Center of Excellence for Ovarian Cancer Surgery, St James’s University Hospital, Leeds, UK
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Upper-Abdominal Cytoreduction for Advanced Ovarian Cancer—Therapeutic Rationale, Surgical Anatomy and Techniques of Cytoreduction. SURGICAL TECHNIQUES DEVELOPMENT 2022. [DOI: 10.3390/std12010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cytoreductive surgery (CRS) is the cornerstone of treating advanced ovarian cancer. Approximately 60–70% of patients with advanced ovarian cancer will have involvement in the upper abdomen or the supracolic compartment of the abdominal cavity. Though the involvement of this region results in poorer survival compared, complete cytoreduction benefits overall survival, making upper-abdominal cytoreduction an essential component of CRS for advanced ovarian cancer. The upper abdomen constitutes several vital organs and large blood vessels draped with the parietal or visceral peritoneum, common sites of disease in ovarian cancer. A surgeon treating advanced ovarian cancer should be well versed in upper-abdominal cytoreduction techniques, including diaphragmatic peritonectomy and diaphragm resection, lesser omentectomy, splenectomy with or without distal pancreatectomy, liver resection, cholecystectomy, and suprarenal retroperitoneal lymphadenectomy. Other procedures such as clearance of the periportal region, Glisson’s capsulectomy, clearance of the superior recess of the lesser sac, and Morrison’s pouch are essential as these regions are often involved in ovarian cancer. This manuscript covers the surgical anatomy of the upper abdomen, the techniques and therapeutic rationale of upper-abdominal cytoreduction, and specific measures for perioperative management of these patients. The main focus is the description of various peritonectomies and regional lymphadenectomies.
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Residual Disease Threshold After Primary Surgical Treatment for Advanced Epithelial Ovarian Cancer, Part 1: A Systematic Review and Network Meta-Analysis. Am J Ther 2022; 30:e36-e55. [PMID: 36608071 PMCID: PMC9812425 DOI: 10.1097/mjt.0000000000001584] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [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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Ade CJ, Dockery L, Walter AC, Benbrook DM, Vesely SK, Hammond ST, Moore KN, Holman LL. Association between Serum Biomarkers with Postoperative Complications and Delay of Adjuvant Chemotherapy Initiation in Ovarian Cancer Patients Undergoing Primary Cytoreductive Surgery: A Pilot Study. Nutr Cancer 2022; 75:662-669. [PMID: 36495155 PMCID: PMC10127353 DOI: 10.1080/01635581.2022.2152060] [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: 03/10/2022] [Accepted: 11/22/2022] [Indexed: 12/14/2022]
Abstract
This study sought to describe and relate the factors associated with complications and delays in adjuvant chemotherapy in patients with ovarian cancer treated with primary cytoreductive surgery. Serum from patients diagnosed with ovarian cancer scheduled for primary cytoreductive surgery were analyzed for prealbumin, 25-OH Vitamin D, intracellular adhesion molecule 1 (ICAM-1), interleukin 6 (IL-6), interleukin 8 (IL-8), monocyte chemoattractant protein 1 (MCP-1), monocyte chemoattractant protein 2 (MCP-2), macrophage derived chemokine (MDC). Postoperative complications were identified using common terminology criteria for adverse events 4.0 and 30 day after surgery. Delays in adjuvant chemotherapy were defined as >1 week interval between surgery and initiation. Patients with postoperative complications (39.6%) were significantly older, had lower serum prealbumin levels, and higher serum IL-6 and IL-8 than those without. Univariate logistic regression found that age (OR: 1.12, 95%CI: 1.00-1.35) and IL-6 (OR: 1.02, 95%CI: 0.99-1.05) were associated with postoperative complications, whereas age remained significant after multivariate analysis (OR:1.14, 95%CI: 1.00-1.29). Patients with delays in chemotherapy exhibited greater BMI and lower 25-OH Vitamin D than those without. Multivariate analysis found that increasing levels of 25-OH Vitamin D were associated with a lower risk of delayed chemotherapy initiation after controlling for age, body mass index, and tumor grade (OR: 0.93, 95%CI:0.87-0.99). This work suggests that in addition to age being predictive of postoperative complications, serum 25-OH Vitamin D may a provide insight into a patient's risk for postsurgical delays in chemotherapy initiation. These findings should, however, be confirmed in a larger study including robust survival analysis.
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Affiliation(s)
- Carl J Ade
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
- Department of Physician Assistant Studies, Kansas State University, Manhattan, Kansas
- Johnson Cancer Center, Kansas State University, Manhattan, Kansas
| | - Lauren Dockery
- Stephenson Cancer Center at the University of Oklahoma HSC, Oklahoma City, Oklahoma
| | - Adam C Walter
- Stephenson Cancer Center at the University of Oklahoma HSC, Oklahoma City, Oklahoma
| | - Doris M Benbrook
- Stephenson Cancer Center at the University of Oklahoma HSC, Oklahoma City, Oklahoma
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Hudson College of Public Health, Oklahoma City, Oklahoma
| | - Stephen T Hammond
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
- Johnson Cancer Center, Kansas State University, Manhattan, Kansas
| | - Kathleen N Moore
- Stephenson Cancer Center at the University of Oklahoma HSC, Oklahoma City, Oklahoma
| | - Laura L Holman
- Stephenson Cancer Center at the University of Oklahoma HSC, Oklahoma City, Oklahoma
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