Aggressive surgery for advanced ovarian cancer performed by a multidisciplinary team: A retrospective analysis on a large series of patients

Multidisciplinary Surgical Approach to Increase Survival for Advanced Ovarian Cancer in a Tertiary Gynaecological Oncology Centre

PURPOSE

The purpose of this paper is to report on changes in overall survival, progression-free survival, and complete cytoreduction rates in the 5-year period after the implementation of a multidisciplinary surgical team (MDT).

METHODS

Two cohorts were used. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients from January 2017 to September 2021.

RESULTS

This study included 146 patients in cohort A (2006-2015) and 174 patients in cohort B (2017-2021) with FIGO stage III/IV ovarian cancer. Median follow-up in cohort A was 60 months and 48 months in cohort B. The rate of primary cytoreductive surgery increased from 38% (55/146) in cohort A to 46.5% (81/174) in cohort B. Complete macroscopic resection increased from 58.9% (86/146) in cohort A to 78.7% (137/174) in cohort B (p < 0.001). At 3 years, 75% (109/144) patients had disease progression in cohort A compared with 48.8% (85/174) in cohort B (log-rank, p < 0.001). Also at 3 years, 64.5% (93/144) of patients had died in cohort A compared with 24% (42/174) of cohort B (log-rank, p < 0.001). Cox multivariate analysis demonstrated that MDT input, residual disease, and age were independent predictors of overall (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.203-0.437, p < 0.001) and progression-free survival (HR 0.31, 95% CI 0.21-0.43, p < 0.001). Major morbidity remained stable throughout both study periods (2006-2021).

CONCLUSIONS

Our data demonstrate that the implementation of multidisciplinary-team, intraoperative approach allowed for a change in surgical philosophy and has resulted in a significant improvement in overall survival, progression-free survival, and complete resection rates.

Major vessel resection for complete cytoreduction in primary advanced and recurrent ovarian malignancies: A case series and systematic review of the literature - pushing the boundaries in oncovascular surgery

INTRODUCTION

Oncovascular surgery (the removal of major blood vessels infiltrated by cancer) is challenging but can be key to achieve complete cytoreduction in patient with advanced ovarian cancer. The aim of this study was to review the literature on oncovascular surgery in ovarian cancer and to report the details of all the cases performed at our institution.

METHODS

We retrospectively reviewed the database of ovarian cancer patients who underwent debulking surgery at the Department of Obstetrics and Gynecology of Verona University between January 2021 and 2023. Patients with at least one major vessel resection during cytoreduction were identified. We then systematically review the literature searching Pubmed and Embase from inception to January 2023 to report all cases of surgery for ovarian cancer with concomitant major vessel resection.

RESULTS

Five patients with advanced/recurrent ovarian cancer underwent major vascular resection at our institution. Vascular involvement was preoperatively identified in all cases and no case of vascular resection was performed after accidental injury. The major vessels removed were the inferior vena cava (n = 2), the common iliac veins (n = 2), the external iliac arteries (n = 2), the left common iliac artery (n = 1), and the left external iliac vein (n = 1). All patients underwent other non-gynecological cytoreductive procedures prior to vessel removal and had R0 obtained. Three (60%) patients experienced one or more postoperative complications. The literature search identified a total of seven cases of major vessels resection in ovarian cancer surgery. A single or multiple major vessels were removed in two (28.6%) and five (72.4%) cases, respectively. All the seven patients underwent vascular reconstruction. Four (57.1%) patients reported postoperative complications. Overall, 66.7% of the 12 total identified patients were free from disease at the last follow-up [median 15.5 months (range 5-25)].

CONCLUSIONS

Oncovascular surgery is feasible in selected patients with ovarian cancer, provided that a multidisciplinary approach with customized care is available.

Impact of 2 years of COVID-19 pandemic on ovarian cancer treatment in IRCCS-AUSL of Reggio Emilia

OBJECTIVE

To assess compliance with the 2019 regional recommendation to centralize epithelial ovarian cancer (EOC) patients and to assess whether the COVID-19 pandemic has affected the quality of care for EOC patients.

METHODS

We compared data from EOC patients treated before the introduction of the 2019 regional recommendation (2018-2019) with data obtained from EOC patients treated after the regional recommendation was adopted during the first 2 years of the COVID-19 pandemic (2020-2021). Data were retrieved from the Optimal Ovarian Cancer Pathway records. R software version 4.1.2 (the R Foundation for Statistical Computing, Vienna, Austria) was used for the statistical analysis.

RESULTS

251 EOC patients were centralized. The number of EOC patients centralized increased from 2% to 49% despite the COVID-19 pandemic. During the COVID-19 pandemic, there was an increase in the use of neoadjuvant chemotherapy and interval debulking surgery. There was an improvement in the percentage of Stage III patients without gross residual disease following both primary and interval debulking surgery. The percentage of EOC cases discussed by the multidisciplinary tumor board (MTB) increased from 66% to 89% of cases.

CONCLUSION

Despite the COVID-19 pandemic, centralization has increased and the quality of care has been preserved thanks to the MTB.

The Predictive Value of PCT and Other Infection Indicators in Postoperative Infection of Epithelial Ovarian Cancer

Purpose

To study the early predictive value of WBC, CRP and PCT on infectious complications after epithelial ovarian cancer surgery, draw ROC curves, and construct a nomogram prediction model.

Patients and Methods

The clinical data of patients with epithelial ovarian cancer in Shengjing Hospital from August 2019 to August 2022 were included. The levels of WBC, CRP and PCT were statistically analyzed on the first, third and fifth days after surgery, and the ROC was plotted. Multivariate logistic regression analysis determined independent influencing factors, individualized nomogram model for predicting the occurrence of postoperative infectious complications was constructed, and the correction curve was used for verification.

Results

A total of 116 patients were enrolled. The postoperative test levels of WBC, CRP and PCT were compared between two groups, and the differences on POD3 and POD5 were statistically significant. The ROC area on POD5 was 0.739, 0.838 and 0.804, respectively, better than that on POD3. Among them, CRP has the greatest value; The predicted value of the combined test of WBC, CRP and PCT on POD5 was greater than that of a single index on POD5. The nomogram model on POD5 was constructed, and the ROC analysis showed that it had a good degree of differentiation.

Conclusion

WBC, CRP and PCT can effectively predict the occurrence of postoperative infectious complications, among which CRP alone has the greatest diagnostic value on POD5, and the combined test value of the three indicators is higher than that of a single index. The nomogram model constructed by the combined indicators on POD5 can assess the risk individually.

Ovarian Cancer in a Northern Italian Province and the Multidisciplinary Team

Ovarian cancer represents one of the most aggressive female cancers in the world, remaining a tumor with high lethality. This study aims to present how a multidisciplinary team (MDT) approach can improve the prognosis in terms of recurrence and death of patients. In total, 448 ovarian cancer cases registered in an Italian Cancer Registry between 2012 and 2020 were included. Information on age, morphology, stage, and treatment was collected. Recurrence and death rates were reported 1 and 2 years after diagnosis, comparing MDT vs. non-MDT approaches. Ninety-three percent had microscopic confirmation, and most showed cystic-mucinous morphology. In total, 50% were older than 65 years old. The distribution by stage was 17.6%, 4%, 44.9%, and 32.6% for stages I, II, III, and IV, respectively. The women followed by the MDT were 24.1%. Disease-free survival 1-year post-diagnosis, recurrences, recurrences-deaths, and deaths were 67.5%, 14.5%, 8.4%, and 9.6%, respectively, better than the non-MDT group (46.2%, 13.2%, 20.8 %, and 19.8%, respectively) (p < 0.01). The same positive results were confirmed two years after diagnosis, particularly for stages III and IV. Albeit small numbers, the study confirms a better prognosis for women managed by MDT with fewer recurrences and deaths, especially within the first 24 months of diagnosis.

Factors Predicting 30-Day Grade IIIa-V Clavien-Dindo Classification Complications and Delayed Chemotherapy Initiation after Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Prospective Cohort Study

Objective: The aim of this study was to evaluate factors associated with 30-day postoperative Clavien−Dindo classification (CDC) grade IIIa or greater complications and delayed initiation of chemotherapy after cytoreductive surgery (CRS) for primary advanced-stage epithelial ovarian cancer (AEOC). Methods: This was a prospective study involving 300 patients who underwent primary or interval CRS for AEOC between February 2018 and September 2020. Postoperative complications were graded according to the CDC. Logistic regression analysis was used to evaluate factors predicting CDC grade ≥IIIa and time to chemotherapy (TTC) >42 days. Results: Interval CRS was performed in 255 (85%) patients. CDC grade ≥IIIa occurred in 51 (17%) patients. In multivariable analysis, age (p = 0.036), cardiovascular comorbidity (p < 0.001), diaphragmatic surgery (p < 0.001), intraoperative urinary tract injury (p = 0.017), and upper-abdominal visceral injury (e.g., pancreas, stomach, liver, or spleen) (p = 0.012) were associated with CDC grade ≥IIIa. In 26% of cases, TTC was >42 days (median (IQR) 39 (29−50) days) in patients with CDC grade ≥IIIa versus 33 (25−41) days in patients without CDC grade ≥ IIIa (p = 0.008). The adjusted odds ratio of developing TTC >42 days was significantly higher in patients associated with WHO performance grade ≥2 (p = 0.045), intraoperative bowel injury (p = 0.043), upper-abdominal visceral injury (p = 0.008), and postoperative CDC grade ≥IIIa (p = 0.032). Conclusions: Patients with advanced age, with cardiovascular comorbidity, and who required diaphragmatic surgery had an increased adjusted odds ratio of developing CDC grade ≥IIIa complications. CDC grade ≥IIIa complications were independently associated with TTC >42 days. Proper patient selection and prevention of intraoperative injury are essential in order to prevent postoperative complications and delayed initiation of chemotherapy.

Retrospective Analysis of Total Parietal Peritonectomy Without Systematic Lymphadenectomy for Advanced Epithelial Ovarian Cancer

BACKGROUND/AIM

Total parietal peritonectomy (TPP) is a surgical procedure used for complete resection of microscopic peritoneal dissemination. This study analyzed the perioperative complications that developed when omitting systematic lymphadenectomy from TPP.

PATIENTS AND METHODS

We retrospectively analyzed perioperative complications in epithelial ovarian cancer patients with stage IIIB-IVB who underwent TPP during primary and interval cytoreductive surgeries between April 2018 and October 2021.

RESULTS

Thirty-three patients were enrolled in the study. The median patient age was 62 years. Of 31 patients (94%) with stage IIIC/IV disease, 24 (73%) had high-grade serous carcinoma. The median operative time and blood loss were 447 min and 2,831 ml, respectively. Complete tumor resection was performed in 30 patients (91%). Only five patients underwent partial lymphadenectomy for clinical metastatic lymph nodes. Further, grade 3 complications were observed in seven (21%) patients, and there were no fatal events in this study. Three patients (9%) had ureteric injuries, which was the most frequent complication in this study. Only one patient developed an intra-abdominal infection due to ascites. In this case, partial para-aortic and pelvic lymphadenectomies were performed.

CONCLUSION

TPP without systematic lymphadenectomy reduces the frequency of perioperative complications associated with ascites.

Factors predicting postoperative morbidity after cytoreductive surgery for ovarian cancer: a systematic review and meta-analysis

Objective

Advances in ovarian cancer cytoreductive surgery have enabled more extensive procedures to achieve maximal cytoreduction but with a consequent increase in postoperative morbidity and mortality. The aim of this study was to evaluate factors for postoperative morbidity after extensive cytoreductive surgery for primary epithelial ovarian cancer (EOC), particularly those which may be modifiable.

Methods

Electronic databases were searched. Meta-analysis was conducted using random-effects models.

Results

Fifteen relevant studies, involving 15,325 ovarian cancer patients, were included in this review. Severe 30-day postoperative complications occurred in 2,357 (15.4%) patients. The postoperative mortality rate was 1.92%. Meta-analysis demonstrated that patient with following risk factors; age (p<0.001), Eastern Cooperative Oncology Group score >0 (p=0.001), albumin level <3.5 g/dL (p<0.001), presence of ascites on CT scan (p=0.013), stage IV disease (p<0.001) and extensive surgical procedure (p<0.001) has a significantly increase risk of developing postoperative complications. Surgical procedures including peritonectomy (p=0.012), splenectomy (p<0.001) and colon surgery (p<0.001) were significant predictors for postoperative complications. Moreover, we found that patients who received neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) had a lower risk of developing severe complications compared to those who underwent primary debulking surgery (PDS) (p<0.001).

Conclusion

Our study demonstrated that patient performance status and hypoalbuminemia were the only significant adjustable preoperative risk factors associated with postoperative complications. Patients who underwent NACT-IDS had a lower risk of developing severe complications compared to PDS.

Trial Registration

International Prospective Register of Systematic Reviews (PROSPERO) Identifier: CRD42021282770

We conducted a meta-analysis to demonstrate factors associated with postoperative complications in cytoreductive surgery for epithelial ovarian cancer. Our findings highlight the importance of patients’ performance and albumin status as the adjustable preoperative factors. These findings could be useful in developing future perioperative protocol to reduce postoperative morbidity.

The role of oncovascular surgery in gynecologic oncology surgery

Oncovascular surgery is a new term used to define tumor resection with simultaneous reconstruction of the great vessels when the tumor infiltrates or firmly adheres to such vessels. The benefit of oncovascular surgery has been widely described in patients with hepato-biliary-pancreatic cancers, retroperitoneal soft tissue sarcoma, and in other areas of gynecologic oncology, such as the lateral compartment of the pelvis, retroperitoneum, and hepato-biliary-pancreatic region, with an increase in complete resections and without increasing the morbidity and mortality rates. In the latter decades of the past century, several advances and accumulating scientific evidence led gynecologic oncologists to perform more thorough cytoreductive surgeries that included multivisceral resections. But to our knowledge, published studies on the frequency and relevance of vascular surgery in gynecological oncology are scarce. Gynecologic oncologists still do not receive formal training in vascular surgery and additionally, with the current reduction in experience with pelvic and para-aortic lymphadenectomy, as well as other types of radical abdominal and pelvic surgeries, trainees will encounter fewer vascular injuries and the opportunity to deal with a variety of management types required. Well-organized collaboration between each subspecialty with a multidisciplinary approach and adequate pre-operative planning are pivotal. The aim of this review is to pave the way towards the understanding that patients with suspicion of great vessels' infiltration or encasement by tumor require personalized and specialized treatment with the need to form an oncovascular surgery team, and that it is necessary for gynecologic oncology surgeons to take a step forward in surgical training.

A multidisciplinary approach remains the best strategy to improve and strengthen the management of ovarian cancer (Review)

Ovarian cancer represents one of the most aggressive female tumors worldwide. Over the decades, the therapeutic options for the treatment of ovarian cancer have been improved significantly through the advancement of surgical techniques as well as the availability of novel effective drugs able to extend the life expectancy of patients. However, due to its clinical, biological and molecular complexity, ovarian cancer is still considered one of the most difficult tumors to manage. In this context, several studies have highlighted how a multidisciplinary approach to this pathology improves the prognosis and survival of patients with ovarian cancer. On these bases, the aim of the present review is to present recent advantages in the diagnosis, staging and treatment of ovarian cancer highlighting the benefits of a patient‑centered care approach and on the importance of a multidisciplinary team for the management of ovarian cancer.

An Italian National Survey on Ovarian Cancer Treatment at first diagnosis. There's None so Deaf as those who will not Hear

Objective: Epithelial ovarian cancer (EOC) is the most lethal gynecological malignancy, crucial prognostic factors are no gross residual disease and centralization of cases. To evaluate the centralization of EOC patients, we report the results of a survey that shows the daily management of EOC patients in Italy.

Methods: A 49-items electronic unblinded survey assessing demographics, practice characteristics, current opinions and approach to managing advanced EOC at first diagnosis was sent both to general gynecologists (GG) and gynecologic oncologists (GO). Differences in frequency distribution of answers between gynecologists with different expertise were evaluated using Fisher exact test. Multivariable analyses were performed applying generalized linear models.

Results: 84/192 (44%) GG and 108/192 (56%) GO from all Italian regions answered to our survey. GOs declared to perform fertility sparing surgery in early EOC more frequently than GG (p=0.002).

GOs can perform a frozen section and have both a gynecopathologist and a dedicated general surgeon. 89% of GOs consider as “optimal debulking” no gross residual disease and 81% achieve this at upfront cytoreduction in more than 40% of patients. Use of neoadjuvant chemotherapy decreases in higher volume centers (p<0.001) while it is lower in the group of GOs than in the GGs group (p<0.001).

Conclusions: EOC patients are still treated by GGs. GOs perform more upfront surgery and achieve optimal debulking in a greater percentage of patients than GGs. In Italy an adequate centralization of cases has not yet been achieved, and this may have detrimental effects on the quality of treatment.

Multidisciplinary Surgical Approach to Increase Complete Cytoreduction Rates for Advanced Ovarian Cancer in a Tertiary Gynecologic Oncology Center

BACKGROUND

Surgical resection remains the cornerstone of ovarian cancer management. In 2017, the authors implemented a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper gastrointestinal (GI) surgeons to increase gross macroscopic resection rates. This report aims to describe changes in complete cytoreduction rates and morbidity after the implementation of a multi-disciplinary surgical team comprising gynecologic oncologists as well as colorectal, hepatobiliary, and upper GI surgeons in a tertiary gynecologic oncology unit.

METHODS

The study used two cohorts. Cohort A was a retrospectively collated cohort from 2006 to 2015. Cohort B was a prospectively collated cohort of patients initiated in 2017. A multidisciplinary approach to preoperative medical optimization, intraoperative management, and postoperative care was implemented in 2017. The patients in cohort B with upper abdominal disease were offered primary cytoreduction with or without hyperthermic intraperitoneal chemotherapy (HIPEC). Before 2017, the patients with upper abdominal disease received neoadjuvant chemotherapy (cohort A).

RESULTS

This study included 146 patients in cohort A (2006-2015) and 93 patients in cohort B (2017-2019) with stages 3 or 4 ovarian cancer. The overall complete macroscopic resection rate (CC0) increased from 58.9 in cohort A to 67.7% in cohort B. The rate of primary cytoreductive surgery (CRS) increased from 38 (55/146) in cohort A to 42% (39/93) in cohort B. The CC0 rate for the patients who underwent primary CRS increased from 49 in cohort A to 77% in cohort B. Major morbidity remained stable throughout both study periods (2006-2019).

CONCLUSIONS

The study data demonstrate that implementation of a multidisciplinary team intraoperative approach and a meticulous approach to preoperative optimization resulted in significantly improved complete resection rates, particularly for women offered primary CRS.