External validation of a laparoscopic-based score to evaluate resectability of advanced ovarian cancers: clues for a simplified score

Assessment of Intraoperative Scoring Systems for Predicting Cytoreduction Outcome in Peritoneal Metastatic Disease: A Systematic Review and Meta-analysis

BACKGROUND

Cytoreductive surgery (CRS) is a widely acknowledged treatment approach for peritoneal metastasis, showing favorable prognosis and long-term survival. Intraoperative scoring systems quantify tumoral burden before CRS and may predict complete cytoreduction (CC). This study reviews the intraoperative scoring systems for predicting CC and optimal cytoreduction (OC) and evaluates the predictive performance of the Peritoneal Cancer Index (PCI) and Predictive Index Value (PIV).

METHODS

Systematic searches were conducted in Embase, MEDLINE, and Web of Science. Meta-analyses of extracted data were performed to compare the absolute predictive performances of PCI and PIV.

RESULTS

Thirty-eight studies (5834 patients) focusing on gynecological (n = 34; 89.5%), gastrointestinal (n = 2; 5.3%) malignancies, and on tumors of various origins (n = 2; 5.3%) were identified. Seventy-seven models assessing the predictive performance of scoring systems (54 for CC and 23 for OC) were identified with PCI (n = 39/77) and PIV (n = 16/77) being the most common. Twenty models (26.0%) reinterpreted previous scoring systems of which ten (13%) used a modified version of PIV (reclassification). Meta-analyses of models predicting CC based on PCI (n = 21) and PIV (n = 8) provided an AUC estimate of 0.83 (95% confidence interval [CI] 0.79-0.86; Q = 119.6, p = 0.0001; I2 = 74.1%) and 0.74 (95% CI 0.68-0.81; Q = 7.2, p = 0.41; I2 = 11.0%), respectively.

CONCLUSIONS

Peritoneal Cancer Index models demonstrate an excellent estimate of CC, while PIV shows an acceptable performance. There is a need for high-quality studies to address management differences, establish standardized cutoff values, and focus on non-gynecological malignancies.

Ovarian Cancer Staging-How CT Scan Descriptions Differ from Surgical Findings

Ovarian cancer is one of the most common causes of cancer death in women worldwide. Most often, it is detected in an advanced stage due to its insidious onset and lack of symptoms in stages I and II. That is why imaging diagnostics is so important. Therefore, we assessed the consistency of the image seen on CT with the actual image assessed during surgery. Objectives: The aim of this study is to compare preoperative evaluation based on CT reports with those obtained during ovarian cancer surgery to determine whether CT is helpful in assessing the possibility of optimal or complete cytoreduction. Methods: This retrospective study included patients diagnosed with ovarian cancer who underwent diagnostic laparoscopy or laparotomy with cytoreduction. We compared ovarian cancer lesions described by radiologists on CT scans to those described during laparoscopy or laparotomy; the Wilcoxon signed-rank test for paired observations was used to compare the variables. Results: We observed that the morphology of the tumor, mesenteric infiltration, and the assessment of the involvement of the abdominal, para-aortic, and iliac lymph nodes may differ in CT examination and during surgery. Conclusions: The site of the tumor exit on a CT scan does not always reflect the original site seen during surgery.

Potential Risks of Severe Infection Following the Exploratory Laparoscopy for Advanced Ovarian Cancer: A Case Report and a Literature Review

Although exploratory laparoscopy in patients with advanced ovarian cancer is a diagnostic tool for determining treatment strategy, its safety has not been completely investigated. We report a case involving a severe abdominal abscess following an exploratory laparoscopy. A 65-year-old woman with advanced ovarian cancer developed a large abdominal abscess following exploratory laparoscopy and neoadjuvant chemotherapy. Emergent laparotomy was performed; while massive bowel adhesion surrounding the abscess did not allow for genital organ resection, an incision in the left port area was made to drain the abscess. The patient's chemotherapy was delayed because she experienced sub-ileus, postoperatively. Only a limited number of studies have been conducted on the safety of these techniques. This intense infection case emphasizes the need for further investigations into the safety of exploratory laparoscopy in patients with progressive diseases under heterogeneous conditions in real-world settings.

First external validity study of the Fagotti score in ovarian cancer

Epithelial ovarian cancer is mostly discovered at the stage of peritoneal carcinosis. Complete cytoreductive surgery improves overall survival. The Fagotti score is a predictive score of resectability based on peritoneal laparoscopic exploratory. Our aim was to study the inter-observer concordance in an external validation of the Fagotti score. An observational, prospective, multicenter study was conducted using the Francogyn research network. The primary outcome was inter-observer concordance of the Fagotti score. 15 patients in which an ovarian mass was discovered were included. For each patient, the first exploratory laparoscopy before any treatment/chemotherapy was recorded. This bank of 15 videos was subject to blind review accompanied by a Fagotti score rating by 11 gynecological surgeons specializing in oncology. A total of 165 blind reviews were performed. Inter-observer concordance was very good for the Fagotti score with an intraclass correlation coefficient (ICC) of 0.83 [95% CI 0.71; 0.93]. Inter-observer concordance for the adjusted Fagotti score, which accounts for unexplorable areas with extensive carcinomatosis, resulted in an ICC of 0.64 [95% CI 0.46; 0.82]. According to the reviewers, the three least explorable parameters were mesentery involvement, stomach infiltration and liver damage. The ICC of the explorable Fagotti score, i.e. score with deletion of the parameters most often unexplored by laparoscopy, was 0.86 [0.75-0.94]. This study confirms the reproducibility of the Fagotti score during first assessment laparoscopies in cases of advanced ovarian cancer. The explorable Fagotti score has an equivalent or better inter-observer concordance than the Fagotti score.

Preoperative serum level of CA153 and a new model to predict the sub-optimal primary debulking surgery in patients with advanced epithelial ovarian cancer

OBJECTIVE

The aim of this study was to establish a preoperative model to predict the outcome of primary debulking surgery (PDS) for advanced ovarian cancer (AOC) patients by combing Suidan predictive model with HE4, CA125, CA153 and ROMA index.

METHODS

76 AOC Patients in revised 2014 International Federation of Gynecology and Obstetrics (FIGO) stage III-IV who underwent PDS between 2017 and 2019 from Yunnan Cancer Hospital were included. Clinical data including the levels of preoperative serum HE4, CA125, CA153 and mid-lower abdominal CT-enhanced scan results were collected. The logistics regression analysis was performed to find factors associated with sub-optimal debulking surgery (SDS). The receiver operating characteristic curve was used to evaluate the predictive performances of selected variables in the outcome of primary debulking surgery. The predictive index value (PIV) model was constructed to predict the outcome of SDS.

RESULTS

Optimal surgical cytoreduction was achieved in 61.84% (47/76) patients. The value for CA125, HE4, CA153, ROMA index and Suidan score was lower in optimal debulking surgery (ODS) group than SDS group. Based on the Youden index, which is widely used for evaluating the performance of predictive models, the best cutoff point for the preoperative serum HE4, CA125, CA153, ROMA index and Suidan score to distinguish SDS were 431.55 pmol/l, 2277 KU/L, 57.19 KU/L, 97.525% and 2.5, respectively. Patients with PIV≥5 may not be able to achieve optimal surgical cytoreduction. The diagnostic accuracy, NPV, PPV and specificity for diagnosing SDS were 73.7%, 82.9%, 62.9% and 72.3%, respectively. In the constructed model, the AUC of the SDS prediction was 0.770 (95% confidence interval: 0.654-0.887), P<0.001.

CONCLUSION

Preoperative serum CA153 level is an important non-invasive predictor of primary SDS in advanced AOC, which has not been reported before. The constructed PIV model based on Suidan's predictive model plus HE4, CA125, CA153 and ROMA index can noninvasively predict SDS in AOC patients, the accuracy of this prediction model still needs to be validated in future studies.

The Cukurova score in the prediction of primary cytoreduction in ovarian cancer

OBJECTIVE

Primary debulking surgery has been the preferred surgical route and is still considered a quality indicator for advanced ovarian cancer surgery. However, a significant number of patients are not amenable to upfront surgery. Neoadjuvant chemotherapy and interval debulking surgery may be the most suitable approach for this group. This study aimed to evaluate a novel score for prediction of the cytoreduction results at primary debulking surgery for ovarian cancer patients.

METHODS

This observational prospective study was conducted at a tertiary gynecologic oncology center between December 2020 and August 2022. Presumed primary stage III-IV epithelial ovarian carcinoma cases were included. Borderline tumors, and metastatic or non-epithelial ovarian malignancies, were excluded. Based on imaging findings, points were assigned to each anticipated surgical procedure required for complete cytoreduction. The sum of these points was multiplied by the patient's Eastern Cooperative Oncology Group (ECOG) score, and thus, the Cukurova-clinic score was established. Furthermore, the required surgical procedures based on laparoscopic evaluation were recorded, and the score was readjusted and calculated to obtain the Cukurova score.

RESULTS

One hundred and fourteen patients were included in the study. Primary debulking surgery was performed in 70% of cases. Among them, complete cytoreduction (Cukurova score ≤12) was obtained in 97.3% of cases. Complete cytoreduction was not achieved in cases with Cukurova score >12. The odds ratio of 90-day mortality was 13.4 for patients with Cukurova score >12, compared with those with Cukurova score ≤12.

CONCLUSION

The Cukurova score is a model for classifying advanced ovarian cancer patients who may be candidates for primary debulking surgery.

Circulating small extracellular vesicles microRNAs plus CA-125 for treatment stratification in advanced ovarian cancer

BACKGROUND

No residual disease (R0 resection) after debulking surgery is the most critical independent prognostic factor for advanced ovarian cancer (AOC). There is an unmet clinical need for selecting primary or interval debulking surgery in AOC patients using existing prediction models.

METHODS

RNA sequencing of circulating small extracellular vesicles (sEVs) was used to discover the differential expression microRNAs (DEMs) profile between any residual disease (R0, n = 17) and no residual disease (non-R0, n = 20) in AOC patients. We further analyzed plasma samples of AOC patients collected before surgery or neoadjuvant chemotherapy via TaqMan qRT-PCR. The combined risk model of residual disease was developed by logistic regression analysis based on the discovery-validation sets.

RESULTS

Using a comprehensive plasma small extracellular vesicles (sEVs) microRNAs (miRNAs) profile in AOC, we identified and optimized a risk prediction model consisting of plasma sEVs-derived 4-miRNA and CA-125 with better performance in predicting R0 resection. Based on 360 clinical human samples, this model was constructed using least absolute shrinkage and selection operator (LASSO) and logistic regression analysis, and it has favorable calibration and discrimination ability (AUC:0.903; sensitivity:0.897; specificity:0.910; PPV:0.926; NPV:0.871). The quantitative evaluation of Net Reclassification Improvement (NRI) and Integrated Discrimination Improvement (IDI) suggested that the additional predictive power of the combined model was significantly improved contrasted with CA-125 or 4-miRNA alone (NRI = 0.471, IDI = 0.538, p < 0.001; NRI = 0.122, IDI = 0.185, p < 0.01).

CONCLUSION

Overall, we established a reliable, non-invasive, and objective detection method composed of circulating tumor-derived sEVs 4-miRNA plus CA-125 to preoperatively anticipate the high-risk AOC patients of residual disease to optimize clinical therapy.

"Things Have Changed"-Laparoscopic Cytoreduction for Advanced and Recurrent Ovarian Cancer: The Experience of a Referral Center on 108 Patients

OBJECTIVE

To report the feasibility of laparoscopic cytoreduction surgery for primary and recurrent ovarian cancer in a select group of patients.

METHODS

A retrospective analysis was conducted on a cohort of patients with FIGO stage IIIA-IV advanced ovarian cancer who underwent laparoscopic primary debulking surgery (PDS), interval debulking surgery (IDS), or secondary debulking surgery (SDS) between June 2008 and January 2020. The primary endpoint was achieving optimal cytoreduction, defined as residual tumor less than 1 cm. Secondary endpoints included evaluating surgical complications and long-term survival, assessed at three-month intervals during the initial two years and then every six months.

RESULTS

This study included a total of 108 patients, among whom, 40 underwent PDS, 44 underwent IDS, and 24 underwent SDS. Optimal cytoreduction rates were found to be 95.0%, 97.7%, and 95.8% for the PDS, ISD, and SDS groups, respectively. Early postoperative complications (<30 days from surgery) occurred in 19.2% of cases, with 7.4% of these cases requiring reintervention. One patient died following postoperative respiratory failure. Late postoperative complications (<30 days from surgery) occurred in 9.3% of cases, and they required surgical reintervention only in one case. After laparoscopic optimal cytoreduction with a median follow-up time of 25 months, the overall recurrence rates were 45.7%, 38.5%, and 39.3% for PDS, ISD, and SDS, respectively. The three-year overall survival rates were 84%, 66%, and 63%, respectively, while the three-year disease-free survival rates were 48%, 51%, and 71%, respectively.

CONCLUSIONS

Laparoscopic cytoreduction surgery is feasible for advanced ovarian cancer in carefully selected patients, resulting in high rates of optimal cytoreduction, satisfactory peri-operative morbidity, and encouraging survival outcomes. Future studies should focus on establishing standardized selection criteria and conducting well-designed investigations to further refine patient selection and evaluate long-term outcomes.

Optimal Time Interval between Neoadjuvant Platinum-Based Chemotherapy and Interval Debulking Surgery in High-Grade Serous Ovarian Cancer

BACKGROUND

There is limited data on the optimal time interval between the last dose of neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) in high-grade serous ovarian carcinoma (HGSC).

METHODS

We retrospectively identified patients with stage IIIC/IV HGSC who received NACT followed by IDS during a 15-year period (January 2003-December 2018) in our Institution.

RESULTS

Overall, 115 patients with stage IIIC/IV HGSC were included. The median age of diagnosis was 62.7 years (IQR: 14.0). A total of 76.5% (88/115) of patients were diagnosed with IIIC HGSC and 23.5% (27/115) with IV HGSC. Median PFS was 15.7 months (95% CI: 13.0-18.5), and median OS was 44.7 months (95% CI: 38.8-50.5). Patients were categorized in groups according to the time interval from NACT to IDS: <4 weeks (group A); 4-5 weeks (group B); 5-6 weeks (group C); >6 weeks (group D). Patients with a time interval IDS to NACT ≥4 weeks had significantly shorter PFS (p = 0.004) and OS (p = 0.002). Median PFS was 26.6 months (95% CI: 24-29.2) for patients undergoing IDS <4 weeks after NACT vs. 14.4 months (95% CI: 12.6-16.2) for those undergoing IDS later (p = 0.004). Accordingly, median OS was 66.3 months (95% CI: 39.1-93.4) vs. 39.4 months (95% CI: 31.8-47.0) in the <4 week vs. >4 week time interval NACT to IDS groups (p = 0.002). On multivariate analysis, the short time interval (<4 weeks) from NACT to IDS was an independent factor of PFS (p = 0.004) and OS (p = 0.003).

CONCLUSION

We have demonstrated that performing IDS within four weeks after NACT may be associated with better survival outcomes. Multidisciplinary coordination among ovarian cancer patients is required to avoid any unnecessary delays.

Prediction of Surgical Outcome in Advanced Ovarian Cancer by Imaging and Laparoscopy: A Narrative Review

Maximal-effort upfront or interval debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of diagnostic imaging is to provide a systematic and structured report on tumour dissemination with emphasis on key sites for resectability. Imaging methods, such as pelvic and abdominal ultrasound, contrast-enhanced computed tomography, whole-body diffusion-weighted magnetic resonance imaging and positron emission tomography, yield high diagnostic performance for diagnosing bulky disease, but they are less accurate for depicting small-volume carcinomatosis, which may lead to unnecessary explorative laparotomies. Diagnostic laparoscopy, on the other hand, may directly visualize intraperitoneal involvement but has limitations in detecting tumours beyond the gastrosplenic ligament, in the lesser sac, mesenteric root or in the retroperitoneum. Laparoscopy has its place in combination with imaging in cases where ima-ging results regarding resectability are unclear. Different imaging models predicting tumour resectability have been developed as an adjunctional objective tool. Incorporating results from tumour quantitative analyses (e.g., radiomics), preoperative biopsies and biomarkers into predictive models may allow for more precise selection of patients eligible for extensive surgery. This review will discuss the ability of imaging and laparoscopy to predict non-resectable disease in patients with advanced ovarian cancer.

Role of diagnostic laparoscopy in deciding primary treatment in advanced-stage ovarian cancer

OBJECTIVE

We evaluated the usefulness of preoperative diagnostic laparoscopy for treatment planning in patients with advanced-stage ovarian cancer.

METHODS

We retrospectively analyzed 614 patients diagnosed with advanced-stage ovarian cancer between January 2010 and May 2018. Primary debulking surgery (PDS) or neoadjuvant chemotherapy (NAC) followed by interval debulking surgery were selected based on preoperative laparoscopic (Group 1, n=192) and computed tomography findings (Group 2, n=422). The primary outcomes in the PDS and NAC groups were suboptimal cytoreduction (residual disease >1 cm) rate and non-high-grade serous carcinoma (non-HGSC) rate, respectively.

RESULTS

The patients who underwent PDS in group 1 and group 2 were 49 (25.5%) and 279 (66.1%), respectively. The suboptimal cytoreduction rate after PDS was lower in Group 1 than in Group 2 (2.0% vs 11.1%, p=0.023). Moreover, Group 1 showed a tendency toward a lower proportion of non-HGSC patients who underwent NAC than that in Group 2 (9.1% vs. 15.4%, p=0.069). Further, Group 1 showed lower rates of postoperative morbidity than Group 2 (5.2% vs. 10.4%, p=0.033). However, Kaplan-Meier analysis showed no significant differences in survival outcomes between the 2 groups.

CONCLUSION

Diagnostic laparoscopy reduced the suboptimal cytoreduction rate in the PDS group and the implementation rate of NAC in non-HGSC patients. Moreover, it reduced postoperative morbidity without affecting survival in both groups. Thus, diagnostic laparoscopy is a valuable diagnostic tool for determining the primary treatment.

Concordance of Radiological, Laparoscopic and Laparotomic Scoring to Predict Complete Cytoreduction in Women with Advanced Ovarian Cancer

OBJECTIVE

To identify the best method among the radiologic, laparoscopic and laparotomic scoring assessment to predict the outcomes of cytoreductive surgery in patients with advanced ovarian cancer (AOC).

METHODS

Patients with AOC who underwent pre-operative computed tomography (CT) scan, laparoscopic evaluation, and cytoreductive surgery between August 2016 and February 2021 were retrospectively reviewed. Predictive Index (PI) score and Peritoneal Cancer Index (PCI) scores were used to estimate the tumor load and predict the residual disease in the primary debulking surgery (PDS) and interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT) groups. Concordance percentages were calculated between the two scores.

RESULTS

Among 100 eligible patients, 69 underwent PDS, and 31 underwent NACT and IDS. Complete cytoreduction was achieved in 72.5% of patients in the PDS group and 77.4% in the IDS. In patients undergoing PDS, the laparoscopic PI and the laparotomic PCI had the best accuracies for complete cytoreduction (R0) [area under the curve (AUC) = 0.78 and AUC = 0.83, respectively]. In the IDS group, the laparotomic PI (AUC = 0.75) and the laparoscopic PCI (AUC= 0.87) were associated with the best accuracy in R0 prediction. Furthermore, radiological assessment, through PI and PCI, was associated with the worst accuracy in either PDS or IDS group (PI in PDS: AUC = 0.64; PCI in PDS: AUC = 0.64; PI in IDS: AUC = 0.46; PCI in IDS: AUC = 0.47).

CONCLUSION

The laparoscopic score assessment had high accuracy for optimal cytoreduction in AOC patients undergoing PDS or IDS. Integrating diagnostic laparoscopy in the decision-making algorithm to accurately triage AOC patients to different treatment strategies seems necessary.

Validation of a risk-based algorithm to reduce poor operative outcomes after complex surgery for ovarian cancer

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.

Laparoscopic Surgery for Ovarian Neoplasms - What is Possible, What is Useful?

The use of minimally invasive surgical techniques is becoming increasingly important in gynecologic oncology due to technical advances and the increasing level of surgical expertise. In addition to laparoscopic approaches for the treatment of benign neoplasms, minimally invasive surgical methods have also become established in some areas for treating gynecologic malignancies. For tumor entities such as endometrial and cervical carcinoma, there are conclusive studies emphasizing the role of laparoscopy in surgical therapy. By contrast, due to a lack of prospective data with survival analyses, no clear conclusions can be drawn on the significance of laparoscopy in the surgical treatment of ovarian carcinoma. However, some smaller, mostly retrospective case-control studies and cohort studies open the way for a discussion, positing the possibility that laparoscopic surgical procedures, particularly for early ovarian carcinoma, are technically feasible and of a quality equivalent to that of conventional longitudinal laparotomy, and may also be associated with lower perioperative morbidity. In this article we discuss the most important aspects of using minimally invasive surgical techniques for ovarian carcinoma based on the current literature. In particular we look at the relevance of laparoscopy as a primary approach for surgical staging of early ovarian carcinoma, and we evaluate the role of diagnostic laparoscopy in assessing the operability of advanced ovarian carcinoma.

The BUMPy road of peritoneal metastases in ovarian cancer

Ovarian cancer is the most common cause of death due to gynecologic malignancies, with more than 70% of patients presenting with advanced stage disease at the time of diagnosis. The extent and distribution of tumor guide primary treatment selection and clinical management. While primary cytoreductive surgery with complete tumor resection improves survival, patients with extensive peritoneal disease may benefit from neoadjuvant chemotherapy first to reduce tumor burden followed by interval cytoreductive surgery. Imaging plays an essential role in triaging patients including selecting patients who may benefit from neoadjuvant chemotherapy before cytoreductive surgery. Interestingly, there are no universally established criteria to predict resectability and local practices depend on local guidelines and surgeon preferences. Nevertheless, certain anatomical tumor locations are known to be difficult to resect and are associated with suboptimal cytoreduction or require special surgical considerations. This review discusses the recent advances in the initial management of patients with ovarian cancer, a practical approach to the assessment and communication of peritoneal metastases locations on CT and MRI. It also explores recent advances in genomics profiling and radiomics that may influence the initial management of these patients.

Comparison of Peritoneal Carcinomatosis Scoring Methods in Predicting Resectability and Prognosis in Gynecologic Malignancies

OBJECTIVE

Peritoneal carcinomatosis is a disease's presentation in the advanced stages of many gynecologic tumours. The distribution and volume of the disease are the main factors in achieving complete debulking. Diagnostic laparoscopy is a technique to allow evaluation of the disease. This study's objective is to compare two laparoscopic scores (Fagotti's index and Sugarbaker's peritoneal cancer index (PCI)) and assess the diagnostic accuracy to select patients for neoadjuvant treatment and reduce unnecessary laparotomies.

METHODS

A non-randomised retrospective cohort study was conducted in patients with peritoneal carcinomatosis (ovarian and endometrial origin) who underwent laparoscopy and subsequent laparotomy. We evaluated the scores' ability to predict incomplete surgery and whether they were related to the patients' prognosis.

RESULTS

We included 34 patients, of which 23.5% received neoadjuvant chemotherapy. The rate of complete cytoreductive surgery was 79.4% (n = 27 patients). The highest sensitivity was obtained with a PCI value greater than 20. It was the best parameter to determine incomplete debulking. Survival curves were analysed according to the "cut off" established for each score, and statically significant differences were found using PCI with respect to Fagotti's Index. However, these differences were not found with Fagotti's score.

CONCLUSION

The best diagnostic method to classify patients with peritoneal cancer is the PCI. It could be adapted to each surgical team because it allows identifying the "cut off point", which depends on incomplete surgery rate.

CT-Based Fagotti Scoring System for Non-Invasive Prediction of Cytoreduction Surgery Outcome in Patients with Advanced Ovarian Cancer

Objective

To construct a CT-based Fagotti scoring system by analyzing the correlations between laparoscopic findings and CT features in patients with advanced ovarian cancer.

Materials and Methods

This retrospective cohort study included patients diagnosed with stage III/IV ovarian cancer who underwent diagnostic laparoscopy and debulking surgery between January 2010 and June 2018. Two radiologists independently reviewed preoperative CT scans and assessed ten CT features known as predictors of suboptimal cytoreduction. Correlation analysis between ten CT features and seven laparoscopic parameters based on the Fagotti scoring system was performed using Spearman's correlation. Variable selection and model construction were performed by logistic regression with the least absolute shrinkage and selection operator method using a predictive index value (PIV) ≥ 8 as an indicator of suboptimal cytoreduction. The final CT-based scoring system was internally validated using 5-fold cross-validation.

Results

A total of 157 patients (median age, 56 years; range, 27–79 years) were evaluated. Among 120 (76.4%) patients with a PIV ≥ 8, 105 patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the optimal cytoreduction rate was 90.5% (95 of 105). Among 37 (23.6%) patients with PIV < 8, 29 patients underwent primary debulking surgery, and the optimal cytoreduction rate was 93.1% (27 of 29). CT features showing significant correlations with PIV ≥ 8 were mesenteric involvement, gastro-transverse mesocolon-splenic space involvement, diaphragmatic involvement, and para-aortic lymphadenopathy. The area under the receiver operating curve of the final model for prediction of PIV ≥ 8 was 0.72 (95% confidence interval: 0.62–0.82).

Conclusion

Central tumor burden and upper abdominal spread features on preoperative CT were identified as distinct predictive factors for high PIV on diagnostic laparoscopy. The CT-based PIV prediction model might be useful for patient stratification before cytoreduction surgery for advanced ovarian cancer.

Validation of three predictive models for suboptimal cytoreductive surgery in advanced ovarian cancer

The standard treatment for advanced ovarian cancer (AOC) is cytoreduction surgery and adjuvant chemotherapy. Tumor volume after surgery is a major prognostic factor for these patients. The ability to perform complete cytoreduction depends on the extent of disease and the skills of the surgical team. Several predictive models have been proposed to evaluate the possibility of performing complete cytoreductive surgery (CCS). External validation of the prognostic value of three predictive models (Fagotti index and the R3 and R4 models) for predicting suboptimal cytoreductive surgery (SCS) in AOC was performed in this study. The scores of the 3 models were evaluated in one hundred and three consecutive patients diagnosed with AOC treated in a tertiary hospital were evaluated. Clinicopathological features were collected prospectively and analyzed retrospectively. The performance of the three models was evaluated, and calibration and discrimination were analyzed. The calibration of the Fagotti, R3 and R4 models showed odds ratios of obtaining SCSs of 1.5, 2.4 and 2.4, respectively, indicating good calibration. The discrimination of the Fagotti, R3 and R4 models showed an area under the ROC curve of 83%, 70% and 81%, respectively. The negative predictive values of the three models were higher than the positive predictive values for SCS. The three models were able to predict suboptimal cytoreductive surgery for advanced ovarian cancer, but they were more reliable for predicting CCS. The R4 model discriminated better because it includes the laparotomic evaluation of the peritoneal carcinomatosis index.

Peroperative scoring systems for predicting the outcome of cytoreductive surgery in advanced-stage ovarian cancer - A systematic review

The extent of peritoneal metastases (PM) largely determines the possibility of complete or optimal cytoreductive surgery in advanced ovarian cancer. An objective scoring system to quantify the extent of PM can help clinicians to decide whether or not to embark on CRS. Therefore several scoring systems have been developed by different research teams and this review summarizes their performance in predicting a complete or optimal cytoreduction in patients with advanced ovarian cancer. A systematic search in the MEDLINE database revealed 19 articles that described a total of five main scoring systems to predict the completeness of CRS in patients with FIGO stage III-IV ovarian cancer based on the surgical exploration of the abdominal cavity; PCI, PIV, Eisenkop, Espada, and Kasper. The Peritoneal Cancer Index (PCI) and the Predictive Index Value (PIV) were mentioned most frequently and showed AUCs of 0.69-0.92 and 0.66-0.98, respectively. Due to the use of different cut-offs sensitivities and specificities greatly varied. Therefore with the current data, no scoring system could be identified as best. An objective measure of the extent of disease can be of great clinical use for identifying ovarian cancer patients for which a complete (or optimal) CRS is achievable, however due to local differences in treatment strategies and surgical policy a widely adopted objective scoring system with a standard cut-off value is not feasible. Nevertheless, objective scoring systems can play an important role to guide treatment decisions.

A prospective study on the diagnostic pathway of patients with stage IIIC-IV ovarian cancer: Exploratory laparoscopy (EXL) + CT scan VS. CT scan

OBJECTIVE

To compare the diagnostic power of CT scan to a combination of exploratory laparoscopy (EXL) and CT scan in patients with stage IIIC-IV Ovarian Cancer (OC) by anatomic areas. To investigate if adding EXL to CT can reduce unnecessary laparotomy.

METHODS

In the period 2009-2017, 350 consecutive patients with FIGO Stage IIIC-IV OC underwent CT and EXL prior to Visceral-Peritoneal debulking (VPD) and were included in the study. Radiologist and surgeons filled an ad-hoc form to report CT scan and EXL of eleven key anatomic areas. The decision to proceed to EXL was based on the CT scan and the decision to proceed to laparotomy (LPT) on CT and EXL. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity, and accuracy of CT, EXL and CT + EXL were calculated. We broke down the diagnostic outcomes by anatomic areas and determined the rate of unnecessary laparotomy avoided with the findings of EXL.

RESULTS

Median time for the EXL was 14 min (SD +/- 3). No complication related to EXL occurred. At EXL, 325 out of 350 patients (93%) proceeded to LPT and 25 patients (7.1%) did not because of exclusion criteria. In 307 patients out of 325 (94.4%) EXL was followed by VPD. Eighteen patients had exclusion criteria found at LPT and had no VPD. EXL reduced the rate of unnecessary/futile laparotomy from 12.2% to 5.1%. CT + EXL showed a significantly higher sensitivity for all anatomic areas except for the lymph nodes. Specificity was not significantly improved. PPV was significantly improved for small bowel, porta hepatis and stomach. NPV displayed a statistical improvement in all anatomic areas except lymph nodes, stomach, and liver.

CONCLUSION

The combination CT + EXL has a higher diagnostic power than CT alone, particularly on diaphragm, small bowel serosa and mesentery. The rate of unnecessary laparotomy decreased by almost 60%.

Concordance of laparoscopic and laparotomic peritoneal cancer index using a two-step surgical protocol to select patients for cytoreductive surgery in advanced ovarian cancer

PURPOSE

The aim of our study was to assess concordance of staging laparoscopy and cytoreductive surgery (CRS) peritoneal cancer index (PCI) when applying a two-step surgical protocol. We also aimed to evaluate the accuracy of diagnostic laparoscopy to triage patients for complete cytoreduction, and to define optimal time between staging laparoscopy and CRS.

METHODS

We designed a retrospective review of prospectively collected data from patients with advanced ovarian cancer who underwent a diagnostic laparoscopy followed by a CRS a few weeks later (two-step surgical protocol), from January 2010 to April 2019. Only patients selected for complete cytoreduction, and with available PCI score from both surgeries were included. PCI concordance was assessed using intraclass correlation coefficient (ICC).

RESULTS

During the study period 543 patients underwent a laparoscopic staging for ovarian carcinomatosis. Among them, 43 patients fulfilled inclusion criteria. ICC between laparoscopic and laparotomic PCI was 0.54. After applying the linear regression equation: laparoscopic PCI + 0.2 x [days between surgeries] + 2, ICC increased to 0.79. Completeness cytoreduction score and laparoscopic PCI were significantly associated (OR 1.27, 95% CI 1.03-1.57, p = 0.03). AUC of laparoscopic PCI to predict complete cytoreduction was 0.90.

CONCLUSION

Concordance between laparoscopic PCI assessment and PCI score at the end of CRS is fair within a two-step surgical management. Laparoscopic assessment underestimates final PCI score by two points, and this difference increases with the delay between both surgeries. Diagnostic laparoscopy can adequately select patients for CRS, and optimal time to perform it is no more than 10 days after laparoscopy.

Treatment of epithelial ovarian cancer

Ovarian cancer is the third most common gynecologic malignancy worldwide but accounts for the highest mortality rate among these cancers. A stepwise approach to assessment, diagnosis, and treatment is vital to appropriate management of this disease process. An integrated approach with gynecologic oncologists as well as medical oncologists, pathologists, and radiologists is of paramount importance to improving outcomes. Surgical cytoreduction to R0 is the mainstay of treatment, followed by adjuvant chemotherapy. Genetic testing for gene mutations that affect treatment is the standard of care for all women with epithelial ovarian cancer. Nearly all women will have a recurrence, and the treatment of recurrent ovarian cancer continues to be nuanced and requires extensive review of up to date modalities that balance efficacy with the patient's quality of life. Maintenance therapy with poly ADP-ribose polymerase inhibitors, bevacizumab, and/or drugs targeting homologous recombination deficiency is becoming more widely used in the treatment of ovarian cancer, and the advancement of immunotherapy is further revolutionizing treatment targets.

Correlation of surgeon radiology assessment with laparoscopic disease site scoring in patients with advanced ovarian cancer

BACKGROUND

Radiographic triage measures in patients with new advanced ovarian cancer have yielded inconsistent results.

OBJECTIVE

To determine the correlation between surgeon radiology assessment and laparoscopic scoring by disease sites in patients with newly diagnosed advanced stage ovarian cancer.

METHODS

Fourteen gynecologic oncology surgeons from a single institution performed a blinded review of pre-operative contrast-enhanced CT imaging from patients with advanced stage ovarian cancer. Each of the patients had also undergone laparoscopic scoring assessment, between April 2013 and December 2017, to determine primary resectability using the validated Fagotti scoring method, and assigned a predictive index value score. Surgeons were asked to provide expected predictive index value scores based on their blinded review of the antecedent CT imaging. Linear mixed models were conducted to calculate the correlation between radiologic and laparoscopic score for surgeons individually, and as a group. Once the model was fit, the inter-class correlation and 95% CI were calculated.

RESULTS

Radiology review was performed on 20 patients with advanced stage ovarian cancer who underwent laparoscopic scoring assessment. Surgeon faculty rank included assistant professor (n=5), associate professor (p=4), and professor (n=5). The kappa inter-rater agreement was -0.017 (95% CI -0.023 to -0.005), indicating low inter-rater agreement between radiology review and actual laparoscopic score. The inter-class correlation in this model was 0.06 (0.02-0.21), indicating that surgeons do not score the same across all the images. When using a clinical cut-off point for the predictive index value of 8, the probability of agreement between radiology and actual laparoscopic score was 0.56 (95% CI 0.49 to 0.73). Examination of disease site sub-scales showed that the probability of agreement was as follows: peritoneum 0.57 (95% CI 0.51 to 0.62), diaphragm 0.54 (95% CI 0.48 to 0.60), mesentery 0.51 (95% CI 0.45 to 0.57), omentum 0.61 (95% CI 0.55 to 0.67), bowel 0.54 (95% CI 0.44 to 0.64), stomach 0.71 (95% CI 0.65 to 0.76), and liver 0.36 (95% CI 0.31 to 0.42). The number of laparoscopic scoring cases, tumor reductive surgery cases, or faculty rank was not significantly associated with overall or sub-scale agreement.

CONCLUSIONS

Surgeon radiology review did not correlate highly with actual laparoscopic scoring assessment findings in patients with advanced stage ovarian cancer. Our study highlights the limited accuracy of surgeon radiographic assessment to determine resectability.

Impact of multidisciplinary tumour board in the management of ovarian carcinoma in the first-line setting. Exhaustive analysis from the Rhone-Alpes region

OBJECTIVE

Epithelial ovarian cancer (EOC) is a poor prognosis disease partly linked to diagnosis at an advanced stage. The quality of care management is a factor that needs to be explored, more specifically optimal organisation of first-line treatment.

METHODS

A retrospective study, dealing with all patients diagnosed within the Rhone-Alpes region with initial diagnosis EOC in 2012, was performed. The aim was to describe the impact of multidisciplinary tumour boards (MTB) in the organisation of care and the consequence on the patient's outcomes.

RESULTS

271 EOC were analysed. 206 patients had an advanced EOC. Median progression-free survival (PFS) is 17.8 months (CI95%, 14.6-21.2) for AOC. 157 patients (57.9%) had a front-line surgery versus 114 patients (42.1%) interval debulking surgery. PFS for AOC patients with no residual disease is 24.3 months compared with 15.3 months for patients with residual disease (p = .01). No macroscopic residual disease is more frequent in the patients discussed before surgery in MTB compared with patients not submitted before surgery (73% vs. 56.2%, p < .001).

CONCLUSION

These results highlight the heterogeneity of medical practices in terms of front-line surgery versus interval surgery, in the administration of neoadjuvant chemotherapy and in the setting of MTB discussion.

Evaluation of surgical resection in advanced ovarian, fallopian tube, and primary peritoneal cancer: laparoscopic assessment. A European Network of Gynaecological Oncology Trial (ENGOT) group survey

OBJECTIVE

Laparoscopy is one of the diagnostic tools available for the complex clinical decision-making process in advanced ovarian, fallopian tube, and peritoneal carcinoma. This article presents the results of a survey conducted within the European Network of Gynaecological Oncology Trial (ENGOT) group aimed at reviewing the current patterns of practice at gynecologic oncology centers with regard to the evaluation of resection in advanced ovarian, fallopian tube, and peritoneal carcinoma.

METHODS

A 24-item questionnaire was sent to the chair of the 20 cooperative groups that are currently part of the ENGOT group, and forwarded to the members within each group.

RESULTS

A total of 142 questionnaires were returned. Only 39 respondents (27.5%) reported using some form of clinical (not operative) score for the evaluation of resection. The frequency of use of diagnostic laparoscopy to assess disease status and feasibility of resection was as follows: never, 21 centers (15%); only in select cases, 83 centers (58.5%); and routinely, 36 centers (25.4%). When laparoscopy was performed, 64% of users declared they made the decision to proceed with maximal effort cytoreductive surgery based on their personal/staff opinion, and 36% based on a laparoscopic score. To the question of whether laparoscopy should be considered the gold standard in the evaluation of resection, 71 respondents (50%) answered no, 66 respondents (46.5%) answered yes, whereas 5 respondents (3.5%) did not provide an answer.

CONCLUSIONS

This study found that laparoscopy was routinely performed to assess feasibility of cytoreduction in only 25.4% of centers in Europe. However, it was commonly used to select patients and in a minority of centers it was never used . When laparoscopy was adopted, the treatment strategy was based on laparoscopic scores only in a minority of centers.

An update on preoperative assessment of the resectability of advanced ovarian cancer

The best prognosis for advanced ovarian cancer is provided by no residual disease after primary cytoreductive surgery. It is thus important to be able to predict resectability that will result in complete cytoreduction, while avoiding unnecessary surgery that may leave residual disease. No single procedure appears to be sufficiently accurate and reliable to predict resectability. The process should include a preoperative workup based on clinical examination, biomarkers, especially tumor markers, and imaging, for which computed tomography, as well as sonography, magnetic resonance imaging and positron-emission tomography, can be used. This workup should provide sufficient information to determine whether complete cytoreduction is possible or if not, to propose neoadjuvant chemotherapy which is preferable in this case. For the remaining patients, laparoscopy is broadly recommended as an ultimate triage step. However, its modalities are still debated, and several scores have been proposed for standardization and improving accuracy. The risk of false negatives requires a final assessment of resectability as the first stage of cytoreductive surgery by laparotomy. Composite models, consisting of several criteria of workup and, sometimes, laparoscopy have been proposed to improve the accuracy of the predictive process. Regardless of the modality, the process appears to be accurate and reliable for predicting residual disease but less so for predicting complete cytoreduction and thus avoiding unnecessary surgery and an inappropriate treatment strategy. Overall, the proposed procedures are heterogeneous, sometimes unvalidated, or do not consider advances in surgery. Future techniques and/or models are still needed to improve the prediction of complete resectability.

Performance of pre-treatment ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography for detecting metastasis in ovarian cancer: a systematic review and meta-analysis

OBJECTIVE

We describe a systematic review and meta-analysis of the performance of ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) positron emission tomography/computed tomography (PET/CT) for detecting metastasis in ovarian cancer.

METHODS

MEDLINE and Embase were searched for diagnostic accuracy studies that used ¹⁸F-FDG PET or PET/CT for pre-treatment staging, using surgical findings as the reference standard. Sensitivities and specificities were pooled and plotted in a hierarchic summary receiver operating characteristic plot. Potential causes of heterogeneity were explored through sensitivity analyses.

RESULTS

Eight studies with 594 patients were included. The overall pooled sensitivity and specificity for metastasis were 0.72 (95% confidence interval [CI]=0.61-0.81) and 0.93 (95% CI=0.85-0.97), respectively. There was considerable heterogeneity in sensitivity (I²=97.57%) and specificity (I²=96.74%). In sensitivity analyses, studies that used laparotomy as the reference standard showed significantly higher sensitivity and specificity (0.77; 95% CI=0.67-0.87 and 0.96; 95% CI=0.92-0.99, respectively) than those including diagnostic laparoscopy (0.62; 95% CI=0.46-0.77 and 0.84; 95% CI=0.69-0.99, respectively). Higher specificity was shown in studies that confirmed surgical findings by pathologic evaluation (0.95; 95% CI=0.90-0.99) than in a study without pathologic confirmation (0.69; 95% CI=0.24-1.00). Studies with a lower prevalence of the FDG-avid subtype showed higher specificity (0.97; 95% CI=0.94-1.00) than those with a greater prevalence (0.89; 95% CI=0.80-0.97).

CONCLUSION

Pre-treatment ¹⁸F-FDG PET/CT shows moderate sensitivity and high specificity for detecting metastasis in ovarian cancer. With its low false-positive rate, it can help select surgical approaches or alternative treatment options.

A radiologic-laparoscopic model to predict suboptimal (or complete and optimal) debulking surgery in advanced ovarian cancer: a pilot study

Introduction: Medical models assist clinicians in making diagnostic and prognostic decisions in complex situations. In advanced ovarian cancer, medical models could help prevent unnecessary exploratory surgery. We designed two models to predict suboptimal or complete and optimal cytoreductive surgery in patients with advanced ovarian cancer.

Methods: We collected clinical, pathological, surgical, and residual tumor data from 110 patients with advanced ovarian cancer. Computed tomographic and laparoscopic data from these patients were used to determine peritoneal cancer index (PCI) and lesion size score. These data were then used to construct two-by-two contingency tables and our two predictive models. Each model included three risk score levels; the R4 model also included operative PCI, while the R3 model did not. Finally, we used the original patient data to validate the models (narrow validation).

Results: Our models predicted suboptimal or complete and optimal cytoreductive surgery with a sensitivity of 83% (R4 model) and 69% (R3 model). Our results also showed that PCI>20 was a major risk factor for unresectability.

Conclusion: Our medical models successfully predicted suboptimal or complete and optimal cytoreductive surgery in 110 patients with advanced ovarian cancer. Our models are easy to construct, based on readily available laboratory test data, simple to use clinically, and could reduce unnecessary exploratory surgery in this patient group.

Accuracy of radiologic- laparoscopic peritoneal carcinomatosis categorization in the prediction of surgical outcome

OBJECTIVE

To evaluate the agreement between multiple detector CT (MDCT) and laparoscopy in the preoperative categorization of peritoneal carcinomatosis, and to determine the impact of this categorization on the prediction of cytoreduction status.

METHODS

This prospective study included 80 consecutive females with primary ovarian cancer eligible for cytoreductive surgery (CRS). MDCT and diagnostic laparoscopy were performed prior to surgery for assessment of peritoneal carcinomatosis extent. Based on PCI (peritoneal cancer index) score, carcinomatosis was categorized into three groups. Categorization agreement between CT and laparoscopy was assessed and compared with the intraoperative-histopathologically proven PCI. Impact of PCI categorization on cytoreduction status was also evaluated.

RESULTS

The overall agreement between CT and laparoscopy in preoperative peritoneal carcinomatosis categorization was good (K =0.71-0.79) in low category group and excellent in both moderate and large group (interclass correlation coeeficient = 0.89-0.91). (p<0.01) Optimal cytoreduction was achieved in 62/80 (77.5%) patients, PCI < 20 was detected in 48/62 (77.4%), pre-operative PCI < 20 correctly predicted optimal cytoreductive surgery (OCS) in 40/48 (83.3%) cases. Suboptimal cytoreduction was performed in 18/80 (22.5%) patients. PCI > 20 was detected in (10/18) 55.6%, preoperative CT and laparoscopy PCI > 20 correctly predicted SCS in 8/10 (80%) cases. The area under receiver operating characteristic curve showed that PCI cut-off <20 was the best predictor of OCS with an accuracy 85%, sensitivity 97%, specificity 40%, negative predictive value 76%, and positive predictive value 93%.

CONCLUSION

Both laparoscopy and CT are equally effective in pre-operative peritoneal carcinomatosis categorization. PCI < 20 is accurate in the prediction of optimal cytoreduction. More than half of patients with suboptimal cytoreduction had PCI > 20 and interval debulking surgery can be recommended.

ADVANCES IN KNOWLEDGE

Both laparoscopy and CT are equally effective in pre-operative peritoneal carcinomatosis categorization. PCI < 20 is accurate in the prediction of optimal cytoreduction. More than half of patients with suboptimal cytoreduction had PCI > 20 and interval debulking surgery can be recommended.

Laparoscopy vs. laparotomy for advanced ovarian cancer: a systematic review of the literature

INTRODUCTION

In the last decade, laparoscopy has been progressively introduced in the management of advanced-stage ovarian cancer (AOC) to evaluate tumor resectability, avoiding an explorative laparotomy, to identify non-responders to submit to second-line chemotherapy and to perform primary or interval minimally invasive debulking surgery in selected patients. This review aims to deeply focus on the differences between laparoscopy and laparotomy in the management of advanced ovarian cancer.

EVIDENCE ACQUISITION

The electronic database search provided a total of 80 results. Out of these, 63 results were excluded because considered not relevant to the review, for linguistic reasons or case reports. A total of 17 articles were considered eligible for the review.

EVIDENCE SYNTHESIS

Many studies have assessed the value of laparoscopy in predicting the optimal resectability of AOC patients avoiding exploratory laparotomies. More recently, its role in primary and interval cytoreduction has been investigated for selected patients in terms of safety, feasibility and oncological outcomes. Published data are comparable to the standard laparotomic management in terms of oncological outcomes but with improved perioperative and psychological results. The selection of patients is crucial to perform a successful surgery.

CONCLUSIONS

To date, laparoscopy has replaced the primary laparotomic approach in the evaluation of optimal resectability. As far as primary and interval minimally invasive debulking surgery are concerned, instead, most of the works report an overlap of oncological outcomes compared to traditional surgery. The selection of patients is a crucial point to reach a successful minimally invasive surgical treatment, taking into account surgical complexity and surgical adequacy.

Laparoscopy for diagnosing resectability of disease in women with advanced ovarian cancer

BACKGROUND

This is an update of a Cochrane Review that was originally published in 2014, Issue 2.The presence of residual disease after primary debulking surgery is a highly significant prognostic factor in women with advanced ovarian cancer. In up to 60% of women, residual tumour of > 1 cm is left behind after primary debulking surgery (defined as suboptimal debulking). These women might have benefited from neoadjuvant chemotherapy (NACT) prior to interval debulking surgery instead of primary debulking surgery followed by chemotherapy. It is therefore important to select accurately those women who would best be treated with primary debulking surgery followed by chemotherapy from those who would benefit from NACT prior to surgery.

OBJECTIVES

To determine if performing a laparoscopy, in addition to conventional diagnostic work-up, in women suspected of advanced ovarian cancer is accurate in predicting the resectability of disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 6) in the Cochrane Library; MEDLINE via Ovid, Embase via Ovid, MEDION and Science Citation Index and Conference Proceedings Citation Index (ISI Web of Science) to July 2018. We also checked references of identified primary studies and review articles.

SELECTION CRITERIA

We included studies that evaluated the diagnostic accuracy of laparoscopy to determine the resectability of disease in women who are suspected of advanced ovarian cancer and planned to receive primary debulking surgery.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently assessed the quality of included studies using QUADAS-2 and extracted data on study and participant characteristics, index test, target condition and reference standard. We extracted data for two-by-two tables and summarised these graphically. We calculated sensitivity and specificity and negative predictive values.

MAIN RESULTS

We included 18 studies, reporting on 14 cohorts of women (including 1563 participants), of which one was a randomised controlled trial (RCT). Laparoscopic assessment suggested that disease was suitable for optimal debulking surgery (no macroscopic residual disease or residual disease < 1 cm (negative predictive values)) in 54% to 96% of women who had macroscopic complete debulking surgery (no visible disease at end of laparotomy) and in 69% to 100% of women who had optimal debulking surgery (residual tumour < 1 cm at end of laparotomy).Only two studies avoided partial verification bias by operating on all women independent of laparoscopic findings, and provided data to calculate sensitivity and specificity. These two studies had no false positive laparoscopies (i.e. no women had a laparoscopy indicating unresectable disease and then went on to have optimal debulking surgery (no disease > 1 cm remaining)).Due to the large heterogeneity pooling of the data was not possible for meta-analysis.

AUTHORS' CONCLUSIONS

Laparoscopy may be a useful tool to identify those women who have unresectable disease, as no women were inappropriately unexplored. However, some women had suboptimal primary debulking surgery, despite laparoscopy predicting optimal debulking and data are at high risk of verification bias as only two studies performed the reference standard (debulking laparotomy) in test (laparoscopy)-positive women. Using a prediction model does not increase the sensitivity and will result in more unnecessarily explored women, due to a lower specificity.

[Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).

[Diagnostic and prognostic value of tumor markers, scores (clinical and biological) algorithms, in front of an ovarian mass suspected of an epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

OBJECTIVES

To evaluate the diagnostic value of serum/urinary biomarkers and the operability diagnosis strategy to make management recommendations.

METHODS

Bibliographical search in French and English languages by consultation of Pubmed, Cochrane and Embase databases.

RESULTS

For the diagnosis of a suspicious adnexal mass on imaging: Serum CA125 antigen is recommended (grade A). Serum CAE is not recommended (grade C). The low evidence in literature concerning diagnostic value of CA19.9 does not allow any recommendation concerning its use. Serum Human epididymis protein 4 (HE4) is recommended (grade A). Comparison of data concerning diagnosis value of CA125 and HE4 show similar results for the prediction of malignancy in case of a suspicious adnexal mass on imaging (NP1). Urinary HE4 is not recommended (grade A). The use of circulating tumor DNA is not recommended (grade A). Tumor associated antigen-antibodies (AAbs) is not recommended (grade B). The use of ROMA score (Risk of Ovarian Malignancy Algorithm) is recommended (grade A). The use of Copenhagen index (CPH-I), R-OPS score, OVA500 is not recommended (grade C). For the prediction of resectability of an ovarian cancer with peritoneal carcinomatosis in the context of a primary debulking surgery: It is not recommendend to use serum CA125 (grade A). The low evidence in literature concerning diagnostic value of HE4 does not allow any recommendation concerning its use in this context. No recommendation can be given concerning CA19.9 and CAE. For the prediction of resectability of an ovarian cancer with peritoneal carcinomatosis in the context of surgery after neoadjuvant chemotherapy: the low evidence in literature concerning diagnostic value of serum markers in this context does not allow any recommendation concerning their use in this context. Place of laparoscopy for the prediction of resectability in case of upfront surgery of an ovarian cancer with peritoneal carcinomatosis robust data shows that the use of laparoscopy significantly reduce futile laparotomies (LE1). Laparoscopy is recommended in this context (grade A). Fagotti score is a reproducible tool (LE1) permitting the evaluation of feasibility of an optimal upfront debulking (NP4), its use is recommended (grade C). A Fagotti score≥8 is correlated to a low probability of complete or optimal debulking surgery (LE4) (grade C). There is no sufficient evidence to recommend the use of the modified Fagotti score or any other laparoscopic score (LE4). In case of laparotomy for an ovarian cancer with peritoneal carcinomatosis, the use of Peritoneal Cancer Index (PCI) is recommended (grade C). For the prediction of overall survival, disease free survival and the prediction of postoperative complications, the clinical and statistical of actually available tools do not allow any recommendation.

Review of methodological challenges in comparing the effectiveness of neoadjuvant chemotherapy versus primary debulking surgery for advanced ovarian cancer in the United States

Randomized trials outside the U.S. have found non-inferior survival for neoadjuvant chemotherapy (NACT) versus primary debulking surgery (PDS) for advanced ovarian cancer (AOC). However, these trials reported lower overall survival and lower rates of optimal debulking than U.S. studies, leading to questions about generalizability to U.S. practice, where aggressive debulking is more common. Consequently, comparative effectiveness in the U.S. remains controversial. We reviewed U.S. comparative effectiveness studies of NACT versus PDS for AOC. Here we describe methodological challenges, compare results to trials outside the U.S., and make suggestions for future research. We identified U.S. studies published in 2010 or later that evaluated the comparative effectiveness of NACT versus PDS on survival in AOC through a PubMed search. Two independent reviewers abstracted data from eligible articles. Nine of 230 articles were eligible for review. Methodological challenges included unmeasured confounders, heterogeneous treatment effects, treatment variations over time, and inconsistent measurement of treatment and survival. Whereas some limitations were unavoidable, several limitations noted across studies were avoidable, including conditioning on mediating factors and immortal time introduced by measuring survival beginning from diagnosis. Without trials in the U.S., non-randomized studies are an important source of evidence for the ideal treatment for AOC. However, several methodological challenges exist when assessing the comparative effectiveness of NACT versus PDS in a non-randomized setting. Future observational studies must ensure that treatment is consistent throughout the study period and that treatment groups are comparable. Rapidly-evolving oncology data networks may allow for identification of treatment intent and other important confounders.

Port-site metastasis as a primary complication following diagnostic laparoscopy of fallopian tube carcinoma: A case report

RATIONALE

Fallopian tube carcinoma is a rare female genital cancer with no specific clinical and surgical features. It is hardly diagnosed on imaging due to non-specific presentation. Laparoscopy has been recommended as the diagnostic procedure for the assessment of suspicious ovarian and adnexal masses. However, it has brought new complications like tumor recurrences at the trocar insertion sites, called port-site metastasis (PSM).

PATIENT CONCERNS

A 65-year-old, postmenopausal woman presented to hospital with loss of appetite, Ultrasound showed ill-defined pelvic mass. The patient was diagnosed with fallopian tube carcinoma by a diagnostic laparoscopy.

DIAGNOSES

The PSM as a primary complication following diagnostic laparoscopy of fallopian tube carcinoma, which is presumed by positron emission tomography/computed tomography and confirmed by Nodule resection and further pathological assessment.

INTERVENTIONS

As port-site metastasis was suspected, the patient was advised to undergo umbilical mass resection.

OUTCOMES

the patient has no signs of recurrence was detected 20 months after the last surgery during follow-up.

LESSIONS

Laparoscopy plays a significant role in the diagnose and treatment of fallopian tubal and ovarian malignancies but has a risk of PSM occurrence. When isolated PSM occurs the management should be local resection.

The role of neoadjuvant chemotherapy in ovarian cancer

INTRODUCTION

Ovarian cancer is mostly diagnosed at advanced stage. Better survival is achieved through complete debulking surgery and chemotherapy. Historically, neoadjuvant chemotherapy (NAC) has been introduced for unresectable disease to decrease tumor load and perform a unique complete surgery. Four randomized control trials have compared primary debulking surgery to NAC, but there is still controversy about the use of neoadjuvant chemotherapy and questions about its modalities. Areas covered: We made a review of knowledge on benefits of NAC compared to primary debulking chemotherapy, in terms of survival and morbidity, methods of administration, new drugs in early and late phase trials, the selection of patients. Similar survival was observed after NAC and interval debulking surgery or primary debulking surgery. Morbidity of surgery was decreased after interval debulking compared primary debulking surgery. Conventional drugs are carboplatin and paclitaxel. Safety of bevacizumab was evaluated in phase 2 trials associated with conventional drugs. Immunotherapy trials are enrolling patients in phase 1 study. Expert commentary: NAC followed by debulking surgery is the best treatment for patients with advanced ovarian cancer.

Meigs to modern times: The evolution of debulking surgery in advanced ovarian cancer

Joe V. Meigs was a visionary clinician and an early adopter of radical techniques in the surgical treatment of ovarian cancer. His 1934 textbook "Tumors of the Female Pelvic Organs", consolidated his approach to this "hopeless" disease, with pearls on diagnosis, outcomes, and even speculations about the benefits of minimally invasive surgery. Decades before adjuvant chemotherapy would prove of value, and in an era when sophisticated statistics were unheard of, he nonetheless tried to eke out what benefits he could using the methods available in his time. We transition his original findings and observations through the advent of platinum-based chemotherapy, retrospective cohort studies supporting the benefits of primary debulking, and finally the long-awaited randomized controlled trial. We aim to provide historical context for the underpinnings of how cytoreductive surgery has evolved into its current role in the treatment of advanced ovarian cancer.

Role of laparoscopy in initial tumour staging in advanced epithelial ovarian cancer: A systematic review

BACKGROUND

The aim of this systematic review was to investigate the accuracy of additional staging laparoscopy (SL) in advanced epithelial ovarian cancer (AEOC) to predict futile laparotomy (FL).

METHODS

Systematic review according to preferred reporting items for systematic reviews and meta-analyses statement (PRISMA) criteria. Clinical studies investigating the role of SL in selecting women with AEOC for primary debulking surgery (PDS) were included. Index test: SL. Reference test: laparotomy. Target condition: incomplete cytoreduction (CR) with remaining disease<1 cm.

RESULTS

Nine prospective and retrospective studies reporting on eight cohorts totalizing 778 LS were included. Reference test was completed in 76 % cases. PPV for FL was between 0.69 and 1.0. In three studies examining the value of a predictive index value (PIV) for predicting FL, sensitivity of the index test (LS with PIV ≥8) was between 46% and 70 %, and specificity between 89 % and 100 %. The proportion of patients that received CR during PDS differed widely between studies (from 50 to 91). Using a PIV did not increase the sensitivity and might result in more patients receiving FL. In the only randomized trial, FL occurred in 10 (10 %) of 102 patients in the LS group versus 39 (39 %) of 99 patients in the primary PDS group (relative risk, 0.25; 95 % CI, 0.13-0.47; p<0.001). Port-site recurrences occurred in 2%-6 % patients. Overall costs of with or without SL were comparable.

CONCLUSIONS

The evidence available from this systematic review supports the inclusion of an additional LS to the conventional initial diagnostic workup in women with AEOC.

Prediction of suboptimal cytoreductive surgery in patients with advanced ovarian cancer based on preoperative and intraoperative determination of the peritoneal carcinomatosis index

Background

The peritoneal carcinomatosis index (PCI) can be used to quantify the tumor burden in patients with advanced ovarian cancer. The aim of the present study was to establish a predictive model for suboptimal cytoreductive surgery (SCS) (residual tumor of > 1 cm) using preoperative and intraoperative determination of the PCI.

Methods

In total, 110 consecutive patients treated for advanced ovarian cancer during a 4-year period in our institution were assessed. Eighty of these patients were eligible for primary debulking surgery and thus included in the present study. All data were prospectively collected and retrospectively evaluated. We determined the PCI both preoperatively and intraoperatively and assessed postoperative complications.

Results

A PCI of > 20 was the best cut-off with which to predict a risk of SCS among all three diagnostic techniques assessed in this study (computed tomography, laparoscopy, and laparotomy). Intraoperative PCI determination was associated with the lowest risk of false negatives for SCS when detecting a PCI of < 20. The combination of preoperative computed tomography and laparoscopy, when both techniques predicted SCS, was associated with the lowest risk of false positives for SCS when detecting a PCI of > 20.

Conclusion

The combination of computed tomography and laparoscopy to obtain the PCI can help to determine which patients with advanced ovarian cancer are suitable for primary debulking surgery and which should undergo neoadjuvant chemotherapy.

A pre-operative predictive score to evaluate the feasibility of complete cytoreductive surgery in patients with epithelial ovarian cancer

Objective

Postoperative residual tumor is the major prognostic factor in ovarian cancer. The feasibility of complete cytoreductive surgery is assessed by laparoscopy. Our goal was to develop a predictive score prior to laparoscopy to evaluate the feasibility of complete cytoreductive surgery in patients with epithelial ovarian cancer.

Methods

We developed a score to predict incomplete cytoreductive surgery by performing multiple logistic regressions after bootstrap procedures on data from a retrospective cohort of 247 patients with advanced ovarian cancer. This score was validated on a different population of 45 patients with ovarian cancer.

Results

Four criteria were independently associated with incomplete cytoreduction, confirmed by surgery: BMI ≥ 30 kg/m² (adjusted odds ratio [aOR], 3.07; 95% confidence interval [95% CI], 1.0–9.6), CA125 > 100 IU/L (aOR, 3.99; 95% CI, 1.6–10.1), diaphragmatic and/or omental carcinomatosis by CT-Scan (aOR, 5.82; 95% CI, 2.6–13.1), and positive parenchymal metastases by PET/CT (aOR, 3.59; 95% CI, 1.0–12.8). The 100-point score was based on these criteria. The area-under-the-curve of the score was 0.79 (95% CI, 0.73–0.86). In the validation group, no patient ranked in the high-risk group of incomplete cytoreductive surgery had a complete upfront cytoreductive surgery (95% CI 0–16). Three of 29 patients for whom primary complete cytoreduction was not possible were classified in the group at low risk of incomplete cytoreductive surgery (12%; 95% CI 4–27).

Conclusion

This pre-operative score may be useful for distinguishing which patients may have complete cytoreductive surgery from those who will receive neoadjuvant chemotherapy, while avoiding unnecessary laparoscopy.

A novel algorithm for the treatment strategy for advanced epithelial ovarian cancer: consecutive imaging, frailty assessment, and diagnostic laparoscopy

Background

This study aimed to evaluate the perioperative outcomes and prognostic impact of the consecutive steps of imaging, frailty assessment, and diagnostic laparoscopy (DLS) in patients with advanced epithelial ovarian cancer (EOC).

Methods

Patients diagnosed with EOC during 2012–2015 were analyzed retrospectively. Surgical and survival outcomes were compared between three treatment groups: patients without high tumor dissemination (HTD) who underwent primary debulking surgery (PDS group); patients with HTD who underwent DLS (DLS group); and patients with HTD diagnosed by cytological confirmation of malignancy followed by neoadjuvant chemotherapy (NACT group).

Results

Of 181 patients, 85, 38, and 58 underwent PDS, DLS, and NACT, respectively. Among the 38 consecutive patients who initially underwent DLS, 6 were considered suitable for PDS; the remaining 32 were eligible for NACT followed by interval debulking surgery. The median operative times of debulking surgery in the PDS, DLS, and NACT groups were 365 min (interquartile range [IQR]: 216.5–476.5 min), 266.2 min (IQR: 160.3–193.5 min), and 339.0 min (IQR: 205–425 min; P = 0.042), respectively, with respective median estimated blood loss volumes of 962.2 mL (IQR: 300–1037.5 mL), 267.1 mL (IQR: 150–450 mL), and 861.7 mL (IQR: 150–1200 mL; P = 0.023). The DLS group had significantly reduced transfusion requirements and intensive care unit admission rates (P = 0.006). The Kaplan–Meier survival analysis indicated significantly poor PFS in the NACT group. However, there was no significant difference in OS among the three groups.

Conclusions

The consecutive steps of imaging, frailty assessment, and DLS might facilitate rapid assessments of peritoneal disease extent and resectability; this novel algorithm might also be used to individualize treatment.

Laparoscopic-based score assessment combined with a multiple disciplinary team in management of recurrent ovarian cancer: A single-center prospective study for personalized surgical therapy

The aim of the study was to evaluate the effect of laparoscopic-based score combined with a multiple disciplinary team (MDT) for predicting optimal cytoreduction and perform personalized surgical treatment in recurrent ovarian cancer (ROC).The study is a single-center, prospective investigation. From March 2013 to May 2015, the consecutive treated patients with platinum-sensitive ROC were collected in Yangpu Hospital. The appropriated patients were enrolled into the study to perform the laparoscopic-based PIV (predictive index value) score assessment with an MDT for predicting optimal cytoreduction. The PIV cutoff value was confirmed to be 8. Patients of PIV <8 received laparoscopic/laparotomy secondary surgery following chemotherapy, and the ones with PIV ≥8 did chemotherapy alone. Sensitivity, specificity, positive predicted value (PPV), negative predicted value (NPV), and overall accuracy for each range of PIV score were calculated. All recruited patients participated in follow-up observation. Overall survival was recorded.In total, 58 eligible ROC patients received laparoscopy assessment. Forty-one patients of PIV <8 received secondary cytoreductive surgeries. Twenty-three (23/41 56.1%) attained optimal cytoreduction. However, 8 of 23 achieved completed cytoreduction. Also, 17 patients of PIV ≥8 underwent chemotherapy alone. Sensitivity, specificity, PPV, NPV, and overall accuracy for PIV ≥8 were 60%, 100%, 100%, 25%, and 64.7%, respectively. Overall survival in patients performing optimal cytoreduction was significantly higher than in those undergoing suboptimal cytoreduction or chemotherapy alone (45.9 ± 2.5 vs 36.7 ± 4.3 months, P = .047; 45.9 ± 2.5 vs 35.8 ± 3.4 months, P = .027).Laparoscopic-based score assessment plus MDT helps to identify the appropriate patients to perform optimal secondary cytoreduction and provide a personalized surgical approach in management of ROC.

Current Recommendations for Minimally Invasive Surgical Staging in Ovarian Cancer

OPINION STATEMENT

Minimally invasive surgery (MIS) currently is performed to stage and treat ovarian cancer at different stages of disease; however, the higher level of evidence from existing studies is IIB. Despite the absence of randomized controlled trials, MIS represents a safe and adequate procedure for treating and staging early ovarian cancer, and its use has increased significantly in clinical practice. Major concerns are related to minimizing tumor disruption or dissemination, removing the adnexal mass intact, adequate retroperitoneal staging, and fertility-sparing surgery for young patients. The main goal for patients with advanced ovarian cancer is to determine the best therapeutic strategy by evaluating the risks and benefits of primary debulking surgery versus neoadjuvant chemotherapy followed by interval debulking surgery. The use of staging laparoscopy in patients with advanced epithelial ovarian cancer appears to be the most researched and accepted approach. Regarding other types and stages of ovarian cancer, although the evidence is very promising, clinical trials performed by expert gynecologic oncology surgeons in referral centers are still needed to prove the efficacy of such an approach in these patients. In particular, MIS has provided an opportunity to remove localized recurrences, with both retroperitoneal and intraperitoneal diffusion.

Is complete cytoreductive surgery feasible in this patient with ovarian cancer?

BACKGROUND

Post-operative residual tumor size is the main prognostic factor in advanced epithelial ovarian cancer. Our objective was to develop a score for predicting the feasibility of complete cytoreductive surgery in patients with advanced epithelial ovarian cancer.

MATERIAL AND METHODS

Using data from a retrospective cohort of 123 patients with advanced ovarian cancer, we developed a score for predicting complete cytoreductive surgery, by performing multiple logistic regression after a jackknife procedure.

RESULTS

Three criteria were independently associated with incomplete cytoreductive surgery confirmed by surgery: age >60 years (adjusted odds ratio [aOR], 6.37; 95% confidence interval [95%CI], 1.9-21.3), diaphragmatic carcinomatosis by computed tomography (aOR, 3.34; 95%CI, 1.1-9.9), and a Peritoneal Cancer Index >10 by diagnostic laparoscopy (aOR, 3.8; 95%CI, 1.4-10.2). A 10-point score was developed based on these three criteria. The area-under-the-curve of the score was 0.76 (95%CI, 0.67-0.86). The score discriminated between groups with low and high risks of incomplete cytoreductive surgery (4.4% [95% CI, 0-10.5] and 42.9% [95% CI, 26.3-59.4], respectively). Using a cutoff of 4, sensitivity of the score was 92.8% (95%CI, 83.2-100) and specificity was 77% (95%CI, 67.1-84.9) for predicting incomplete cytoreductive surgery.

CONCLUSION

This easy-to-calculate score may prove useful to identify patients with ovarian peritoneal carcinomatosis in whom complete cytoreductive surgery is feasible.

Transvaginal Sonography-Guided Core Biopsy of Adnexal Masses as a Useful Diagnostic Alternative Replacing Cytologic Examination or Laparoscopy in Advanced Ovarian Cancer Patients

Objective

The aim of this study was to evaluate transvaginal sonography (TVS)-guided core biopsy of the adnexal masses for neoadjuvant chemotherapy (NACT) in patients with advanced ovarian malignancies.

Materials and Methods

We retrospectively reviewed the medical records of 52 patients who had undergone TVS-guided core biopsies in our gynecologic cancer center between May 2009 and October 2015. TVS-guided core biopsies were performed on patients with advanced ovarian malignancies who were considered as candidates for NACT and patients with adnexal masses who required a differential diagnosis of non-gynecologic tumors.

Results

Thirty-seven patients (71.2%) were scheduled to undergo NACT owing to the presence of coexisting illness, age, tumor burden, and location of metastatic sites. Fifteen patients (28.8%) underwent TVS-guided core biopsies to determine if they had primary or secondary ovarian tumors. Histopathologic examinations revealed primary ovarian tumors in 44 patients (84.6%). Nongynecologic tumors including gastrointestinal stromal tumor and metastatic tumor from gallbladder, gastric, and colorectal cancer were found to be the second most common disease (n = 5 [9.6%]). Findings in the samples were nondiagnostic in 4 patients (5.8%). With respect to the histological concordance rate between TVS-guided core biopsy and surgical specimen, diagnostic accuracy was 93.6%. There were no biopsy-related complications.

Conclusions

TVS-guided core biopsy may be a feasible procedure to diagnose adnexal masses, particularly in patients with advanced ovarian malignancies who are more likely to benefit from NACT.

Single-port or Classic Laparoscopy Compared With Laparotomy to Assess the Peritoneal Cancer Index in Primary Advanced Epithelial Ovarian Cancer

A thorough laparoscopic assessment of the abdominopelvic cavity is a crucial step in the workup of primary advanced epithelial ovarian cancer to decide whether up-front cytoreductive surgery or neoadjuvant chemotherapy is the best option for adequate management. The purpose of our study was to compare single-port laparoscopy (SPL), classic laparoscopy (CL), and laparotomy using the peritoneal cancer index (PCI). Patients treated for Fédération Internationale de Gynécologie et d'Obstétrique stage 3 or 4 epithelial ovarian cancer were included in our study when they underwent a PCI evaluation by laparoscopy followed by laparotomy for cytoreduction. According to the technique used for the "noninvasive" procedure (SPL vs CL), 2 groups were compared retrospectively. The individual records of all patients were reviewed and analyzed. From 2011 to 2014, 21 patients were assessed for PCI by SPL plus laparotomy versus 21 by CL plus laparotomy. The clinicopathological features were similar in both groups (not significant [NS]), except for performance status >0, which was more frequent in the SPL group (39% vs 6%, p = .04). Quotation of PCI was possible for all patients. Nonbrowsing areas marked 3 procedures in the SPL group and 2 procedures in the CL group (NS). The mean PCI score and the score of each region assessed by SPL and CL were comparable with the evaluation by laparotomy (NS). Completeness of cytoreduction was achieved in 78% of cases in both groups (NS). SPL and widely mini-invasive procedures seem to be effective tools compared with laparotomy to adequately assess the resectability of a peritoneal carcinomatosis using the PCI.