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Chen Q. Overall survival in ovarian cancer patients after cytoreductive surgery. A systematic review and meta-analysis. Curr Probl Surg 2024; 61:101542. [PMID: 39168528 DOI: 10.1016/j.cpsurg.2024.101542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/27/2024] [Accepted: 06/12/2024] [Indexed: 08/23/2024]
Affiliation(s)
- Qiaoying Chen
- Department of Gynecology, Women's and Children's Hospital of Ningbo University, No.339 Liuting Street, Haishu District, Ningbo, 315012, Zhejiang, China.
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Gurusamy K, Leung J, Vale C, Roberts D, Linden A, Wei Tan X, Taribagil P, Patel S, Pizzo E, Davidson B, Mould T, Saunders M, Aziz O, O'Dwyer S. Hyperthermic intraoperative peritoneal chemotherapy and cytoreductive surgery for people with peritoneal metastases: a systematic review and cost-effectiveness analysis. Health Technol Assess 2024; 28:1-139. [PMID: 39254852 PMCID: PMC11417642 DOI: 10.3310/kwdg6338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/11/2024] Open
Abstract
Background We compared the relative benefits, harms and cost-effectiveness of hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery ± systemic chemotherapy versus cytoreductive surgery ± systemic chemotherapy or systemic chemotherapy alone in people with peritoneal metastases from colorectal, gastric or ovarian cancers by a systematic review, meta-analysis and model-based cost-utility analysis. Methods We searched MEDLINE, EMBASE, Cochrane Library and the Science Citation Index, ClinicalTrials.gov and WHO ICTRP trial registers until 14 April 2022. We included only randomised controlled trials addressing the research objectives. We used the Cochrane risk of bias tool version 2 to assess the risk of bias in randomised controlled trials. We used the random-effects model for data synthesis when applicable. For the cost-effectiveness analysis, we performed a model-based cost-utility analysis using methods recommended by The National Institute for Health and Care Excellence. Results The systematic review included a total of eight randomised controlled trials (seven randomised controlled trials, 955 participants included in the quantitative analysis). All comparisons other than those for stage III or greater epithelial ovarian cancer contained only one trial, indicating the paucity of randomised controlled trials that provided data. For colorectal cancer, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably results in little to no difference in all-cause mortality (60.6% vs. 60.6%; hazard ratio 1.00, 95% confidence interval 0.63 to 1.58) and may increase the serious adverse event proportions compared to cytoreductive surgery ± systemic chemotherapy (25.6% vs. 15.2%; risk ratio 1.69, 95% confidence interval 1.03 to 2.77). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably decreases all-cause mortality compared to fluorouracil-based systemic chemotherapy alone (40.8% vs. 60.8%; hazard ratio 0.55, 95% confidence interval 0.32 to 0.95). For gastric cancer, there is high uncertainty about the effects of hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy versus cytoreductive surgery + systemic chemotherapy or systemic chemotherapy alone on all-cause mortality. For stage III or greater epithelial ovarian cancer undergoing interval cytoreductive surgery, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy probably decreases all-cause mortality compared to cytoreductive surgery + systemic chemotherapy (46.3% vs. 57.4%; hazard ratio 0.73, 95% confidence interval 0.57 to 0.93). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy may not be cost-effective versus cytoreductive surgery + systemic chemotherapy for colorectal cancer but may be cost-effective for the remaining comparisons. Limitations We were unable to obtain individual participant data as planned. The limited number of randomised controlled trials for each comparison and the paucity of data on health-related quality of life mean that the recommendations may change as new evidence (from trials with a low risk of bias) emerges. Conclusions In people with peritoneal metastases from colorectal cancer with limited peritoneal metastases and who are likely to withstand major surgery, hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy should not be used in routine clinical practice (strong recommendation). There is considerable uncertainty as to whether hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy or cytoreductive surgery + systemic chemotherapy should be offered to patients with gastric cancer and peritoneal metastases (no recommendation). Hyperthermic intraoperative peritoneal chemotherapy + cytoreductive surgery + systemic chemotherapy should be offered routinely to women with stage III or greater epithelial ovarian cancer and metastases confined to the abdomen requiring and likely to withstand interval cytoreductive surgery after chemotherapy (strong recommendation). Future work More randomised controlled trials are necessary. Study registration This study is registered as PROSPERO CRD42019130504. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/135/02) and is published in full in Health Technology Assessment; Vol. 28, No. 51. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Kurinchi Gurusamy
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Jeffrey Leung
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Claire Vale
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Danielle Roberts
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Audrey Linden
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Xiao Wei Tan
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Priyal Taribagil
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Sonam Patel
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Elena Pizzo
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Brian Davidson
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Tim Mould
- Department of Gynaecological Oncology, University College London NHS Foundation Trust, London, UK
| | - Mark Saunders
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
| | - Omer Aziz
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
| | - Sarah O'Dwyer
- Colorectal and Peritoneal Oncology Centre, The Christie NHS Foundation Trust, Manchester, UK
- Institute of Cancer Sciences, University of Manchester, Manchester, UK
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Okunade KS, Adekanye TV, Osunwusi B, Soibi-Harry A, Okoro AC, Toks-Omage E, Okunowo AA, Ohazurike EO, Anorlu RI. Survival outcomes following interval versus primary debulking surgery in advanced epithelial ovarian cancer: A retrospective cohort study in Lagos, Southwest Nigeria. RESEARCH SQUARE 2024:rs.3.rs-3834135. [PMID: 38260667 PMCID: PMC10802718 DOI: 10.21203/rs.3.rs-3834135/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background There is conflicting evidence regarding the survival benefit of interval debulking surgery (IDS) compared to conventional treatment with primary debulking surgery (PDS) in women with advanced epithelial ovarian cancer (EOC). Objectives We compared the survivals following PDS followed by adjuvant chemotherapy (ACT) versus IDS after neoadjuvant chemotherapy (NACT) in women with advanced EOC at the gynaecological oncology unit of a tertiary referral centre in Lagos, Southwest Nigeria. Methods The data of 126 women with advanced EOC who had standard treatment with either PDS and ACT or NACT and IDS between January 2008 and December 2017 were analyzed. Kaplan-Meier estimates of progression-free (PFS) and overall survival (OS) time stratified by the types of upfront debulking surgery were calculated and compared by employing the log-rank test statistics. Cox proportional hazard models were then used to estimate hazard ratios of the association between the type of surgical debulking and survivals while adjusting for all necessary covariates. Results We recorded no statistically significant differences in PFS (adjusted hazard ratio=1.28, 95% confidence interval 0.82-2.01, P=0.282) and OS (adjusted hazard ratio=1.23, 95% confidence interval 0.68-2.25, P=0.491) between IDS and PDS among women with advanced EOC. Conclusions There is a need for a larger prospective multicenter study to further compare the impact of upfront surgical debulking types on the survival of women with advanced EOC in our setting. In the meantime, giving interval debulking surgery after a few courses of neoadjuvant chemotherapy should be an acceptable standard of care for women with advanced EOC.
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Hawarden A, Price M, Russell B, Wilson G, Farrelly L, Embleton-Thirsk A, Parmar M, Edmondson R. A three protein signature fails to externally validate as a biomarker to predict surgical outcome in high-grade epithelial ovarian cancer. PLoS One 2023; 18:e0281798. [PMID: 36952534 PMCID: PMC10035831 DOI: 10.1371/journal.pone.0281798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 01/27/2023] [Indexed: 03/25/2023] Open
Abstract
Introduction For patients with advanced epithelial ovarian cancer, complete surgical cytoreduction remains the strongest predictor of outcome. However, identifying patients who are likely to benefit from such surgery remains elusive and to date few surgical outcome prediction tools have been validated. Here we attempted to externally validate a promising three protein signature, which had previously shown strong association with suboptimal surgical debulking (AUC 0.89, accuracy 92.8%), (Riester, M., et al., (2014)). Methods 238 high-grade epithelial ovarian cancer samples were collected from patients who participated in a large multicentre trial (ICON5). Samples were collected at the time of initial surgery and before randomisation. Surgical outcome data were collated from prospectively collected study records. Immunohistochemical scores were generated by two independent observers for the three proteins in the original signature (POSTN, CXCL14 and pSmad2/3). Predictive values were generated for individual and combination protein signatures. Results When assessed individually, none of the proteins showed any evidence of predictive affinity for suboptimal surgical outcome in our cohort (AUC POSTN 0.55, pSmad 2/3 0.53, CXCL 14 0.62). The combined signature again showed poor predictive ability with an AUC 0.58. Conclusions Despite showing original promise, when this protein signature is applied to a large external cohort, it is unable to accurately predict surgical outcomes. This could be attributed to overfitting of the original model, or differences in surgical practice between cohorts.
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Affiliation(s)
- Amy Hawarden
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, Manchester Academic Health Science Centre, St Mary’s Hospital, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Level 5, Research, Manchester, United Kingdom
| | - Marcus Price
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester, United Kingdom
| | - Bryn Russell
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester, United Kingdom
| | - Godfrey Wilson
- Department of Histopathology, Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Laura Farrelly
- CRUK and UCL Cancer Trials Centre, UCL, London, United Kingdom
| | | | - Mahesh Parmar
- Institute of Clinical Trials and Methodology, UCL, London, United Kingdom
| | - Richard Edmondson
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, St Mary’s Hospital, Manchester, United Kingdom
- Department of Obstetrics and Gynaecology, Manchester Academic Health Science Centre, St Mary’s Hospital, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Level 5, Research, Manchester, United Kingdom
- * E-mail:
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Frankinet L, Bhatt A, Alcazer V, Classe JM, Bereder JM, Meeus P, Pomel C, Mithieux F, Abboud K, Wermert R, Lavoue V, Marchal F, Glehen O, Bakrin N. Role of Hyperthermic Intraperitoneal Chemotherapy Combined with Cytoreductive Surgery as Consolidation Therapy for Advanced Epithelial Ovarian Cancer. Ann Surg Oncol 2023; 30:3287-3299. [PMID: 36820940 DOI: 10.1245/s10434-023-13242-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/28/2022] [Indexed: 02/24/2023]
Abstract
BACKGROUND Patients with advanced epithelial ovarian cancer who undergo incomplete surgery followed by six cycles of chemotherapy could benefit from second-look or consolidation cytoreductive surgery (CCRS). The primary goal of this study was to evaluate the overall survival (OS) in patients undergoing complete CCRS and the factors affecting survival. The secondary goal was to study the benefit of hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients. METHODS This was a retrospective analysis of 173 patients with CCRS with (n = 118) or without (n = 55) HIPEC treated at 12 French centers. Only patients having a completeness of cytoreduction (CC) 0/1 resection and a minimum of 5 years of follow-up were included. HIPEC was performed systematically for all patients except those treated at the four centers that did not perform HIPEC. RESULTS The median Peritoneal Cancer Index was 6 (range 0-33). Closed HIPEC was performed in 59 (34.1%) patients and open HIPEC was performed in 56 (32.3%) patients. Grade 3-4 complications occurred in 64 (36.9%) patients. The median OS was 35.67 months (95% confidence interval [CI] 29.8-46.1) and was significantly longer for CCRS + HIPEC (31.4 months without HIPEC and 42.5 months with HIPEC; p = 0.022). On multivariate analysis, closed HIPEC (hazard ratio [HR] 0.46, 95% CI 0.29-0.73; p < 0.001) resulted in a longer OS, and age > 65 years (HR 2.17, 95% CI 1.14-4.11; p = 0.018) and bowel resection (HR 1.98, 95% CI 1.27-3.08; p = 0.020) led to a shorter OS. On multivariate logistic regression analysis, closed HIPEC (odds ratio 0.18; p = 0.001) was associated with a lower risk of dying at 5 years. CONCLUSIONS CCRS was performed with an acceptable morbidity and resulted in good overall survival. The role of HIPEC in addition to CCRS should be evaluated in prospective, randomized studies and the closed technique prospectively compared with the open technique.
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Affiliation(s)
- Lisa Frankinet
- Department of General Surgery, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France
| | - Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Vincent Alcazer
- Department of Medical Oncology, Centre Hospitalier Lyon Sud, Lyon, France
| | - Jean-Marc Classe
- Department of Surgical Oncology, Centre René Gauducheau, Nantes, France
| | - Jean-Marc Bereder
- Department of Surgical Oncology, Centre Hospitalier L'Archet, Nice, France
| | - Pierre Meeus
- Department of Surgical Oncology, Centre Léon Bérard, Lyon, France
| | - Christophe Pomel
- Department of Surgical Oncology, Centre Jean Perrin, Clermont-Ferrand, France
| | - Francois Mithieux
- Department of Surgical Oncology, Hopital Privé Jean Mermoz, Lyon, France
| | - Karine Abboud
- Department of Surgical Oncology, Hopital Nord St Etienne, St Étienne, France
| | - Romauld Wermert
- Department of Surgical Oncology, Centre Paul Papin, Angers, France
| | - Vincent Lavoue
- Department of Surgical Oncology, Centre Hospitralo-Universitaire Rennes, Rennes, France
| | - Frederic Marchal
- Department of Surgical Oncology, Institut de Cancérologir de Lorraine Alexis Vautrin, Université de Lorraine, Nancy, France
| | - Olivier Glehen
- Department of General Surgery, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France. .,CICLY, Lyon 1 University, Lyon, France.
| | - Naoual Bakrin
- Department of General Surgery, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Lyon, France.,CICLY, Lyon 1 University, Lyon, France
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Dellinger TH. HIPEC in the Consolidation Setting: A Consolation Prize for Chemorefractory Ovarian Cancer? Ann Surg Oncol 2023; 30:3177-3179. [PMID: 36811736 DOI: 10.1245/s10434-023-13263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/06/2023] [Indexed: 02/24/2023]
Affiliation(s)
- Thanh H Dellinger
- Department of Surgery, Division of Gynecologic Oncology, City of Hope National Medical Center (COH), City of Hope Comprehensive Cancer Center, Duarte, CA, USA.
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Bhatt A, Alcazer V, Frankinet L, Bakrin N, Glehen O. ASO Author Reflections: Redefining Consolidation Cytoreductive Surgery for Ovarian Cancer. Ann Surg Oncol 2023; 30:3300-3301. [PMID: 36808321 DOI: 10.1245/s10434-023-13244-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Aditi Bhatt
- Department of Surgical Oncology, Zydus Hospital, Ahmedabad, India
| | - Vincent Alcazer
- Department of Medical Oncology, Centre Hospitalier Lyon-Sud, Lyon, France
| | - Lisa Frankinet
- Department of Surgical Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Lyon, France
| | - Naoual Bakrin
- Department of Surgical Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Lyon, France.,Centre pour l'Innovation en Cancérologie de Lyon (CICLY), Claude Bernard University Lyon 1, Lyon, France
| | - Olivier Glehen
- Department of Surgical Oncology, Hospices Civils de Lyon, Centre Hospitalier Lyon-Sud, Lyon, France. .,Centre pour l'Innovation en Cancérologie de Lyon (CICLY), Claude Bernard University Lyon 1, Lyon, France.
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Bryant A, Johnson E, Grayling M, Hiu S, Elattar A, Gajjar K, Craig D, Vale L, Naik R. Residual Disease Threshold After Primary Surgical Treatment for Advanced Epithelial Ovarian Cancer, Part 1: A Systematic Review and Network Meta-Analysis. Am J Ther 2023; 30:e36-e55. [PMID: 36608071 PMCID: PMC9812425 DOI: 10.1097/mjt.0000000000001584] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We present a systematic review and network meta-analysis (NMA) that is the precursor underpinning the Bayesian analyses that adjust for publication bias, presented in the same edition in AJT. The review assesses optimal cytoreduction for women undergoing primary advanced epithelial ovarian cancer (EOC) surgery. AREAS OF UNCERTAINTY To assess the impact of residual disease (RD) after primary debulking surgery in women with advanced EOC. This review explores the impact of leaving varying levels of primary debulking surgery. DATA SOURCES We conducted a systematic review and random-effects NMA for overall survival (OS) to incorporate direct and indirect estimates of RD thresholds, including concurrent comparative, retrospective studies of ≥100 adult women (18+ years) with surgically staged advanced EOC (FIGO stage III/IV) who had confirmed histological diagnoses of ovarian cancer. Pairwise meta-analyses of all directly compared RD thresholds was previously performed before conducting this NMA, and the statistical heterogeneity of studies within each comparison was evaluated using recommended methods. THERAPEUTIC ADVANCES Twenty-five studies (n = 20,927) were included. Analyses demonstrated the prognostic importance of complete cytoreduction to no macroscopic residual disease (NMRD), with a hazard ratio for OS of 2.0 (95% confidence interval, 1.8-2.2) for <1 cm RD threshold versus NMRD. NMRD was associated with prolonged survival across all RD thresholds. Leaving NMRD was predicted to provide longest survival (probability of being best = 99%). The results were robust to sensitivity analysis including only those studies that adjusted for extent of disease at primary surgery (hazard ratio 2.3, 95% confidence interval, 1.9-2.6). The overall certainty of evidence was moderate and statistical adjustment of effect estimates in included studies minimized bias. CONCLUSIONS The results confirm a strong association between complete cytoreduction to NMRD and improved OS. The NMA approach forms part of the methods guidance underpinning policy making in many jurisdictions. Our analyses present an extension to the previous work in this area.
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Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eugenie Johnson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael Grayling
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ahmed Elattar
- Pan-Birmingham Gynaecological Oncology Cancer Centre, Birmingham, United Kingdom
| | - Ketankumar Gajjar
- Nottingham City hospital, Obstetrics and Gynaecology, Nottingham, United Kingdom; and
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Raj Naik
- Northern Gynaecological Oncology Centre, Gateshead, United Kingdom
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Droste A, Anic K, Hasenburg A. Laparoscopic Surgery for Ovarian Neoplasms - What is Possible, What is Useful? Geburtshilfe Frauenheilkd 2022; 82:1368-1377. [PMID: 36467976 PMCID: PMC9715350 DOI: 10.1055/a-1787-9144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Annika Droste
- 611615Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany,Korrespondenzadresse Dr. med. univ. Annika Droste Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Klinik und Poliklinik für
Geburtshilfe und FrauengesundheitLangenbeckstraße 155131
MainzGermany
| | - Katharina Anic
- 611615Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany
| | - Annette Hasenburg
- 611615Department of Gynecology and Obstetrics, University Medical Center Mainz, Mainz, Germany
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Liu X, Zhao Y, Jiao X, Yu Y, Li R, Zeng S, Chi J, Ma G, Huo Y, Li M, Peng Z, Liu J, Zhou Q, Zou D, Wang L, Li Q, Wang J, Yao S, Chen Y, Ma D, Hu T, Gao Q. Does the primary treatment sequence affect post-relapse survival in recurrent epithelial ovarian cancer? A real-world multicentre retrospective study. BJOG 2022; 129 Suppl 2:70-78. [PMID: 36485065 DOI: 10.1111/1471-0528.17329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To explore the impact of the primary treatment sequence (primary debulking surgery, PDS, versus neoadjuvant chemotherapy and interval debulking surgery, NACT-IDS) on post-relapse survival (PRS) and recurrence characteristics of recurrent epithelial ovarian cancer (REOC). DESIGN Real-world retrospective study. SETTING Tertiary hospitals in China. POPULATION A total of 853 patients with REOC at International Federation of Gynaecology and Obstetrics stages IIIC-IV from September 2007 to June 2020. Overall, 377 and 476 patients received NACT-IDS and PDS, respectively. METHODS Propensity score-based inverse probability of treatment weighting (IPTW) was performed to balance the between-group differences. MAIN OUTCOME MEASURES Clinicopathological factors related to PRS. RESULTS The overall median PRS was 29.3 months (95% CI 27.0-31.5 months). Multivariate analysis before and after IPTW adjustment showed that NACT-IDS and residual R1/R2 disease were independent risk factors for PRS (p < 0.05). Patients with diffuse carcinomatosis and platinum-free interval (PFI) ≤ 12 months had a significantly worse PRS (p < 0.001). Logistic regression analysis revealed that NACT-IDS was an independent risk factor for diffuse carcinomatosis (OR 1.36, 95% CI 1.01-1.82, p = 0.040) and PFI ≤ 12 months (OR 1.59, 95% CI 1.08-2.35, p = 0.019). In IPTW analysis, NACT-IDS was still significantly associated with diffuse carcinomatosis (OR 1.29, 95% CI 1.05-1.58, p = 0.015) and PFI ≤ 12 months (OR 1.90, 95% CI 1.52-2.38, p < 0.001). CONCLUSIONS The primary treatment sequence may affect the PRS of patients with REOC by altering the recurrence pattern and PFI duration.
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Affiliation(s)
- Xingyu Liu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yingjun Zhao
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofei Jiao
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang Yu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ruyuan Li
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shaoqing Zeng
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianhua Chi
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Guanchen Ma
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yabing Huo
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ming Li
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zikun Peng
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jiahao Liu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qi Zhou
- Department of Gynecologic Oncology, Chongqing University Cancer Hospital, Chongqing, China.,Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Dongling Zou
- Department of Gynecologic Oncology, Chongqing University Cancer Hospital, Chongqing, China.,Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Li Wang
- Department of Cancer Biology Immunotherapy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Qingshui Li
- Department of Gynecologic Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Jing Wang
- Hunan Clinical Research Center in Gynecologic Cancer, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China.,Department of Gynecologic Cancer, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Shuzhong Yao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Youguo Chen
- Department of Gynecology & Obstetrics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Ding Ma
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ting Hu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qinglei Gao
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.,National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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11
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Metser U, Kulanthaivelu R, Chawla T, Johnson S, Avery L, Hussey D, Veit-Haibach P, Bernardini M, Hogen L. 18F-DCFPyL PET/CT in advanced high-grade epithelial ovarian cancer: A prospective pilot study. Front Oncol 2022; 12:1025475. [PMID: 36313720 PMCID: PMC9606351 DOI: 10.3389/fonc.2022.1025475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/26/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Glutamate carboxypeptidase-II (GCP-II), a zinc metalloenzyme that resides in cell membrane, has been reported as overexpressed in the neovasculature of ovarian cancers. The study objective was to determine whether GCP-II targeted imaging with 18F-DCFPyL PET/CT can detect disease sites in women with advanced high-grade serous ovarian cancer (HGSOC). Materials and methods Twenty treatment-naïve women with advanced HGSOC were recruited (median age 60 years). Prior to commencing therapy (primary cytoreductive surgery [n=9] or neoadjuvant chemotherapy [n=11]), subjects underwent routine staging with contrast-enhanced abdominopelvic CT (=CT), followed by 18F-DCFPyL PET/CT (=PET). CT and PET were reported independently using a standardized reporting template assessing 25 sites. The performance of PET was compared to CT in all subjects and to surgery and surgical histopathology in 9 patients who underwent primary cytoreductive surgery. Results Of the 25 sites assessed in 20 patients, CT detected disease in 292/500 (58.4%) locations and PET detected disease in 171/500 (34.2%). Compared to CT the sensitivity (95% CI) of PET to detect disease in the upper abdomen, the gastrointestinal tract or the peritoneum was 0.29 (0.20,0.40), 0.21 (0.11,0.33) and 0.74 (0.64,0.82), respectively. In the surgical cohort, 220 sites in 9 patients were evaluated. The sensitivity and specificity of CT and PET were 0.85 versus 0.54 (p<0.001) and 0.73 versus 0.93 (p<0.001), respectively. Conclusion Although 18F-DCFPyL has higher specificity than CT in detecting advanced HGSOC tumor sites, it detects less disease sites than CT, especially in the upper abdomen and along the gastrointestinal tract, likely limiting its clinical utility. Clinical trial registration ClinicalTrials.gov, NCT03811899.
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Affiliation(s)
- Ur Metser
- Joint Department of Medical Imaging, University Health Network, Sinai Health Systems, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
- *Correspondence: Ur Metser,
| | - Roshini Kulanthaivelu
- Joint Department of Medical Imaging, University Health Network, Sinai Health Systems, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Tanya Chawla
- Joint Department of Medical Imaging, University Health Network, Sinai Health Systems, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Sarah Johnson
- Joint Department of Medical Imaging, University Health Network, Sinai Health Systems, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Lisa Avery
- Department of Biostatistics, University Health Network, Toronto, ON, Canada
| | - Douglas Hussey
- Joint Department of Medical Imaging, University Health Network, Sinai Health Systems, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Patrick Veit-Haibach
- Joint Department of Medical Imaging, University Health Network, Sinai Health Systems, Women’s College Hospital, University of Toronto, Toronto, ON, Canada
| | - Marcus Bernardini
- Division of Gynecologic Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Liat Hogen
- Division of Gynecologic Oncology, University Health Network, University of Toronto, Toronto, ON, Canada
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12
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Bryant A, Hiu S, Kunonga PT, Gajjar K, Craig D, Vale L, Winter-Roach BA, Elattar A, Naik R. Impact of residual disease as a prognostic factor for survival in women with advanced epithelial ovarian cancer after primary surgery. Cochrane Database Syst Rev 2022; 9:CD015048. [PMID: 36161421 PMCID: PMC9512080 DOI: 10.1002/14651858.cd015048.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Ovarian cancer is the seventh most common cancer among women and a leading cause of death from gynaecological malignancies. Epithelial ovarian cancer is the most common type, accounting for around 90% of all ovarian cancers. This specific type of ovarian cancer starts in the surface layer covering the ovary or lining of the fallopian tube. Surgery is performed either before chemotherapy (upfront or primary debulking surgery (PDS)) or in the middle of a course of treatment with chemotherapy (neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS)), with the aim of removing all visible tumour and achieving no macroscopic residual disease (NMRD). The aim of this review is to investigate the prognostic impact of size of residual disease nodules (RD) in women who received upfront or interval cytoreductive surgery for advanced (stage III and IV) epithelial ovarian cancer (EOC). OBJECTIVES To assess the prognostic impact of residual disease after primary surgery on survival outcomes for advanced (stage III and IV) epithelial ovarian cancer. In separate analyses, primary surgery included both upfront primary debulking surgery (PDS) followed by adjuvant chemotherapy and neoadjuvant chemotherapy followed by interval debulking surgery (IDS). Each residual disease threshold is considered as a separate prognostic factor. SEARCH METHODS We searched CENTRAL (2021, Issue 8), MEDLINE via Ovid (to 30 August 2021) and Embase via Ovid (to 30 August 2021). SELECTION CRITERIA We included survival data from studies of at least 100 women with advanced EOC after primary surgery. Residual disease was assessed as a prognostic factor in multivariate prognostic models. We excluded studies that reported fewer than 100 women, women with concurrent malignancies or studies that only reported unadjusted results. Women were included into two distinct groups: those who received PDS followed by platinum-based chemotherapy and those who received IDS, analysed separately. We included studies that reported all RD thresholds after surgery, but the main thresholds of interest were microscopic RD (labelled NMRD), RD 0.1 cm to 1 cm (small-volume residual disease (SVRD)) and RD > 1 cm (large-volume residual disease (LVRD)). DATA COLLECTION AND ANALYSIS Two review authors independently abstracted data and assessed risk of bias. Where possible, we synthesised the data in meta-analysis. To assess the adequacy of adjustment factors used in multivariate Cox models, we used the 'adjustment for other prognostic factors' and 'statistical analysis and reporting' domains of the quality in prognosis studies (QUIPS) tool. We also made judgements about the certainty of the evidence for each outcome in the main comparisons, using GRADE. We examined differences between FIGO stages III and IV for different thresholds of RD after primary surgery. We considered factors such as age, grade, length of follow-up, type and experience of surgeon, and type of surgery in the interpretation of any heterogeneity. We also performed sensitivity analyses that distinguished between studies that included NMRD in RD categories of < 1 cm and those that did not. This was applicable to comparisons involving RD < 1 cm with the exception of RD < 1 cm versus NMRD. We evaluated women undergoing PDS and IDS in separate analyses. MAIN RESULTS We found 46 studies reporting multivariate prognostic analyses, including RD as a prognostic factor, which met our inclusion criteria: 22,376 women who underwent PDS and 3697 who underwent IDS, all with varying levels of RD. While we identified a range of different RD thresholds, we mainly report on comparisons that are the focus of a key area of clinical uncertainty (involving NMRD, SVRD and LVRD). The comparison involving any visible disease (RD > 0 cm) and NMRD was also important. SVRD versus NMRD in a PDS setting In PDS studies, most showed an increased risk of death in all RD groups when those with macroscopic RD (MRD) were compared to NMRD. Women who had SVRD after PDS had more than twice the risk of death compared to women with NMRD (hazard ratio (HR) 2.03, 95% confidence interval (CI) 1.80 to 2.29; I2 = 50%; 17 studies; 9404 participants; moderate-certainty). The analysis of progression-free survival found that women who had SVRD after PDS had nearly twice the risk of death compared to women with NMRD (HR 1.88, 95% CI 1.63 to 2.16; I2 = 63%; 10 studies; 6596 participants; moderate-certainty). LVRD versus SVRD in a PDS setting When we compared LVRD versus SVRD following surgery, the estimates were attenuated compared to NMRD comparisons. All analyses showed an overall survival benefit in women who had RD < 1 cm after surgery (HR 1.22, 95% CI 1.13 to 1.32; I2 = 0%; 5 studies; 6000 participants; moderate-certainty). The results were robust to analyses of progression-free survival. SVRD and LVRD versus NMRD in an IDS setting The one study that defined the categories as NMRD, SVRD and LVRD showed that women who had SVRD and LVRD after IDS had more than twice the risk of death compared to women who had NMRD (HR 2.09, 95% CI 1.20 to 3.66; 310 participants; I2 = 56%, and HR 2.23, 95% CI 1.49 to 3.34; 343 participants; I2 = 35%; very low-certainty, for SVRD versus NMRD and LVRD versus NMRD, respectively). LVRD versus SVRD + NMRD in an IDS setting Meta-analysis found that women who had LVRD had a greater risk of death and disease progression compared to women who had either SVRD or NMRD (HR 1.60, 95% CI 1.21 to 2.11; 6 studies; 1572 participants; I2 = 58% for overall survival and HR 1.76, 95% CI 1.23 to 2.52; 1145 participants; I2 = 60% for progression-free survival; very low-certainty). However, this result is biased as in all but one study it was not possible to distinguish NMRD within the < 1 cm thresholds. Only one study separated NMRD from SVRD; all others included NMRD in the SVRD group, which may create bias when comparing with LVRD, making interpretation challenging. MRD versus NMRD in an IDS setting Women who had any amount of MRD after IDS had more than twice the risk of death compared to women with NMRD (HR 2.11, 95% CI 1.35 to 3.29, I2 = 81%; 906 participants; very low-certainty). AUTHORS' CONCLUSIONS In a PDS setting, there is moderate-certainty evidence that the amount of RD after primary surgery is a prognostic factor for overall and progression-free survival in women with advanced ovarian cancer. We separated our analysis into three distinct categories for the survival outcome including NMRD, SVRD and LVRD. After IDS, there may be only two categories required, although this is based on very low-certainty evidence, as all but one study included NMRD in the SVRD category. The one study that separated NMRD from SVRD showed no improved survival outcome in the SVRD category, compared to LVRD. Further low-certainty evidence also supported restricting to two categories, where women who had any amount of MRD after IDS had a significantly greater risk of death compared to women with NMRD. Therefore, the evidence presented in this review cannot conclude that using three categories applies in an IDS setting (very low-certainty evidence), as was supported for PDS (which has convincing moderate-certainty evidence).
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Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Shaun Hiu
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Patience T Kunonga
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ketankumar Gajjar
- Department of Gynaecological Oncology, 1st Floor Maternity Unit, City Hospital Campus, Nottingham, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Brett A Winter-Roach
- The Department of Surgery, Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Ahmed Elattar
- City Hospital & Birmingham Treatment Centre, Birmingham, UK
| | - Raj Naik
- Gynaecological Oncology, Northern Gynaecological Oncology Centre, Gateshead, UK
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13
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Christou C, Krouskou SE, Koutras A, Ntounis T, Fasoulakis Z, Valsamaki A, Pergialiotis V, Sotiriou S, Konis K, Symeonidis P, Samara AA, Pagkalos A, Chionis A, Daskalakis G, Kontomanolis EN. The Significance of Peritoneal Washing as a Prognostic Indicator for Ovarian Cancer Patients. CANCER DIAGNOSIS & PROGNOSIS 2022; 2:512-519. [PMID: 36060022 PMCID: PMC9425574 DOI: 10.21873/cdp.10135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 07/25/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND/AIM During ovarian cancer (OC) debulking surgery, the surgeon can examine the peritoneal cavity for malignant cancer cells with peritoneal washing (PW) cytology. The goal of this study was to examine the significance of peritoneal washing as a prognostic indicator for ovarian cancer patients. PATIENTS AND METHODS Information considering the prognostic factors of OC and their impact in PW's result was collected, compared, and combined. RESULTS Omental metastasis, tumor type, tumor invasion, tumor size, tumor grade/ stage, tumor's cytoreduction, and recurrence affect both the peritoneal washing result and the patient's prognosis. The correlation that most of the above factors have with a positive PW and dismal prognosis, led us to the assumption that PW has a significance as a prognostic indicator. CONCLUSION The significance of PW as a prognostic indicator remains an assumption.
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Affiliation(s)
- Christina Christou
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece
| | | | - Antonios Koutras
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Thomas Ntounis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Zacharias Fasoulakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Asimina Valsamaki
- Department of Internal Medicine, General Hospital of Larisa, Larissa, Greece
| | - Vasilios Pergialiotis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Sotirios Sotiriou
- Department of Embryology, University Hospital of Thessaly, Larissa, Greece
| | - Kyriakos Konis
- Department of Obstetrics and Gynecology, General Hospital of Arta, Arta, Greece
| | | | - Athina A Samara
- Department of Embryology, University Hospital of Thessaly, Larissa, Greece
| | - Athanasios Pagkalos
- Department of Obstetrics and Gynecology, General Hospital of Xanthi, Xanthi, Greece
| | - Athanasios Chionis
- Department of Obstetrics and Gynecology, Laiko General hospital of Athens, Athens, Greece
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, General Hospital of Athens 'ALEXANDRA', Athens, Greece
| | - Emmanuel N Kontomanolis
- Department of Obstetrics and Gynecology, Democritus University of Thrace, Alexandroupolis, Greece
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14
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Nikolaidi A, Fountzilas E, Fostira F, Psyrri A, Gogas H, Papadimitriou C. Neoadjuvant treatment in ovarian cancer: New perspectives, new challenges. Front Oncol 2022; 12:820128. [PMID: 35957909 PMCID: PMC9360510 DOI: 10.3389/fonc.2022.820128] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 07/01/2022] [Indexed: 11/13/2022] Open
Abstract
Ovarian cancer remains the leading cause of death from gynecological cancer. Survival is significantly related to the stage of the disease at diagnosis. Of quite importance is primary cytoreductive surgery, having as a goal to remove all visible tumor tissue, and is the standard primary treatment in combination with platinum-based chemotherapy for patients with advanced ovarian carcinoma. Neo-adjuvant chemotherapy (NACT) has been implemented mostly in treating advanced disease, with studies performed having numerous limitations. Data extrapolated from these studies have not shown inferiority survival of NACT, compared to primary debulking surgery. The role of NACT is of particular interest because of the intrinsic mechanisms that are involved in the process, which can be proven as therapeutic approaches with enormous potential. NACT increases immune infiltration and programmed death ligand-1 (PDL-1) expression, induces local immune activation, and can potentiate the immunogenicity of immune-exclude high grade serous ovarian tumors, while the combination of NACT with bevacizumab, PARP inhibitors or immunotherapy remains to be evaluated. This article summarizes all available data on studies implementing NACT in the treatment of ovarian cancer, focusing on clinical outcomes and study limitations. High mortality rates observed among ovarian cancer patients necessitates the identification of more effective treatments, along with biomarkers that will aid treatment individualization.
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Affiliation(s)
- Adamantia Nikolaidi
- Oncology Department, Private General Maternity, Gynecological and Pediatric Clinic “MITERA“ Hospital, Athens, Greece
- *Correspondence: Adamantia Nikolaidi,
| | - Elena Fountzilas
- Second Department of Medical Oncology, Euromedica General Clinic of Thessaloniki, Thessaloniki, Greece
- European University Cyprus, Engomi, Cyprus
| | - Florentia Fostira
- Molecular Diagnostics Laboratory, National Centre for Scientific Research ‘Demokritos’, Athens, Greece
| | - Amanda Psyrri
- Section of Medical Oncology, Department of Internal Medicine, “Attikon” Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Helen Gogas
- First Department of Medicine, ‘Laiko’ General Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Christos Papadimitriou
- Oncology Unit, Second Department of Surgery, “Aretaieion” University Hospital, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
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15
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Cummings M, Nicolais O, Shahin M. Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction. Diagnostics (Basel) 2022; 12:988. [PMID: 35454036 PMCID: PMC9026414 DOI: 10.3390/diagnostics12040988] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/07/2022] [Accepted: 04/08/2022] [Indexed: 12/01/2022] Open
Abstract
Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials-CHORUS, JCOG0602, and SCORPION-have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.
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Affiliation(s)
- Mackenzie Cummings
- Department of Obstetrics and Gynecology, Jefferson Abington Hospital, Abington, PA 19001, USA; (M.C.); (O.N.)
| | - Olivia Nicolais
- Department of Obstetrics and Gynecology, Jefferson Abington Hospital, Abington, PA 19001, USA; (M.C.); (O.N.)
| | - Mark Shahin
- Asplundh Cancer Pavilion, Sidney Kimmel Cancer Center, Hanjani Institute for Gynecologic Oncology, Thomas Jefferson University, Willow Grove, PA 19090, USA
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16
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Management of inoperable endometrial cancer. Obstet Gynecol Sci 2022; 65:303-316. [PMID: 35345085 PMCID: PMC9304437 DOI: 10.5468/ogs.21219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 03/07/2022] [Indexed: 11/08/2022] Open
Abstract
Some endometrial cancer (EMC) patients are not good candidates for primary surgery. The three major types of treatment for inoperable EMC are radiation therapy, chemotherapy, or their combination as neoadjuvant treatment before surgery. Radiation therapy alone (of different modes) has been used as the sole definitive therapeutic modality, particularly for early-stage disease that is limited to the uterine body and cervix with or without parametrial invasion. The most common treatment modality is neoadjuvant treatment before surgery. Postoperative adjuvant treatment is also occasionally used, depending mainly on the sites of the disease and the results of surgery. Data on neoadjuvant hormonal or radiation therapy are limited, with studies focusing on laboratory outcomes or having only a small number of patients. Most neoadjuvant treatments before surgery involved chemotherapy and fewer combined chemoradiotherapy. Surgery was generally performed, particularly in patients who had shown responses or at least stable disease to neoadjuvant treatment. Perioperative outcomes after neoadjuvant treatment were superior to those after primary surgery, whereas survival data were still inconsistent. Features that had or tended to have a favorable prognosis were younger age, early-stage disease, response to neoadjuvant treatment, low preoperative cancer antigen-125 level, and optimal surgery. Among different modalities of neoadjuvant treatment, which has become a frequent mode of treatment, neoadjuvant chemotherapy was more common than radiation therapy alone or chemoradiation.
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17
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Classe JM, Ferron G, Ouldamer L, Gauthier T, Emambux S, Gladieff L, Dupre PF, Anota A. CHRONO: randomized trial of the CHROnology of surgery after Neoadjuvant chemotherapy for Ovarian cancer. Int J Gynecol Cancer 2022; 32:1071-1075. [PMID: 35321888 DOI: 10.1136/ijgc-2021-003320] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND In patients treated for advanced ovarian cancer not suitable for complete primary surgery, interval surgery after three courses of neoadjuvant chemotherapy has been considered standard management since the EORTC randomized trial published in 2010. An alternative approach with delayed surgery after six courses of neoadjuvant chemotherapy was reported in retrospective series. PRIMARY OBJECTIVES To assess the efficacy on progression free survival of interval cytoreduction surgery after three cycles of neoadjuvant chemotherapy compared with delayed surgery after six cycles of neoadjuvant chemotherapy. STUDY HYPOTHESIS In women with ovarian cancer not suitable for primary surgical cytoreduction, surgery after six cycles of neoadjuvant chemotherapy will prove better disease-free survival than cytoreductive surgery after only three cycles. TRIAL DESIGN CHRONO is a multicenter, randomized phase III trial. After three courses of neoadjuvant chemotherapy, eligible patients will be randomized (1:1) to either completion surgery followed by an additional five cycles of chemotherapy (control arm) or an additional three cycles of neoadjuvant chemotherapy followed by completion surgery and then two additional cycles of chemotherapy (experimental arm). Patients in both groups will receive eight total cycles of chemotherapy. MAJOR INCLUSION/EXCLUSION CRITERIA The main inclusion criteria are histologically confirmed epithelial high-grade serous or endometrioid ovarian cancer, documented FIGO stage IIIB-IVA unsuitable for complete primary surgery but considered resectable after three courses of neoadjuvant chemotherapy. The main exclusion criteria are mucinous, clear cell, carcinosarcoma, or low-grade serous histologies. PRIMARY ENDPOINT The primary endpoint is progression-free survival. SAMPLE SIZE 210 eligible patients ESTIMATED DATES FOR COMPLETING ACCRUAL AND PRESENTING RESULTS: The estimated date for completing accrual will be Q2 2023. The estimated date for presentation of the first results is Q3 2028. TRIAL REGISTRATION NUMBER NCT03579394.
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Affiliation(s)
- Jean-Marc Classe
- Department of Surgical Oncology, Institut de Cancerologie de l'Ouest, Saint Herblain, France
| | - Gwennael Ferron
- Department of Surgical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, Toulouse, France
| | - Lobna Ouldamer
- Department of Gynecology, Centre Hospitalier Régional Universitaire de Tours, Tours, France
| | - Tristan Gauthier
- Department of Obstetrics and Gynecology, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Sheik Emambux
- Department of Medical Oncology, Centre Hospitalier Universitaire, Poitiers, France
| | - Laurence Gladieff
- Department of Medical Oncology, Institut Claudius Regaud, Institut Universitaire du Cancer, Toulouse, France
| | - Pierre-Francois Dupre
- Department of Gynecology and Surgery, Centre Hospitalier Universitaire, Brest, France
| | - Amélie Anota
- Department of Biostatistics, Centre Leon Berard, Lyon, France
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18
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Houvenaeghel G, de Nonneville A, Blache G, Buttarelli M, Jauffret C, Mokart D, Sabiani L. Posterior pelvic exenteration for ovarian cancer: surgical and oncological outcomes. J Gynecol Oncol 2022; 33:e31. [PMID: 35320883 PMCID: PMC9024184 DOI: 10.3802/jgo.2022.33.e31] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/08/2021] [Accepted: 01/02/2022] [Indexed: 12/24/2022] Open
Abstract
Objective Posterior pelvic exenteration (PPE) can be required to achieve complete resection in ovarian cancer (OC) patients with large pelvic disease. This study aimed to analyze morbidity, complete resection rate, and survival of PPE. Methods Ninety patients who underwent PPE in our Comprehensive Cancer Center between January 2010 and February 2021 were retrospectively identified. To analyze practice evolution, 2 periods were determined: P1 from 2010 to 2017 and P2 from 2018 to 2021. Results A 82.2% complete resection rate after PPE was obtained, with rectal anastomosis in 96.7% of patients. Complication rate was at 30% (grade 3 in 9 patients), without significant difference according to periods or quality of resection. In a binary logistic regression adjusted on age and stoma, only age of 51–74 years old was associated with a lower rate of complication (odds ratio=0.223; p=0.026). Median overall and disease-free survivals (OS and DFS) from initial diagnosis were 75.21 and 29.84 months, respectively. A negative impact on OS and DFS was observed in case of incomplete resection, and on DFS in case of final cytoreductive surgery (FCS: after ≥6 chemotherapy cycles). Age ≥75-years had a negative impact on DFS for new OC surgery. For patients with complete resection, OS and DFS were decreased in case of interval cytoreductive surgery and FCS in comparison with primary cytoreductive surgery. Conclusion PPE is an effective surgical measure to achieve complete resection for a majority of patients. High rate of colorectal anastomosis was achieved without any mortality, with acceptable morbidity and high protective stoma rate. Posterior-pelvic-exenteration (PPE) can be required to achieve complete cyto-reductive-surgery (CS) in ovarian cancer (OC) patients. A 82.2% complete-CS rate was obtained for PPE, with rectal anastomosis in 96.7%. Complication rate was 30%. Negative impact on DFS for patients with incomplete-CS or final-CS or age ≥75-years for new OC and PPE.
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Affiliation(s)
- Gilles Houvenaeghel
- Institut Paoli Calmettes, Department of Surgical Oncology, Marseille, France
- Faculty of Medical Sciences, Aix-Marseille University, CNRS, Inserm, CRCM, Marseille, France
| | | | - Guillaume Blache
- Institut Paoli Calmettes, Department of Surgical Oncology, Marseille, France
| | - Max Buttarelli
- Institut Paoli Calmettes, Department of Surgical Oncology, Marseille, France
| | - Camille Jauffret
- Institut Paoli Calmettes, Department of Surgical Oncology, Marseille, France
| | - Djamel Mokart
- Institut Paoli Calmettes, Department of Anesthesiology and Critical Care, Marseille, France
| | - Laura Sabiani
- Institut Paoli Calmettes, Department of Surgical Oncology, Marseille, France
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High Density of CD16+ Tumor-Infiltrating Immune Cells in Recurrent Ovarian Cancer Is Associated with Enhanced Responsiveness to Chemotherapy and Prolonged Overall Survival. Cancers (Basel) 2021; 13:cancers13225783. [PMID: 34830938 PMCID: PMC8616362 DOI: 10.3390/cancers13225783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/10/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022] Open
Abstract
Simple Summary The late—and in most cases at an advanced stage—diagnosis of patients with ovarian cancer (OC) and the high recurrence rate make this malignant disease the most lethal among gynecological cancers. With a mortality-to-incidence ratio of 0.74, OC is a tumor with the fifth most frequent progression after esophageal cancer, liver cancer, pancreatic cancer, and brain tumors. The updated FIGO staging system is the gold standard in the clinic and includes surgical, radiologic, and pathologic elements to describe the extent of OC. This system is used to describe tumor extent, plan further therapy, and predict prognosis. However, it is consistently observed that patients with identical stages and treatments have a completely different outcome in terms of survival and recurrence. This fact indicates that this classification alone is not sufficient for the prognosis of OC in the vast majority of cases. Over the last two decades, many studies have demonstrated the critical role of the tumor microenvironment in tumorigenesis, progression, prognosis, and response to chemotherapy. In the current study, we investigate the role of CD16 expression in OC. Abstract Background: Ovarian cancer (OC) is the most aggressive and fatal malignancy of the female reproductive system. Debulking surgery with adjuvant chemotherapy represents the standard treatment, but recurrence rates are particularly high. Over the past decades, the association between the immune system and cancer progression has been extensively investigated. However, the interaction between chemotherapy and cancer immune infiltration is still unclear. In this study, we examined the prognostic role of CD16 expression in OC, as related to the effectiveness of standard adjuvant chemotherapy treatment. Methods: We analyzed the infiltration by immune cells expressing CD16, a well-characterized natural killer (NK) and myeloid cell marker, in a tissue microarray (TMA) of 47 patient specimens of primary OCs and their matching recurrences by immunohistochemistry (IHC). We analyzed our data first in the whole cohort, then in the primary tumors, and finally in recurrences. We focused on recurrence-free survival (RFS), overall survival (OS), and chemosensitivity. Chemosensitivity was defined as RFS of more than 6 months. Results: There was no significant correlation between CD16 expression and prognosis in primary carcinomas. However, interestingly, a high density of CD16-expressing tumor-infiltrating immune cells (TICs) in recurrent carcinoma was associated with better RFS (p = 0.008) and OS (p = 0.029). Moreover, high CD16 cell density in recurrent ovarian carcinoma showed a significant association with chemosensitivity (p = 0.034). Univariate Cox regression analysis revealed that the high expression of CD16+ TIC in recurrent cancer biopsies is significantly associated with an increased RFS (HR = 0.49; 95% CI 0.24–0.99; p = 0.047) and OS (HR = 0.28; 95% CI 0.10–0.77; p = 0.013). However, this was not independent of known prognostic factors such as age, FIGO stage, resection status, and the number of chemotherapy cycles. Conclusions: The high density of CD16-expressing TICs in recurrent ovarian cancer is associated with a better RFS and OS, thereby suggesting a previously unsuspected interaction between standard OC chemotherapy and immune cell infiltration.
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20
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Harrison R, Zighelboim I, Cloven NG, Marcus JZ, Coleman RL, Karam A. Secondary cytoreductive surgery for recurrent ovarian cancer: An SGO clinical practice statement. Gynecol Oncol 2021; 163:448-452. [PMID: 34686355 DOI: 10.1016/j.ygyno.2021.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- R Harrison
- Department of Gynecologic Oncology & Reproductive Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - I Zighelboim
- Division of Gynecologic Oncology and Department of Obstetrics and Gynecology, St. Luke's University Health Network, Bethlehem, PA, USA
| | - N G Cloven
- Gynecologist Oncologist, Texas Oncology, Fort Worth Cancer Center, Fort Worth, TX, USA
| | - J Z Marcus
- Rutgers, New Jersey Medical School, Department of Obstetrics, Gynecology and Reproductive Health, Newark, NJ, USA
| | - R L Coleman
- Gynecologic Oncology, US Oncology & US Oncology Research, The Woodlands, TX, USA
| | - A Karam
- Stanford School of Medicine, Stanford, CA, USA.
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21
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Bryant A, Hiu S, Kunonga P, Gajjar K, Craig D, Vale L, Winter-Roach BA, Elattar A, Naik R. Impact of residual disease as a prognostic factor for survival in women with advanced epithelial ovarian cancer after primary surgery. Cochrane Database Syst Rev 2021. [DOI: 10.1002/14651858.cd015048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Andrew Bryant
- Population Health Sciences Institute; Newcastle University; Newcastle upon Tyne UK
| | - Shaun Hiu
- Population Health Sciences Institute; Newcastle University; Newcastle upon Tyne UK
| | - Patience Kunonga
- Population Health Sciences Institute; Newcastle University; Newcastle upon Tyne UK
| | - Ketankumar Gajjar
- Department of Gynaecological Oncology; 1st Floor Maternity Unit, City Hospital Campus; Nottingham UK
| | - Dawn Craig
- Population Health Sciences Institute; Newcastle University; Newcastle upon Tyne UK
| | - Luke Vale
- Population Health Sciences Institute; Newcastle University; Newcastle upon Tyne UK
| | - Brett A Winter-Roach
- The Department of Surgery; Christie Hospital NHS Foundation Trust; Manchester UK
| | - Ahmed Elattar
- City Hospital & Birmingham Treatment Centre; Birmingham UK
| | - Raj Naik
- Gynaecological Oncology; Northern Gynaecological Oncology Centre; Gateshead UK
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22
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De Pauw A, Naert E, Van de Vijver K, Philippe T, Vandecasteele K, Denys H. A CLEARER VIEW ON OVARIAN CLEAR CELL CARCINOMA. Acta Clin Belg 2021; 77:792-804. [PMID: 34404331 DOI: 10.1080/17843286.2021.1964051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Ovarian clear cell carcinoma (OCCC) is a less common subtype accounting for approximately 5% of all epithelial ovarian cancers (EOCs). Clinical experience and research findings confirm the remarkable differences in clinical behavior, molecular alterations and pathogenesis of OCCC. The diagnosis of OCCC is typically set at a younger age, and earlier stage and in a background of endometriosis.Results: Molecularly, OCCCs rarely harbor BRCA1/BRCA2 mutations and have fewer copy number variants (CNVs). The most common molecular changes occur in the SWI/SNF chromatin remodeling complex genes, the PI3K/AKT signaling pathway and the receptor tyrosine kinase (RTK)/Ras signaling pathway.Five-year disease-specific survival of patients with OCCC is worse compared to high grade serous carcinomas (HGSOC). The current treatment options for OCCC are based on studies that included patients with predominantly HGSOC and only a minor proportion of cancers with clear cell histology. In order to improve outcomes for patients with OCCC, research should be specific for this subtype.Discussion: As the available information about the specific characteristics of OCCC is increasing, especially at a molecular level, it should be possible to continuously improve the specific diagnostics and treatment. Since OCCC is so rare, it is essential to collect new evidence at an international level. To avoid extrapolation from EOC trials with possible erroneous conclusions, patients should always be encouraged to participate in specific histological trials and basket trials, while paying extra attention to OCCC-like subtypes.
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Affiliation(s)
- Aglaja De Pauw
- Department of Internal Medicine and Pediatrics, Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Eline Naert
- Department of Internal Medicine and Pediatrics, Medical Oncology, Ghent University Hospital, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
| | - Koen Van de Vijver
- Department of Diagnostic Sciences, Pathology, Ghent University Hospital, Ghent, Belgium
| | - Tummers Philippe
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
- Department of Human Structure and Repair, Gynecology, Gent University Hospital, Ghent, Belgium
| | - Katrien Vandecasteele
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
- Department of Human Structure and Repair, Radiation Therapy, Ghent University Hospital, Ghent, Belgium
| | - Hannelore Denys
- Department of Internal Medicine and Pediatrics, Medical Oncology, Ghent University Hospital, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent, Belgium
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23
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Neoadjuvant chemotherapy before surgery versus surgery followed by chemotherapy for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 7:CD005343. [PMID: 34328210 PMCID: PMC8406953 DOI: 10.1002/14651858.cd005343.pub6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require a combination of surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases up to 9 October 2020: the Cochrane Central Register of Controlled Trials (CENTRAL), Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. We extracted data of overall (OS) and progression-free survival (PFS), adverse events, surgically-related mortality and morbidity and quality of life outcomes. We used GRADE methods to determine the certainty of evidence. MAIN RESULTS We identified 2227 titles and abstracts through our searches, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1774 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the four studies where data were available and found little or no difference with regard to overall survival (OS) (Hazard Ratio (HR) 0.96, 95% CI 0.86 to 1.08; participants = 1692; studies = 4; high-certainty evidence) or progression-free survival in four trials where we were able to pool data (Hazard Ratio 0.98, 95% CI 0.88 to 1.08; participants = 1692; studies = 4; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were variably and incompletely reported across studies. There are probably clinically meaningful differences in favour of NACT compared to PDS with regard to overall postoperative serious adverse effects (SAE grade 3+): 6% in NACT group, versus 29% in PDS group, (risk ratio (RR) 0.22, 95% CI 0.13 to 0.38; participants = 435; studies = 2; heterogeneity index (I2) = 0%; moderate-certainty evidence). NACT probably results in a large reduction in the need for stoma formation: 5.9% in NACT group, versus 20.4% in PDS group, (RR 0.29, 95% CI 0.12 to 0.74; participants = 632; studies = 2; I2 = 70%; moderate-certainty evidence), and probably reduces the risk of needing bowel resection at the time of surgery: 13.0% in NACT group versus 26.6% in PDS group (RR 0.49, 95% CI 0.30 to 0.79; participants = 1565; studies = 4; I2 = 79%; moderate-certainty evidence). NACT reduces postoperative mortality: 0.6% in NACT group, versus 3.6% in PDS group, (RR 0.16, 95% CI 0.06 to 0.46; participants = 1623; studies = 5; I2 = 0%; high-certainty evidence). QoL on the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) scale produced inconsistent and imprecise results in three studies (MD -0.29, 95% CI -2.77 to 2.20; participants = 524; studies = 3; I2 = 81%; very low-certainty evidence) but the evidence is very uncertain and should be interpreted with caution. AUTHORS' CONCLUSIONS The available high to moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT probably reduces the risk of serious adverse events, especially those around the time of surgery, and reduces the risk of postoperative mortality and the need for stoma formation. These data will inform women and clinicians (involving specialist gynaecological multidisciplinary teams) and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Department of Obstetrics and Gynaecology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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24
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Postoperative outcomes of primary and interval cytoreductive surgery for advanced ovarian cancer registered in the Dutch Gynecological Oncology Audit (DGOA). Gynecol Oncol 2021; 162:331-338. [PMID: 34147284 DOI: 10.1016/j.ygyno.2021.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 05/26/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The challenge when performing cytoreductive surgery (CRS) is to balance the benefits and risks. The aim of this study was to report short term postoperative morbidity and mortality in relation to surgical outcome in patients undergoing primary debulking surgery (PDS) or interval debulking (IDS) surgery in the Netherlands. METHODS The Dutch Gynecological Oncology Audit (DGOA) was used for retrospective analysis. Patients undergoing PDS or IDS between January 1st, 2015 - December 31st, 2018 were included. Outcome was frequency of postoperative complications. Median time to adjuvant chemotherapy and severity of complications were related to outcome of CRS. Complications with Clavien-Dindo ≥3 were analyzed per region and case mix corrected. Statistical analysis was performed with R.Studio. RESULTS 1027 patients with PDS and 1355 patients with IDS were included. Complications with re-invention were significantly higher in PDS compared to IDS (5.7% vs. 3.6%, p = 0.048). Complete cytoreduction was 69.7% in PDS and 62.1% IDS, p < 0.001. Time to adjuvant chemotherapy was 49 days in patients with complete CRS and a complication with re-intervention. Regional variation for severe complications showed one region outside confidence intervals. CONCLUSIONS Higher complete cytoreduction rate in the PDS group indicates that the correct patients have been selected, but is associated with a higher percentage of complication with re-intervention. As result, time to start adjuvant chemotherapy is longer in this group. Maintaining a balance in aggressiveness of surgery and outcome of the surgical procedure with respect to severe complications is underlined. Bench marked data should be discussed nationally to improve this balance.
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25
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CANBAY E, İREZ T, YONEMURA Y. Ovarian Carcinoma with Peritoneal Metastasis: Rethinking of Management. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2021. [DOI: 10.25000/acem.867155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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26
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Ramspott JP, Baert T, MacKintosh ML, Traut A, Ataseven B, Bommert M, Heitz F, Plett H, Schneider S, Waltering KU, Heikaus S, Harter P, du Bois A. Response evaluation after neoadjuvant therapy: evaluation of chemotherapy response score and serological and/or radiological assessment of response in ovarian cancer patients. Arch Gynecol Obstet 2021; 304:1021-1032. [PMID: 33661392 DOI: 10.1007/s00404-021-06020-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/23/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE The chemotherapy response score (CRS) is a histopathological tool to evaluate response to neoadjuvant chemotherapy (NACT) in high-grade serous ovarian cancer (OC). We critically evaluated the clinical value of CRS and compared its predictive power to standard serological (CA125) and radiological response. METHODS A retrospective analysis of 277 OC patients, who received primary chemotherapy, was performed. CRS, serological, and radiological findings were correlated with progression-free (PFS) and overall survival (OS). RESULTS CRS could be determined in 172 of 277 patients (62.1%). In patients with CRS3, a longer median PFS and OS was observed compared with CRS1/2 patients (31.2 vs. 18.9, P < 0.001; 55.0 vs. 36.1 months, P = 0.050). CA125 and radiological response evaluation were also predictive for PFS and OS. Patients with serological and radiological complete response showed longer PFS (23.0 vs. 14.4, P = 0.011; 21.4 vs. 9.6 months, P < 0.001) and OS (49.5 vs. 29.0, P = 0.003; 45.0 vs. 12.9 months, P < 0.001). Patients with pathological complete response (pCR) had the best median PFS (52.8 months), even compared with non-pCR CRS3 (27.8 months). In the total study cohort, serological, and radiological complete response was better at predicting PFS (hazard ratio 2.23 and 2.77). CONCLUSION In this study, evaluation of response to chemotherapy by CRS was not superior to conventional methods (CA125 or radiology). Independent of the evaluation method, response to NACT was predictive of PFS and OS. We observed no added value for CRS as a prognostic marker. The clinical relevance of CRS should be discussed, as no therapeutic consequences result from CRS evaluation.
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Affiliation(s)
- Jan Philipp Ramspott
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany. .,Department of Gynecology and Obstetrics, Münster University Hospital, Münster, Germany.
| | - Thaïs Baert
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany.,Department of Oncology, Laboratory of Tumor Immunology and Immunotherapy, ImmunOvar Research Group, KU Leuven, Leuven, Belgium
| | - Michelle Louise MacKintosh
- Department of Gynaecological Oncology, St Mary's Hospital, Manchester University Hospitals NHS Trust, Manchester, UK
| | - Alexander Traut
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
| | - Beyhan Ataseven
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany.,Department of Obstetrics and Gynecology, University Hospital, LMU Munich, Munich, Germany
| | - Mareike Bommert
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
| | - Florian Heitz
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany.,Department of Gynecology, Campus Virchow Clinic, Charité Medical University, Berlin, Germany
| | - Helmut Plett
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany.,Department of Gynecology, Campus Virchow Clinic, Charité Medical University, Berlin, Germany
| | - Stephanie Schneider
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
| | | | | | - Philipp Harter
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
| | - Andreas du Bois
- Department of Gynecology and Gynecologic Oncology, Ev. Kliniken Essen-Mitte, Essen, Germany
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27
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Yuan F, Wei SH, Konecny GE, Memarzadeh S, Suh RD, Sayre J, Lu DS, Raman SS. Image-Guided Percutaneous Thermal Ablation of Oligometastatic Ovarian and Non-Ovarian Gynecologic Tumors. J Vasc Interv Radiol 2021; 32:729-738. [PMID: 33608192 DOI: 10.1016/j.jvir.2021.01.270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 12/30/2020] [Accepted: 01/17/2021] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To assess the safety, feasibility, and efficacy of percutaneous thermal ablation (TA) in the treatment of metastatic gynecologic (GYN) tumors. MATERIALS AND METHODS A study cohort of 42 consecutive women (mean age, 59. years; range, 25-78 years) with metastatic GYN tumors (119 metastatic tumors) treated with radiofrequency (n = 47 tumors), microwave (n = 47 tumors), or cryogenic (n = 30 tumors) ablation from over 2,800 ablations performed from January 2001 to January 2019 was identified. The primary GYN neoplasms consisted of ovarian (27 patients; 77 tumors; mean tumor diameter [MTD], 2.50 cm), uterine (7 patients; 26 tumors; MTD, 1.89 cm), endometrial (5 patients; 10 tumors; MTD, 2.8 cm), vaginal (2 patients; 5 tumors; MTD, 2.40 cm), and cervical (1 patient; 1 tumor; MTD, 1.90 cm) cancers. In order of descending frequency, metastatic tumors treated by TA were located in the liver or liver capsule (74%), lungs (13%), and peritoneal implants (9%). Single tumors were also treated in the kidneys, rectus muscle, perirectal soft tissue (2.5%), and retroperitoneal lymph nodes (1.6%). All efficacy parameters of TA and definitions of major and minor adverse events are categorized by the latest Society of Interventional Radiology reporting standards. RESULTS The median follow-up of treated patients was 10 months. After the initial ablation, 95.6% of the patients achieved a complete tumor response confirmed by contrast-enhanced magnetic resonance imaging or computed tomography. On surveillance imaging, 8.5% of the ablated tumors developed local progression over a median follow-up period of 4.1 months. Five of 8 tumors with local recurrence underwent repeated treatment over a mean follow-up period of 18 months, and 4 of 5 tumors achieved complete eradication after 1 additional treatment session that resulted in a secondary efficacy of 80%. The overall technique efficacy of TA was 96.2% over a median follow-up period of 10 months. CONCLUSIONS TA was safe and effective for the local control of metastatic GYN tumors in the lungs, abdomen, and pelvis, with an overall survival rate of 37.5 months and a local progression-free survival rate of 16.5 months, with only 4.8% of treated patients experiencing a major adverse event.
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Affiliation(s)
- Frank Yuan
- Division of Abdominal Imaging and Cross-Sectional Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California.
| | - Sindy H Wei
- Division of Abdominal Imaging and Cross-Sectional Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
| | - Gottfried E Konecny
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
| | - Sanaz Memarzadeh
- Division of Gynecological Oncology, Department of Obstetrics and Gynecology, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
| | - Robert D Suh
- Division of Thoracic Diagnostic and Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
| | - James Sayre
- Department of Radiological Sciences & Biostatistics, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
| | - David S Lu
- Division of Abdominal Imaging and Cross-Sectional Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
| | - Steven S Raman
- Division of Abdominal Imaging and Cross-Sectional Interventional Radiology, Department of Radiological Sciences, David Geffen School of Medicine, Ronald Reagan UCLA Medical Center, Los Angles, California
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Coleridge SL, Bryant A, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2021; 2:CD005343. [PMID: 33543776 PMCID: PMC8094177 DOI: 10.1002/14651858.cd005343.pub5] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; Hazard Ratio (HR) 0.95, 95% CI 0.84 to 1.07; I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 0.97, 95% CI 0.87 to 1.07; I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Obstetrics and Gynaecology, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sean Kehoe
- Institute of Cancer and Genomics, University of Birmingham, Birmingham, UK
| | - Jo Morrison
- Department of Gynaecological Oncology, Musgrove Park Hospital, Taunton, UK
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Critical Analysis of Stage IV Epithelial Ovarian Cancer Patients after Treatment with Neoadjuvant Chemotherapy followed by Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC). Int J Surg Oncol 2020; 2020:1467403. [PMID: 33381312 PMCID: PMC7759396 DOI: 10.1155/2020/1467403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 10/14/2020] [Accepted: 11/26/2020] [Indexed: 12/02/2022] Open
Abstract
Background Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) after neoadjuvant chemotherapy (NACT) showed promise as initial treatment for stage IIIC (SIII) epithelial ovarian cancer (EOC); however, stage IV (SIV) outcomes are rarely reported. We assessed our experience and outcomes treating newly diagnosed SIV EOC with NACT plus CRS/HIPEC compared to SIII patients. Methods Advanced EOC from 2015–2018 managed with NACT (carboplatin/paclitaxel) due to unresectable disease or poor performance status followed by interval CRS/HIPEC were reviewed. Perioperative factors were assessed. Overall survival (OS) and progression-free survival (PFS) were analyzed by stage. Results Twenty-seven FIGO stage IIIC (n = 12) and IV (n = 15) patients were reviewed. Median NACT cycles were 3 and 4, respectively. Post-NACT omental caking, ascites, and pleural effusions decreased/resolved in 91%, 91%, and 100% of SIII and 85%, 92%, and 71% of SIV. SIII/SIV median PCI was 21 and 20 obtaining 92% and 100% complete cytoreduction (≤0.25 cm), respectively. Median organ resections were 6 and 7, respectively. Grade III/IV surgical complications were 0% SIII and 23% SIV, without hospital mortality. Median time to adjuvant chemotherapy was 53 and 74 days, respectively (p=0.007). SIII OS at 1 and 2 years was 100% and 83% and 87% and 76% in SIV (p=0.269). SIII 1-year PFS was 54%; median PFS: 12 months. SIV 1- and 2- year PFS was 47% and 23%; median PFS: 12 months (p=0.944). Conclusion Outcomes in select initially diagnosed and unresectable SIV EOC are similar to SIII after NACT plus CRS/HIPEC. SIV EOC may benefit from CRS/HIPEC, and further studies should explore this treatment approach.
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Ultra-radical upfront surgery does not improve survival in women with advanced epithelial ovarian cancer; a natural experiment in a complete population. Gynecol Oncol 2020; 159:58-65. [PMID: 32712154 DOI: 10.1016/j.ygyno.2020.07.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Ultra-radical surgery to achieve complete resection in advanced epithelial ovarian cancer (EOC) has been widely accepted without strong supporting data. Our objective was to assess overall survival after a structured shift to an ultra-radical upfront surgical treatment algorithm and to investigate changes in the distribution of primary treatments after this shift. PATIENTS AND METHODS In this population-based cohort study, all women with suspected EOC in the Stockholm-Gotland region of Sweden reported to the Swedish Quality Registry for Gynecologic Cancer (SQRGC) and National Cancer Registry (NCR) were selected in two 3-year cohorts, based on year of diagnosis (before (cohort1) or after (cohort 2) change in surgical treatment algorithm) and followed for at least three years. 5-year overall survival (OS) in non-surgically and surgically treated women was analyzed. Moreover, proportional distribution of primary treatment was evaluated. RESULTS 752 women were included in the final analysis (n = 364 and 388 in cohort 1 and 2 respectively) with a median follow-up of 29 and 27 months. The complete resection rate increased from 37 to 67% (p ≤ 0.001) as well as proportion non-surgically treated women, 24 to 33%. No improvement in OS was observed in non-surgically (HR 0.76 (95% CI, 0.58-1.01); p = 0.06) or surgically treated (HR 0.94 (95% CI, 0.75-1.18); p = 0.59) women, even when complete resection was achieved (HR 1.31 (95% CI, 0.89-1.92); p = 0.17). CONCLUSION A shift to ultra-radical upfront surgery in EOC did not improve survival despite a significant increase in complete resection rate. Identifying the limitations of surgical treatment remains a challenge.
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Machida H, Tokunaga H, Matsuo K, Matsumura N, Kobayashi Y, Tabata T, Kaneuchi M, Nagase S, Mikami M. Survival outcome and perioperative complication related to neoadjuvant chemotherapy with carboplatin and paclitaxel for advanced ovarian cancer: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2020; 46:868-875. [PMID: 31818526 PMCID: PMC7535131 DOI: 10.1016/j.ejso.2019.11.520] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 11/26/2019] [Accepted: 11/30/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the effectiveness and safety of neoadjuvant chemotherapy with carboplatin/paclitaxel followed by interval debulking surgery (NACT-IDS) to primary debulking surgery plus postoperative chemotherapy (PDS) for advanced ovarian cancer. METHODS A comprehensive systematic review and meta-analysis were conducted by an Expert Panel of the Japan Society of Gynecologic Oncology Ovarian Cancer Committee. Multiple public search engines including PubMed/MEDLINE and the Cochrane Database, were searched in March 2019 using the entry keywords "ovarian cancer [all fields]" AND "interval debulking surgery [all fields]", AND "neoadjuvant chemotherapy [all fields]". Key inclusion criteria were prospective clinical trials examining platinum-based NACT for stage II-IV epithelial ovarian cancer. The primary outcome of interest was survival, and the secondary outcome was adverse events with each intervention. RESULTS After screening 333 studies, four phase III randomized clinical trials were identified that met the inclusion criteria. These trials included 1692 women (847 receiving NACT-IDS and 845 receiving PDS). It was found that NACT-IDS and PDS had similar overall survival (hazard ratio [HR]: 0.97, 95% confidence interval [CI]: 0.87-1.07, P = 0.53) and progression-free survival (HR: 0.98, 95%CI: 0.90-1.08, P = 0.74). In contrast, NACT-IDS was associated with significantly lower rates of perioperative complications (odds ratio [OR] 0.27, 95%CI: 0.20-0.36, P < 0.001) and perioperative mortality (OR: 0.17, 95%CI: 0.06-0.50, P < 0.001) compared to PDS. CONCLUSION This systematic review and meta-analysis suggests that NACT-IDS with carboplatin and paclitaxel does not negatively impact the survival of women with advanced ovarian cancer compared to PDS, while perioperative complications and mortality are significantly reduced by 70-80%.
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Affiliation(s)
- Hiroko Machida
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Japan
| | - Hideki Tokunaga
- Department of Obstetrics and Gynecology, Tohoku University, Japan
| | - Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, USA
| | | | - Yoichi Kobayashi
- Department of Obstetrics and Gynecology, Kyorin University School of Medicine, Japan
| | - Tsutomu Tabata
- Department of Obstetrics and Gynecology, Tokyo Women's Medical University, Japan
| | - Masanori Kaneuchi
- Department of Obstetrics and Gynecology, Otaru General Hospital, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Japan
| | - Mikio Mikami
- Department of Obstetrics and Gynecology, Tokai University School of Medicine, Japan; Department of Obstetrics and Gynecology, Niigata University School of Medicine, Niigata, Japan.
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Isolated lymph node recurrence in epithelial ovarian cancer: Recurrence with better prognosis? Eur J Obstet Gynecol Reprod Biol 2020; 249:64-69. [PMID: 32381349 DOI: 10.1016/j.ejogrb.2020.04.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 04/14/2020] [Accepted: 04/20/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The aim of this study was to compare overall survival (OS) between women with isolated lymph node recurrence (ILNR) and those with isolated peritoneal localization of recurrence (ICR), in patients managed for epithelial ovarian cancer. METHODS Data from 1508 patients with ovarian cancer were collected retrospectively from1 January 2000 to 31 December 2016, from the FRANCOGYN database, pooling data from 11 centres specialized in ovary treatment. Median overall survival was determined using the Kaplan-Meier method. Univariate and multivariate analyses were performed to define prognostic factors of overall survival. Patients included had a first recurrence defined as ILNR or ICR during their follow up. RESULTS 79 patients (5.2 %) presented with ILNR, and 247 (16.4 %) patients had isolated carcinomatosis recurrence. Complete lymphadenectomy was performed more frequently in the ILNR group vs. the ICR group (67.1 % vs. 53.4 %, p = 0.004) and the number of pelvic lymph nodes involved was higher (2.4 vs. 1.1, p = 0.008). The number of involved pelvic LN was an independent predictor of ILNR (OR = 1.231, 95 % CI [1.074-1.412], p = 0.0024). The 3-year and 5-year OS rates in the ILNR group were 85.2 % and 53.7 % respectively, compared to 68.1 % and 46.8 % in patients with ICR. There was no significant difference in terms of OS after initial diagnosis (p = 0.18). 3- year and 5-year OS rates after diagnosis of recurrence were 62.6 % and 15.6 % in the ILNR group, and 44 % and 15.7 % in patients with ICR (p = 0.21). CONCLUSION ILNR does not seem to be associated with a better prognosis in terms of OS.
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Onda T, Satoh T, Ogawa G, Saito T, Kasamatsu T, Nakanishi T, Mizutani T, Takehara K, Okamoto A, Ushijima K, Kobayashi H, Kawana K, Yokota H, Takano M, Kanao H, Watanabe Y, Yamamoto K, Yaegashi N, Kamura T, Yoshikawa H. Comparison of survival between primary debulking surgery and neoadjuvant chemotherapy for stage III/IV ovarian, tubal and peritoneal cancers in phase III randomised trial. Eur J Cancer 2020; 130:114-125. [PMID: 32179446 DOI: 10.1016/j.ejca.2020.02.020] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 02/05/2020] [Accepted: 02/09/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Regarding the comparison between primary debulking surgery (PDS) and neoadjuvant chemotherapy (NACT) for stage III/IV ovarian, tubal and peritoneal cancers, EORTC55971 and CHORUS studies demonstrated noninferiority of NACT. Previously, we reported reduced invasiveness of NACT in JCOG0602. This is a final analysis including the primary endpoint of overall survival (OS). METHODS Patients were randomised to PDS (PDS followed by 8x paclitaxel and carboplatin, i.e. TC regimen) or NACT (4x TC, interval debulking surgery [IDS], 4x TC). The primary endpoint was OS. The noninferiority hazard ratio (HR) margin for NACT compared with PDS was 1·161. The planned sample size was 300. FINDINGS Between 2006 and 2011, 301 patients were randomised, 149 to PDS and 152 to NACT. The median OS was 49·0 and 44·3 months in the PDS and NACT. HR for NACT was 1·052 [90·8% confidence interval (CI) 0·835-1·326], and one-sided noninferiority p-value was 0·24. Median progression-free survival was 15·1 and 16·4 months in the PDS and NACT (HR: 0·96 [95%CI 0·75-1·23]). In the PDS arm, 147/149 underwent PDS and 49/147 underwent IDS. In the NACT arm 130/152 underwent IDS. Complete resection was achieved in 12% (17/147) of PDS and 31% (45/147) of PDS ± IDS in the PDS arm and in 64% (83/130) of IDS in the NACT arm. Optimal surgery (residual tumour <1 cm) was achieved in 37% (55/147), 63% (92/147), and 82% (107/130 respectively. In the NACT, PS 2/3, serum albumin ≤2·5, CA125 > 2000 an institution with low study activity was advantageous, whereas clear/mucinous histology was disadvantageous for OS. INTERPRETATION The noninferiority of NACT was not confirmed. NACT may not always be a substitute for PDS. However, as our study had smaller numbers, the noninferiority of the previous studies cannot be denied. FUNDING Ministry of Health, Labour and Welfare, Japan and the National Cancer Center, Japan. CLINICAL TRIAL INFORMATION UMIN000000523.
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Affiliation(s)
- Takashi Onda
- Department of Gynecology, Kitasato University School of Medicine, Sagamihara, Japan.
| | - Toyomi Satoh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Gakuto Ogawa
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Toshiaki Saito
- Gynecology Service, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Takahiro Kasamatsu
- Department of Gynecologic Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - Toru Nakanishi
- Department of Gynecologic Oncology, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Tomonori Mizutani
- JCOG Data Center/Operations Office, National Cancer Center Hospital, Tokyo, Japan
| | - Kazuhiro Takehara
- Department of Gynecologic Oncology, National Hospital Organization Shikoku Cancer Center, Matsuyama, Japan
| | - Aikou Okamoto
- Department of Obstetrics and Gynecology, The Jikei University School of Medicine, Tokyo, Japan
| | - Kimio Ushijima
- Department of Obstetrics and Gynecology, Kurume University School of Medicine, Kurume, Japan
| | - Hiroaki Kobayashi
- Department of Gynecology and Obstetrics, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kei Kawana
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Harushige Yokota
- Department of Gynecology, Saitama Cancer Center, Kita Adachi Gun, Japan
| | - Masashi Takano
- Department of Clinical Oncology, National Defense Medical College Hospital, Tokorozawa, Japan
| | - Hiroyuki Kanao
- Department of Gynecological Oncology, Cancer Institute Hospital, Tokyo, Japan
| | - Yoh Watanabe
- Department of Obstetrics and Gynecology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Kaichiro Yamamoto
- Department of Obstetrics and Gynecology, Faculty of Medicine, Kindai University, Sakai Hospital, Sakai, Japan
| | - Nobuo Yaegashi
- Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Toshiharu Kamura
- Medical Care Education Research Foundation, Yanagawa Hospital, Yanagawa, Japan
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Wen A, Mei X, Feng C, Shen C, Wang B, Zhang X. Electrosprayed nanoparticles of poly(p-dioxanone-co-melphalan) macromolecular prodrugs for treatment of xenograft ovarian carcinoma. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2020; 111:110759. [PMID: 32279799 DOI: 10.1016/j.msec.2020.110759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 02/16/2020] [Accepted: 02/16/2020] [Indexed: 01/18/2023]
Abstract
Ovarian cancer is considered to be the most fatal reproductive cancers. Melphalan is used to treat ovarian cancer as an intraperitoneal chemotherapy agent. However, elucidating its pharmacokinetic behavior and preparing it for administration are challenging since it undergoes spontaneous hydrolysis. In this study, melphalan is transformed into a macromolecular prodrug by copolymerizing with p-dioxanone. The hydrophobicity of copolymer chains protects melphalan from hydrolysis. Poly(p-dioxanone-co-melphalan; PDCM) is electrosprayed and converted into nanoparticles (PDCM NPs) with diameters of ~300-350 nm to facilitate its intracellular delivery. UPLC-MS and HPLC are applied to verify and monitor the release of melphalan from PDCM NPs. PDCM NPs could suppress the proliferation of SKOV-3 cells. The IC50 of 4.3% melphalan-containing PDCM-3 NP was 70 mg/L, 72 h post administration. These suppression characteristics not only affected by the degradation and then the extracellular release of melphalan from PDCM NPs, but also the uptake via phagocytosis phenomenon in SKOV-3 cells. As revealed by flow cytometry, phagocytosis is a first-order process. Once phagocytosed, PDCM NPs are digested by lysosomes, causing a rapid release of melphalan into the cytoplasm, which ultimately causes suppression of SKOV-3 cell proliferation. Finally, the in vivo antitumor effects of PDCM NPs are verified in xenograft ovarian carcinoma. After a 20-day treatment, the tumor growth rate of the PDCM-3 NP group was (266 ± 178%) which was lower than those in the free melphalan group (367 ± 150%) and control group (648 ± 149%). Besides, significant tissue necrosis and growth suppression were observed in animals administered injections of PDCM NPs. Furthermore, the in vivo tracing results of Nile red-labeled PDCM NPs demonstrated that PDCM-3 NPs might be phagocytosed by macrophages and then taken to adjacent lymph nodes, which is a way of prevention or early treatment of lymphatic metastasis of tumors.
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Affiliation(s)
- Aiping Wen
- Department of Gynecology and Obstetrics, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Xue Mei
- School of Pharmacy, North Sichuan Medical College, Nanchong, China
| | - Chengmin Feng
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Chengyi Shen
- Sichuan Key Laboratory of Medical Imaging & Institute of Morphological Research, North Sichuan Medical College, Nanchong, China
| | - Bing Wang
- Sichuan Key Laboratory of Medical Imaging & Department of Chemistry, School of Preclinical Medicine, North Sichuan Medical College, Nanchong 637000, China.
| | - Xiaoming Zhang
- Sichuan Key Laboratory of Medical Imaging & Department of Radiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
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Thakur S, Chandrakant L, Fotedar V, Gupta M. Breaking the survival barriers: A case of stage IV carcinoma ovary with brain metastasis. CLINICAL CANCER INVESTIGATION JOURNAL 2020. [DOI: 10.4103/ccij.ccij_19_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Coleridge SL, Bryant A, Lyons TJ, Goodall RJ, Kehoe S, Morrison J. Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer. Cochrane Database Syst Rev 2019; 2019:CD005343. [PMID: 31684686 PMCID: PMC6822157 DOI: 10.1002/14651858.cd005343.pub4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Epithelial ovarian cancer presents at an advanced stage in the majority of women. These women require surgery and chemotherapy for optimal treatment. Conventional treatment has been to perform surgery first and then give chemotherapy. However, there may be advantages to using chemotherapy before surgery. OBJECTIVES To assess whether there is an advantage to treating women with advanced epithelial ovarian cancer with chemotherapy before debulking surgery (neoadjuvant chemotherapy (NACT)) compared with conventional treatment where chemotherapy follows debulking surgery (primary debulking surgery (PDS)). SEARCH METHODS We searched the following databases on 11 February 2019: CENTRAL, Embase via Ovid, MEDLINE (Silver Platter/Ovid), PDQ and MetaRegister. We also checked the reference lists of relevant papers that were identified to search for further studies. The main investigators of relevant trials were contacted for further information. SELECTION CRITERIA Randomised controlled trials (RCTs) of women with advanced epithelial ovarian cancer (Federation of International Gynaecologists and Obstetricians (FIGO) stage III/IV) who were randomly allocated to treatment groups that compared platinum-based chemotherapy before cytoreductive surgery with platinum-based chemotherapy following cytoreductive surgery. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed risk of bias in each included trial. MAIN RESULTS We found 1952 potential titles, with a most recent search date of February 2019, of which five RCTs of varying quality and size met the inclusion criteria. These studies assessed a total of 1713 women with stage IIIc/IV ovarian cancer randomised to NACT followed by interval debulking surgery (IDS) or PDS followed by chemotherapy. We pooled results of the three studies where data were available and found little or no difference with regard to overall survival (OS) (1521 women; hazard ratio (HR) 1.06; 95% confidence interval (CI) 0.94 to 1.19, I2 = 0%; moderate-certainty evidence) or progression-free survival in four trials where we were able to pool data (1631 women; HR 1.02; 95% CI 0.92 to 1.13, I2 = 0%; moderate-certainty evidence). Adverse events, surgical morbidity and quality of life (QoL) outcomes were poorly and incompletely reported across studies. There may be clinically meaningful differences in favour of NACT compared to PDS with regard to serious adverse effects (SAE grade 3+). These data suggest that NACT may reduce the risk of need for blood transfusion (risk ratio (RR) 0.80; 95% CI 0.64 to 0.99; four studies,1085 women; low-certainty evidence), venous thromboembolism (RR 0.28; 95% CI 0.09 to 0.90; four studies, 1490 women; low-certainty evidence), infection (RR 0.30; 95% CI 0.16 to 0.56; four studies, 1490 women; moderate-certainty evidence), compared to PDS. NACT probably reduces the need for stoma formation (RR 0.43, 95% CI 0.26 to 0.72; two studies, 581 women; moderate-certainty evidence) and bowel resection (RR 0.49, 95% CI 0.26 to 0.92; three studies, 1213 women; moderate-certainty evidence), as well as reducing postoperative mortality (RR 0.18; 95% CI 0.06 to 0.54:five studies, 1571 women; moderate-certainty evidence). QoL on the EORTC QLQ-C30 scale produced inconsistent and imprecise results in two studies (MD -1.34, 95% CI -2.36 to -0.32; participants = 307; very low-certainty evidence) and use of the QLQC-30 and QLQC-Ov28 in another study (MD 7.60, 95% CI 1.89 to 13.31; participants = 217; very low-certainty evidence) meant that little could be inferred. AUTHORS' CONCLUSIONS The available moderate-certainty evidence suggests there is little or no difference in primary survival outcomes between PDS and NACT. NACT may reduce the risk of serious adverse events, especially those around the time of surgery, and the need for bowel resection and stoma formation. These data will inform women and clinicians and allow treatment to be tailored to the person, taking into account surgical resectability, age, histology, stage and performance status. Data from an unpublished study and ongoing studies are awaited.
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Affiliation(s)
- Sarah L Coleridge
- Taunton and Somerset NHS Foundation TrustObstetrics and GynaecologyMusgrove Park HospitalTauntonUKTA1 5DA
| | - Andrew Bryant
- Newcastle UniversityInstitute of Health & SocietyMedical School New BuildRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Thomas J Lyons
- University of BristolSchool of Medical Sciences38 Kings Parade AvenueBristolUKBS8 2RB
| | - Richard J Goodall
- Imperial College LondonDepartment of Surgery and CancerKensingtonLondonUKSW7 2AZ
| | - Sean Kehoe
- University of BirminghamInstitute of Cancer and GenomicsBirminghamUKB15 2TT
| | - Jo Morrison
- Musgrove Park HospitalDepartment of Gynaecological OncologyTaunton and Somerset NHS Foundation TrustTauntonSomersetUKTA1 5DA
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du Bois A, Baert T, Vergote I. Role of Neoadjuvant Chemotherapy in Advanced Epithelial Ovarian Cancer. J Clin Oncol 2019; 37:2398-2405. [DOI: 10.1200/jco.19.00022] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | - Thaïs Baert
- Kliniken Essen-Mitte, Essen, Germany
- Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ignace Vergote
- Katholieke Universiteit Leuven, Leuven, Belgium
- Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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Tsibulak I, Zeimet AG, Marth C. Hopes and failures in front-line ovarian cancer therapy. Crit Rev Oncol Hematol 2019; 143:14-19. [PMID: 31449982 DOI: 10.1016/j.critrevonc.2019.08.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 08/07/2019] [Accepted: 08/09/2019] [Indexed: 10/26/2022] Open
Abstract
Through the last three decades, the combination of paclitaxel and carboplatin remains the standard of care chemotherapy in newly diagnosed epithelial ovarian cancer (EOC). Based on a single trial, first-line maintenance therapy with angiogenesis inhibitor bevacizumab was approved in Europe and widely applied. In 2018, based on a second trial bevacizumab was approved for first-line maintenance in the United States. Despite complete remission upon chemotherapy, the majority of the patients recur. A large number of randomized trials were conducted to explore the optimal front-line therapy regimen, but neither dose-densing, nor adding of a third chemotherapy agent or intraperitoneal administration could improve overall survival (OS). Also implementation of hyperthermic intraperitoneal chemotherapy (HIPEC) or the neoadjuvant approach failed to improve OS. Recently, maintenance therapy with PARP inhibitors showed encouraging results in patients with BRCA1/2 mutation. Further trials with targeted therapies are ongoing. Here we review the achievements of front-line therapy in primary advanced EOC through the last three decades and discuss future treatment strategies.
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Affiliation(s)
- Irina Tsibulak
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Alain G Zeimet
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria.
| | - Christian Marth
- Department of Obstetrics and Gynecology, Medical University of Innsbruck, Innsbruck, Austria.
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Gómez-Ruiz ÁJ, González-Gil A, Gil J, Navarro-Barrios Á, Alconchel F, Gil E, Martínez J, Nieto A, Barceló F, Cascales-Campos PA. Peritoneal Surface Disease Severity Score (PSDSS), AGO-score and TIAN model in patients with platinum-sensitive recurrent ovarian cancer treated by cytoreductive surgery plus HIPEC. Clin Exp Metastasis 2019; 36:433-439. [PMID: 31270731 DOI: 10.1007/s10585-019-09982-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/24/2019] [Indexed: 01/18/2023]
Abstract
In patients with platinum sensitive recurrent ovarian cancer selected for a secondary cytoreduction, the use of prognostic scores allows predicting the possibilities of a new complete cytoreduction. The aim of this work is to evaluate the usefulness of PSDSSov, the AGO-score and the TIAN-model as prognostic tools in these patients. Sixty four patients with recurrent platinum sensitive ovarian cancer treated by cytoreduction and HIPEC were analyzed between January 2008 and December 2016. Since 2012, the data needed to calculate the PSDSS, AGO-score and TIAN model were collected prospectively. Fifty patients (78%) received systemic chemotherapy before cytoreduction and HIPEC. In 57 patients (89%) a CC-0 was achieved. Patients with PSDSSov I-II and TIAN model of "low risk" had a DFS at 1 and 5 years of 71% and 57%, respectively, without reaching the median of DFS. PSDSSov is a useful prognostic tool and can be used in decision making in patients with peritoneal carcinomatosis due to recurrent platinum-sensitive ovarian cancer. Its combination with the Tian model makes it possible to identify patients with an especially favorable prognosis.
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Affiliation(s)
- Álvaro Jesús Gómez-Ruiz
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain.
| | - Alida González-Gil
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain
| | - José Gil
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain
| | - Álvaro Navarro-Barrios
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain
| | - Felipe Alconchel
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain
| | - Elena Gil
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain
| | - Jerónimo Martínez
- Department of Ginecology, Hospital Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Aníbal Nieto
- Department of Ginecology, Hospital Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Francisco Barceló
- Department of Ginecology, Hospital Universitario Virgen De La Arrixaca, Murcia, Spain
| | - Pedro Antonio Cascales-Campos
- Peritoneal Carcinomatosis Unit, Department of Surgery, Hospital Universitario Virgen De La Arrixaca, Carretera del Palmar S/N, El Palmar, 30123, Murcia, Spain
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DiSilvestro PA. Shaping the standard of care in ovarian cancer management: A review of Gynecologic Oncology Group (GOG)/NRG oncology clinical trials of the past twenty years. Gynecol Oncol 2019; 153:479-486. [DOI: 10.1016/j.ygyno.2019.02.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/15/2019] [Accepted: 02/20/2019] [Indexed: 10/27/2022]
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Timmermans M, van der Hel O, Sonke G, Van de Vijver K, van der Aa M, Kruitwagen R. The prognostic value of residual disease after neoadjuvant chemotherapy in advanced ovarian cancer; A systematic review. Gynecol Oncol 2019; 153:445-451. [DOI: 10.1016/j.ygyno.2019.02.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 01/12/2023]
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Lheureux S, Gourley C, Vergote I, Oza AM. Epithelial ovarian cancer. Lancet 2019; 393:1240-1253. [PMID: 30910306 DOI: 10.1016/s0140-6736(18)32552-2] [Citation(s) in RCA: 989] [Impact Index Per Article: 197.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 10/02/2018] [Accepted: 10/10/2018] [Indexed: 12/17/2022]
Abstract
Epithelial ovarian cancer generally presents at an advanced stage and is the most common cause of gynaecological cancer death. Treatment requires expert multidisciplinary care. Population-based screening has been ineffective, but new approaches for early diagnosis and prevention that leverage molecular genomics are in development. Initial therapy includes surgery and adjuvant therapy. Epithelial ovarian cancer is composed of distinct histological subtypes with unique genomic characteristics, which are improving the precision and effectiveness of therapy, allowing discovery of predictors of response such as mutations in breast cancer susceptibility genes BRCA1 and BRCA2, and homologous recombination deficiency for DNA damage response pathway inhibitors or resistance (cyclin E1). Rapidly evolving techniques to measure genomic changes in tumour and blood allow for assessment of sensitivity and emergence of resistance to therapy, and might be accurate indicators of residual disease. Recurrence is usually incurable, and patient symptom control and quality of life are key considerations at this stage. Treatments for recurrence have to be designed from a patient's perspective and incorporate meaningful measures of benefit. Urgent progress is needed to develop evidence and consensus-based treatment guidelines for each subgroup, and requires close international cooperation in conducting clinical trials through academic research groups such as the Gynecologic Cancer Intergroup.
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Affiliation(s)
- Stephanie Lheureux
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Charlie Gourley
- Nicola Murray Centre for Ovarian Cancer Research, Edinburgh Cancer Research UK Centre, MRC IGMM, University of Edinburgh, Western General Hospital, Edinburgh, UK; Edinburgh Cancer Centre, Western General Hospital, Edinburgh, UK
| | - Ignace Vergote
- Division of Gynaecological Oncology, Leuven Cancer Institute, Department of Gynaecology and Obstetrics, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Amit M Oza
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, University of Toronto, Toronto, ON, Canada.
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Bogani G, Ditto A, Raspagliesi F. Regarding “When Less Is More: Minimally Invasive Surgery Compared to Laparotomy for Interval Debulking after Neoadjuvant Chemotherapy in Women with Advanced Ovarian Cancer”. J Minim Invasive Gynecol 2019; 26:573-574. [DOI: 10.1016/j.jmig.2018.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
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Kaban A, Topuz S, Saip P, Sözen H, Salihoğlu Y. In patients with advanced ovarian cancer, primary suboptimal surgery has better survival outcome than interval suboptimal surgery. J Turk Ger Gynecol Assoc 2019; 20:31-36. [PMID: 29545229 PMCID: PMC6501870 DOI: 10.4274/jtgga.galenos.2018.2018.0015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Objective It is known that optimal or complete cytoreduction is the most important factor in patients with advanced ovarian cancer. The aim of this study was to examine the results of patients who did not undergo optimal cytoreduction and to examine subgroup analysis based on neoadjuvant chemotherapy (NAC). Material and Methods Patients with advanced ovarian cancer and suboptimal surgery were retrospectively reviewed. Results A total of 99 patients with a median age of 59.0 years (range, 22-87 years) were studied. The median follow-up time was 39±32.7 months, 81 patients (81.8%) died and 18 patients (18.2%) were alive. The five-year survival rate was 27.6%. Of the patients, 37 (37.4%) were underwent surgery after NAC, 62 (62.3%) were primary. More patients with NAC died within 3 years compared with those without NAC (83.9% vs 56.0%) (p=0.015). Patients with NAC had less tumor spread (presence of visible tumor in the upper abdomen during surgery) (29.7% vs 72.6%; p<0.001) and had less overall survival times when compared with patients who underwent primary surgery [median 22.3±1.2; 95% CI: (19.9-24.7) vs (37.5±11.2); 95% CI: (15.4-59.5) months; log rank test p=0.055]. The relationship between overall survival and factors such as age, NAC, presence of metastasis in the upper abdomen, and tumor histology (serous vs. non-serous) were analyzed using univariate cox regression analysis. Of these factors, only NAC was close to significant, but it did not reach significance (p=0.055). Conclusion NAC reduces tumor burden before surgery in advanced ovarian cancer. The prognosis of patients who are not eligible for optimal surgery despite NAC is worse than in patients who do not receive NAC.
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Affiliation(s)
- Alpaslan Kaban
- Clinic of Gynecologic Oncology, İstanbul Training and Research Hospital, İstanbul, Turkey
| | - Samet Topuz
- epartment of Gynecologic Oncology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Pınar Saip
- epartment of Gynecologic Oncology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Hamdullah Sözen
- epartment of Gynecologic Oncology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
| | - Yavuz Salihoğlu
- epartment of Gynecologic Oncology, İstanbul University İstanbul School of Medicine, İstanbul, Turkey
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Rose PG, Java JJ, Salani R, Geller MA, Alvarez A, Tewari KS, Bender DP, Mutch DG, Friedlander ML, Van Le L, Method MW, Hamilton CA, Lee RB, Wenham RM, Guntupalli SR, Markman M, Muggia FM, Armstrong DK, Bookman MA, Burger RA, Copeland LJ. Nomogram for Predicting Individual Survival After Recurrence of Advanced-Stage, High-Grade Ovarian Carcinoma. Obstet Gynecol 2019; 133:245-254. [PMID: 30633128 PMCID: PMC6551603 DOI: 10.1097/aog.0000000000003086] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE To analyze clinical prognostic factors for survival after recurrence of high-grade, advanced-stage ovarian-peritoneal-tubal carcinoma and to develop a nomogram to predict individual survival after recurrence. METHODS We retrospectively analyzed patients treated in multicenter Gynecologic Oncology Group protocols for stage III and IV ovarian-peritoneal-tubal carcinoma who underwent primary debulking surgery, received chemotherapy with paclitaxel and a platinum compound, and subsequently developed recurrence. Prognostic factors affecting survival were identified and used to develop a nomogram, which was both internally and externally validated. RESULTS There were 4,739 patients included in this analysis, of whom, 84% had stage III and 16% had stage IV ovarian carcinoma. At a median follow-up of 88.8 months (95% CI 86.2-92.0 months), the vast majority of patients (89.4%) had died. The median survival after recurrence was 21.4 months (95% CI 20.5-21.9 months). Time to recurrence after initial chemotherapy, clear cell or mucinous histology, performance status, stage IV disease, and age were significant variables used to develop a nomogram for survival after recurrence, which had a concordance index of 0.67. The time to recurrence alone accounted for 85% of the prognostic information. Similar results were found for patients who underwent second look laparotomy and had a complete pathologic response or received intraperitoneal chemotherapy. CONCLUSION For individuals with advanced-stage ovarian carcinoma who recur after standard first-line therapy, estimated survivals after recurrence are closely related to the time to recurrence after chemotherapy and prognostic variables can be used to predict subsequent survival. CLINICAL TRIAL REGISTRATION ClinialTrials.gov, NCT00002568, NCT00837993, NCT00002717, NCT01074398, and NCT00011986.
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Affiliation(s)
- Peter G Rose
- Cleveland Clinic Foundation and Case Western Reserve University, Cleveland, OH;
| | - James J Java
- NRG Oncology Statistics and Data Management Center, Roswell Park Cancer Institute, Buffalo, NY;
| | | | | | | | | | | | - David G Mutch
- Washington University School of Medicine, St. Louis, MO;
| | | | | | - Michael W Method
- Community Health Network and Indiana University School of Medicine, Indianapolis, IN;
| | | | | | | | | | | | | | | | | | - Robert A Burger
- University of Pennsylvania Medical Center, Philadelphia, PA:
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Prognostic Value of Pathologic Chemotherapy Response Score in Patients With Ovarian Cancer After Neoadjuvant Chemotherapy. Int J Gynecol Cancer 2018; 28:1676-1682. [DOI: 10.1097/igc.0000000000001366] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ObjectivesThe aim of the study was to investigate the correlation of chemotherapy response score (CRS) after neoadjuvant chemotherapy (NACT) to treatment outcomes in ovarian cancer (OC).MethodsChemotherapy response score was retrospectively determined on pathology slides of all patients with epithelial OC that had interval debulking surgery (IDS) between 2009–2014. Chemotherapy response score 1 was given when tumor was present and infiltrated by inflammatory cells, CRS 2 when both tumor and regressive chemotherapy changes were present, and CRS 3 when scant tumor was seen within extensive chemotherapy-induced changes. Patients’ characteristics including survival data were collected and compared between CRS groups.ResultsPathology slides of 132 patients were reviewed. Forty-nine patients had CRS 1, 65 had CRS 2, and 18 had CRS 3. Age, stage, and grade were not different across CRS groups. A higher percent of CRS 1 and 2 patients required more than 3 cycles of NACT, whereas CRS 3 patients had higher rates of no residual disease at completion of IDS. Chemotherapy response score 3 group showed the most significant CA125 decrease after NACT (97% decrease,P= 0.016). Kaplan-Meir survival curves showed a significantly longer progression-free survival but not overall survival for patients with CRS 3 (median progression-free survival = 7.5, 12, and 17 months for CRS 1, 2, and 3, respectively,P= 0.012), and this remained statistically significant in both univariate and multivariate analysis. Interobserver reproducibility for CRS was good (weighed κ = 0.762).ConclusionsPatients with CRS 3 have longest progression-free survival and highest CA125 drop after NACT. These parameters have important prognostic value and can be used for clinical decision-making.
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Di Lorenzo G, Ricci G, Severini GM, Romano F, Biffi S. Imaging and therapy of ovarian cancer: clinical application of nanoparticles and future perspectives. Theranostics 2018; 8:4279-4294. [PMID: 30214620 PMCID: PMC6134923 DOI: 10.7150/thno.26345] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/08/2018] [Indexed: 12/16/2022] Open
Abstract
Despite significant advances in cancer diagnostics and treatment, ovarian cancers (OC) continue to kill more than 150,000 women every year worldwide. Due to the relatively asymptomatic nature and the advanced stage of the disease at the time of diagnosis, OC is the most lethal gynecologic malignancy. The current treatment for advanced OC relies on the synergistic effect of combining surgical cytoreduction and chemotherapy; however, beside the fact that chemotherapy resistance is a major challenge in OC management, new imaging strategies are needed to target microscopic lesions and improve both cytoreductive surgery and patient outcomes. In this context, nanostructured probes are emerging as a new class of medical tool that can simultaneously provide imaging contrast, target tumor cells, and carry a wide range of medicines resulting in better diagnosis and therapeutic precision. Herein we summarize several exemplary efforts in nanomedicine for addressing unmet clinical needs.
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Affiliation(s)
| | | | | | | | - Stefania Biffi
- Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
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Abstract
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.
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Qin M, Jin Y, Ma L, Zhang YY, Pan LY. The role of neoadjuvant chemotherapy followed by interval debulking surgery in advanced ovarian cancer: a systematic review and meta-analysis of randomized controlled trials and observational studies. Oncotarget 2018; 9:8614-8628. [PMID: 29492221 PMCID: PMC5823572 DOI: 10.18632/oncotarget.23808] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 11/15/2017] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE We aimed to performed a meta-analysis and systematic review on the role of neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) in advanced ovarian cancer (AOC) patients. MATERIALS AND METHODS We searched PubMed, EMBASE, and the Cochrane Library for relevant articles. All statistical analyses were performed in Review Manager 5.3.5. RESULTS In two randomized controlled trials (RCTs), there was no significant difference in overall survival (OS) (HR = 0.93, 95% CI: 0.81-1.06) or progression-free survival (PFS) (HR = 0.97, 95% CI: 0.86-1.09). Few adverse events (HR = 0.37, 95% CI: 0.19-0.72) and a high optimal debulking surgery rate (HR = 1.69, 95% CI: 1.50-1.91) were observed with NACT. In 22 observational studies, primary debulking surgery (PDS) yielded better OS (HR = 1.38, 95% CI: 1.19-1.60) but not progression-free survival (PFS) (HR = 1.03, 95% CI: 0.86-1.23). An increased optimal cytoreduction rate (HR = 1.17, 95% CI: 1.12-1.22) was observed with NACT. Irrespective of the degree of residual disease, OS was longer in the PDS group than that in the NACT group. Patients with FIGO stage III (HR = 1.43, 95% CI: 1.05-1.95) and IV (HR = 1.14, 95% CI: 1.06-1.23) disease had better survival with PDS. CONCLUSIONS Treatment with NACT-IDS improves perioperative outcomes and optimal cytoreduction rates, but it may not improve OS. NACT-IDS is not inferior to PDS-CT in terms of survival outcomes in selected AOC patients. Future studies should focus on candidate selection for NACT.
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Affiliation(s)
- Meng Qin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ying Jin
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Li Ma
- Department of Interventional Radiology and Vascular Surgery, Taiyuan Center Hospital, Taiyuan 030009, China
| | - Yan-Yan Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Ling-Ya Pan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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van Driel WJ, Koole SN, Sikorska K, Schagen van Leeuwen JH, Schreuder HWR, Hermans RHM, de Hingh IHJT, van der Velden J, Arts HJ, Massuger LFAG, Aalbers AGJ, Verwaal VJ, Kieffer JM, Van de Vijver KK, van Tinteren H, Aaronson NK, Sonke GS. Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer. N Engl J Med 2018; 378:230-240. [PMID: 29342393 DOI: 10.1056/nejmoa1708618] [Citation(s) in RCA: 888] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Treatment of newly diagnosed advanced-stage ovarian cancer typically involves cytoreductive surgery and systemic chemotherapy. We conducted a trial to investigate whether the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery would improve outcomes among patients who were receiving neoadjuvant chemotherapy for stage III epithelial ovarian cancer. METHODS In a multicenter, open-label, phase 3 trial, we randomly assigned 245 patients who had at least stable disease after three cycles of carboplatin (area under the curve of 5 to 6 mg per milliliter per minute) and paclitaxel (175 mg per square meter of body-surface area) to undergo interval cytoreductive surgery either with or without administration of HIPEC with cisplatin (100 mg per square meter). Randomization was performed at the time of surgery in cases in which surgery that would result in no visible disease (complete cytoreduction) or surgery after which one or more residual tumors measuring 10 mm or less in diameter remain (optimal cytoreduction) was deemed to be feasible. Three additional cycles of carboplatin and paclitaxel were administered postoperatively. The primary end point was recurrence-free survival. Overall survival and the side-effect profile were key secondary end points. RESULTS In the intention-to-treat analysis, events of disease recurrence or death occurred in 110 of the 123 patients (89%) who underwent cytoreductive surgery without HIPEC (surgery group) and in 99 of the 122 patients (81%) who underwent cytoreductive surgery with HIPEC (surgery-plus-HIPEC group) (hazard ratio for disease recurrence or death, 0.66; 95% confidence interval [CI], 0.50 to 0.87; P=0.003). The median recurrence-free survival was 10.7 months in the surgery group and 14.2 months in the surgery-plus-HIPEC group. At a median follow-up of 4.7 years, 76 patients (62%) in the surgery group and 61 patients (50%) in the surgery-plus-HIPEC group had died (hazard ratio, 0.67; 95% CI, 0.48 to 0.94; P=0.02). The median overall survival was 33.9 months in the surgery group and 45.7 months in the surgery-plus-HIPEC group. The percentage of patients who had adverse events of grade 3 or 4 was similar in the two groups (25% in the surgery group and 27% in the surgery-plus-HIPEC group, P=0.76). CONCLUSIONS Among patients with stage III epithelial ovarian cancer, the addition of HIPEC to interval cytoreductive surgery resulted in longer recurrence-free survival and overall survival than surgery alone and did not result in higher rates of side effects. (Funded by the Dutch Cancer Society; ClinicalTrials.gov number, NCT00426257 ; EudraCT number, 2006-003466-34 .).
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Affiliation(s)
- Willemien J van Driel
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Simone N Koole
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Karolina Sikorska
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Jules H Schagen van Leeuwen
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Henk W R Schreuder
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Ralph H M Hermans
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Ignace H J T de Hingh
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Jacobus van der Velden
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Henriëtte J Arts
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Leon F A G Massuger
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Arend G J Aalbers
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Victor J Verwaal
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Jacobien M Kieffer
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Koen K Van de Vijver
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Harm van Tinteren
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Neil K Aaronson
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
| | - Gabe S Sonke
- From the Departments of Gynecology (W.J.D., S.N.K.), Biometrics (K.S., H.T.), Surgical Oncology (A.G.J.A.), Pathology (K.K.V.V.), and Medical Oncology (S.N.K., G.S.S.) and the Division of Psychosocial Research and Epidemiology (J.M.K., N.K.A.), the Netherlands Cancer Institute, Amsterdam, the Center for Gynecologic Oncology Amsterdam, Amsterdam (W.J.D., S.N.K., J.V.), the Dutch Gynecologic Oncology Group (W.J.D., J.H.S.L., H.W.R.S., R.H.M.H., J.V., H.J.A., L.F.A.G.M., G.S.S.), the Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam (J.V.), the Department of Obstetrics and Gynecology, Sint Antonius Hospital, Nieuwegein (J.H.S.L.), the Department of Gynecologic Oncology, UMC Utrecht Cancer Center, University Medical Center Utrecht, Utrecht (H.W.R.S.), the Departments of Gynecology and Obstetrics (R.H.M.H.) and Surgery (I.H.J.T.H.), Catharina Hospital, Eindhoven, the Dutch Peritoneal Oncology Group (I.H.J.T.H., A.G.J.A.), the Department of Gynecologic Oncology, University of Groningen, University Medical Center Groningen, Groningen (H.J.A.), and the Department of Gynecologic Oncology, Radboud University Medical Center, Nijmegen (L.F.A.G.M.) - all in the Netherlands; and the Department of Surgery, Aarhus University Hospital, Aarhus, Denmark (V.J.V.)
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