Preoperative Factors Predicting Survival After Secondary Cytoreduction for Recurrent Ovarian Cancer:

Prognosis Following Surgery for Recurrent Ovarian Cancer and Diagnostic Criteria Predictive of Cytoreduction Success: A Systematic Review and Meta-Analysis

For women achieving clinical remission after the completion of initial treatment for epithelial ovarian cancer, 80% with advanced-stage disease will develop recurrence. However, the standard treatment of women with recurrent platinum-sensitive diseases remains poorly defined. Secondary (SCS), tertiary (TCS) or quaternary (QCS) cytoreduction surgery for recurrence has been suggested to be associated with increased overall survival (OS). We searched five databases for studies reporting death rate, OS, cytoreduction rates, post-operative morbidity/mortality and diagnostic models predicting complete cytoreduction in a platinum-sensitive disease recurrence setting. Death rates calculated from raw data were pooled based on a random-effects model. Meta-regression/linear regression was performed to explore the role of complete or optimal cytoreduction as a moderator. Pooled death rates were 45%, 51%, 66% for SCS, TCS and QCS, respectively. Median OS for optimal cytoreduction ranged from 16-91, 24-99 and 39-135 months for SCS, TCS and QCS, respectively. Every 10% increase in complete cytoreduction rates at SCS corresponds to a 7% increase in median OS. Complete cytoreduction rates ranged from 9-100%, 35-90% and 33-100% for SCS, TCS and QCS, respectively. Major post-operative thirty-day morbidity was reported to range from 0-47%, 13-33% and 15-29% for SCS, TCS and QCS, respectively. Thirty-day post-operative mortality was 0-6%, 0-3% and 0-2% for SCS, TCS and QCS, respectively. There were two externally validated diagnostic models predicting complete cytoreduction at SCS, but none for TCS and QCS. In conclusion, our data confirm that maximal effort higher order cytoreductive surgery resulting in complete cytoreduction can improve survival.

Secondary Cytoreductive Surgery in Platinum-Sensitive Recurrent Ovarian Cancer: A Meta-Analysis

PURPOSE

The survival impact of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer was studied.

METHODS

We identified published studies from 1983 to 2021 following our inclusion criteria from MEDLINE, EMBASE, and Cochrane library. To integrate the effect size of single-arm studies, meta-analysis was performed using death rate as a primary outcome. The effect of complete cytoreduction and optimal cytoreduction on survival was evaluated using meta-regression. The pooled death rate was presented with a 95% CI. The publication bias was evaluated with the funnel plot and Egger's test, and sensitivity analysis was performed. To overcome missing death rates, the linear regression model was performed on log-transformed median overall survival (OS) time using study size as a weight.

RESULTS

Thirty-six studies with 2,805 patients reporting death rates were used for this meta-analysis of the 80 eligible studies. There was strong heterogeneity, with the P value of the Cochrane Q test of < 0.0001 and Higgins's I² statistics of 86%; thus, we considered a random effect model. The pooled death rate was 44.2% (95% CI, 39.0 to 49.5), and both the complete and optimal cytoreductions were associated with better survival outcomes as significant moderators in the meta-regression model (P < .001 and P = .005, respectively). Although 14 studies were located outside the funnel plot, Egger's test indicated no publication bias (P = .327). A sensitivity analysis excluding 14 studies showed similar results. In the linear regression model on the basis of 57 studies, the median OS time increased by 8.97% and 7.04% when the complete and optimal cytoreduction proportion increased by 10%, respectively, after adjusting other variables.

CONCLUSION

Secondary cytoreductive surgery, resulting in maximal tumor resection, significantly prolongs OS in platinum-sensitive recurrent ovarian cancer.

Preoperative predictors that impact the survival and outcome of patients undergoing secondary cytoreduction for ovarian cancer

This study aimed to examine the factors affecting feasibility of optimal and complete secondary cytoreductive surgery (SCRS) and to characterise the prognostic factors that correlate with improved survival in patients who underwent SCRS. This is a retrospective single-institutional cohort study of patients who underwent SCRS for recurrent epithelial ovarian cancer (EOC). One hundred and forty-eight patients met inclusion criteria. Platinum sensitivity was associated with complete cytoreduction at SCRS. Factors associated with suboptimal cytoreduction (SOC) were age >55 years, serous histology, largest tumour implant size >4 cm, and SOC at primary surgery. Overall survival analysis showed significantly longer survival with complete cytoreduction compared to optimal and SOC. Surgical outcome of SCRS was an independent predictor of survival regardless of the outcome of primary cytoreduction. Location of the largest implant, DFI and timing of chemotherapy also impact on survival.

Current and Emerging Clinical Applications of Multispectral Optoacoustic Tomography (MSOT) in Oncology

Accurate detection and characterization of cancers are key for providing timely intervention and effective treatments. Current imaging technologies are particularly limited when it comes to detecting very small tumors in vivo, i.e., very early cancers or metastases, differentiating viable tumor from surrounding dead tumor tissue, and evaluating tumor metabolism within tissue. Optoacoustic imaging offers potential solutions to these imaging problems because of its ability to image optical absorption properties of both intrinsic tissue chromophores and exogenous contrast agents without the involvement of ionizing radiation. Optoacoustic imaging uses pulsed laser to induce localized thermoelastic expansion that generates acoustic waves detectable by an ultrasound transducer. To date, multispectral optoacoustic tomography (MSOT) has primarily been used in preclinical research; however, its use in translational and clinical research is expanding. This review focuses on current and emerging applications of optoacoustic imaging for molecular imaging of cancer using both exogenous and endogenous contrast agents and sheds light on potential future clinical applications. Clin Cancer Res; 22(14); 3432-9. ©2016 AACR.

Survival Impact of Secondary Cytoreductive Surgery for Recurrent Ovarian Cancer in an Asian Population

OBJECTIVE

The aim of this study was to evaluate the role of secondary cytoreductive surgery in Asian patients with recurrent ovarian cancer and to assess prognostic variables on overall post-recurrence survival time.

METHODS

We conducted a retrospective review of patients with recurrent ovarian cancer who underwent secondary cytoreduction at the Gynaecological Cancer Center at the KK Women's and Children's Hospital, Singapore, between 1999 and 2009. Eligible patients included those who had been firstly treated by primary cytoreductive surgery and followed by adjuvant chemotherapy and had a period of clinical remission of at least six months and subsequently underwent secondary cytoreductive surgery for recurrence. Univariate analysis was performed to evaluate various variables influencing the overall survival.

RESULTS

Twenty-five patients met our eligibility criteria. The median age was 52 years (range=31-78 years). The median time from completion of primary treatment to recurrence was 25.1 months (range=6.4-83.4). Secondary cytoreduction was optimal in 20 of 25 patients (80%). The median follow-up duration was 38.9 months (range=17.8-72.4) and median overall survival time was 33.1 months (95% confidence interval, 15.3-undefined.). Ten (40.0%) patients required bowel resection, but no end colostomy was performed. One (4.0%) patient had wedge resection of the liver, one (4.0%) had a distal pancreatectomy, one (4.0%) had a unilateral nephrectomy, and one (4.0%) had adrenalectomy. There were no operative deaths. The overall survival of patients who responded to secondary cytoreductive surgery and adjuvant chemotherapy was significantly longer than those patients who did not respond to the treatment. Of those patients who responded to the surgical management, patients with clear cell carcinoma fared well compared to those with the endometrioid, mucinous adenocarcinoma, and papillary serous type (p<0.001). Complete secondary cytoreductive surgery appeared to have some relationship to overall survival but was not statistically significant.

CONCLUSION

In carefully selected patients with recurrent ovarian cancer, optimal cytoreductive surgery is possible and in a subgroup of patients who respond to surgery and chemotherapy survival is significantly longer.

Robotic surgery for ovarian cancers: individualization of the surgical approach to select ovarian cancer patients

BACKGROUND

While well-accepted treatment for endometrial and cervical cancers, the role of robotic surgery in the management of primary and recurrent ovarian cancers remains an area of active study and debate.

METHODS

Narrative review of the pertinent literature on the use of robotics in the treatment of ovarian cancers.

RESULTS

The available evidence may indicate the feasibility of robotics for primary and secondary debulking of ovarian cancers. The use of robotics can be considered for the surgical treatment of patients requiring primary tumour excision, alone or with one additional major procedure, and patients with isolated recurrences. However, most of the publications are underpowered, retrospective, fail to provide sufficient data on long-term oncological outcomes and are published by highly skilled minimally invasive surgeons.

CONCLUSIONS

Robot-assisted surgery may provide a tool to individualize the surgical approach to select ovarian cancer patients. Copyright © 2015 John Wiley & Sons, Ltd.

The role of secondary cytoreduction in low-grade serous ovarian cancer or peritoneal cancer

OBJECTIVES

We sought to determine the benefit of secondary cytoreductive surgery (SCRS) in patients with low-grade serous ovarian or peritoneal carcinoma, and whether cytoreduction to no gross residual disease affects survival.

METHODS

A single institution retrospective chart review was conducted in patients with recurrent low-grade serous carcinoma who underwent SCRS between 1995 and 2012. Data including demographics, survival, chemotherapy, disease characteristics at the time of surgery, residual disease, and operative complications were collected. Overall survival (OS) and progression-free survival (PFS) were calculated. Kaplan-Meier and log-rank tests were used to examine survival outcomes.

RESULTS

Forty-one patients met inclusion criteria. The median time between primary tumor debulking and SCRS was 33.2 months. Of 41 eligible patients who underwent SCRS, 32 (78%) had gross residual disease at the completion of secondary surgery. The median PFS for patients with no gross residual disease after SCRS was 60.3 months, compared to 10.7 months for patients with gross residual disease (p = 0.008). Median OS from diagnosis for patients with no gross residual disease after SCRS was 167.5 months compared to 88.9 months (p = 0.10). Median OS from the time of SCRS for patients with no gross residual disease was 93.6 months compared to 45.8 months (p = 0.04). Complications occurred in 61% of patients after SCRS; there were no deaths directly attributable to surgery.

CONCLUSION

Our results suggest a benefit to SCRS in patients with recurrent low-grade serous carcinoma. Efforts to maximally cytoreduce patients should be made as patients with no gross residual disease had a better PFS and a trend toward better OS.

Role of minimally invasive surgery in ovarian cancer

The standard treatment of ovarian cancer includes upfront surgery with intent to accurately diagnose and stage the disease and to perform maximal cytoreduction, followed by chemotherapy in most cases. Surgical staging of ovarian cancer traditionally has included exploratory laparotomy with peritoneal washings, hysterectomy, salpingo-oophorectomy, omentectomy, multiple peritoneal biopsies, and possible pelvic and para-aortic lymphadenectomy. In the early 1990s, pioneers in laparoscopic surgery used minimally invasive techniques to treat gynecologic cancers, including laparoscopic staging of early ovarian cancer and primary and secondary cytoreduction in advanced and recurrent disease in selected cases. Since then, the role of minimally invasive surgery in gynecologic oncology has been continually expanding, and today advanced laparoscopic and robotic-assisted laparoscopic techniques are used to evaluate and treat cervical and endometrial cancer. However, the important question about the place of the minimally invasive approach in surgical treatment of ovarian cancer remains to be evaluated and answered. Overall, the potential role of minimally invasive surgery in treatment of ovarian cancer is as follows: i) laparoscopic evaluation, diagnosis, and staging of apparent early ovarian cancer; ii) laparoscopic assessment of feasibility of upfront surgical cytoreduction to no visible disease; iii) laparoscopic debulking of advanced ovarian cancer; iv) laparoscopic reassessment in patients with complete remission after primary treatment; and v) laparoscopic assessment and cytoreduction of recurrent disease. The accurate diagnosis of suspect adnexal masses, the safety and feasibility of this surgical approach in early ovarian cancer, the promise of laparoscopy as the most accurate tool for triaging patients with advanced disease for surgery vs upfront chemotherapy or neoadjuvant chemotherapy, and its potential in treatment of advanced cancer have been documented and therefore should be incorporated in the surgical methods of every gynecologic oncology unit and in the training programs in gynecologic oncology.

Adverse events associated with complementary and alternative medicine use in ovarian cancer patients

INTRODUCTION

Many women with ovarian cancer are choosing to include complementary and alternative medicine (CAM) substances in conjunction with their conventional treatment for ovarian cancer. Many oncologists express concern that the adjunct use of CAM substances may be detrimental to the achievement of therapeutic levels of chemotherapy leading to increases in drug toxicity, under-treatment of disease or other adverse events. In an effort to ascertain the extent of the potential problem with simultaneous use of CAM with conventional treatment we undertook comprehensive systematic review of published case reports describing CAM-related adverse events among ovarian cancer patients.

STUDY DESIGN

This article describes a systematic literature review.

METHODS

The Natural Medicines Comprehensive Database (NMCD). PubMed, EMBASE® and the Cochrane Central Register of Controlled Trials (CCTR) were systematically reviewed for research articles pertaining to case reports describing adverse events in patients, and clinical trials which examined the effects of herbs and supplements used during cancer treatment.

RESULTS

Only one case report and one clinical trial were identified which met our inclusion criteria and were relevant to the current investigation.

CONCLUSION

Although there are concerns about the potential for adverse events related to concurrent use of CAM substances during conventional treatment we found few case reports and clinical trials in the literature which support this.

CA-125-indicated asymptomatic relapse confers survival benefit to ovarian cancer patients who underwent secondary cytoreduction surgery

Background

There is no consensus regarding the management of ovarian cancer patients, who have shown complete clinical response (CCR) to primary therapy and have rising cancer antigen CA-125 levels but have no symptoms of recurrent disease. The present study aims to determine whether follow-up CA-125 levels can be used to identify the need for imaging studies and secondary cytoreductive surgery (CRS).

Methods

We identified 410 ovarian cancer patients treated at The University of Texas MD Anderson Cancer Center between 1984 and 2011. These patients had shown CCR to primary therapy. Follow-up was conducted based on the surveillance protocol of the MD Anderson Cancer Center. We used the Cox proportional hazards model and log-rank test to assess the associations between the follow-up CA-125 levels and secondary CRS and survival duration.

Results

The CA-125 level of 1.68 × nadir was defined as the indicator of recurrent disease (p < 0.001). The specificity and sensitivity of this criterion were 82.9% and 85.6%, respectively, and the median lead-time of the CA-125 biochemical progression prior to clinically-defined relapse was 31 days (ranging from 1 to 391 days). The median number of the negative imaging studies for the clinical relapse findings in patients with a CA-125 level of < 1.68 × nadir was 3 (ranging from 0 to 24 times). The increase of CA-125 level at relapse was an independent predictor of overall and progression free survival in patients who had shown CCR to primary therapy (p = 0.04 and 0.02 respectively). The overall and progression free survival durations in patients with a CA-125 level ≤ 1.68 × nadir at relapse (69.4 and 13.8 months) were longer than those with a CA-125 level > 1.68 × nadir at relapse (55.7 and 10.4 months; p = 0.04 and 0.01, respectively). The overall and progression free survival duration of patients with asymptomatic relapse and underwent a secondary CRS was longer than that of patients with symptomatic relapse (p = 0.02 and 0.04 respectively).

Conclusions

The increase of serum CA-125 levels is an early warning of clinical relapse in ovarian cancer. Using CA-125 levels in guiding the treatment of patients with asymptomatic recurrent ovarian cancer, who have shown CCR to primary therapy, can facilitate optimal secondary CRS and extend the survival duration of the patients.

Surgical management of epithelial ovarian cancer

Ovarian cancer affects approximately 21,880 women and accounts for over 13,000 deaths annually in the United States. Although survival rates have improved over the past several decades, directly as a result of advances in chemotherapy and surgery, ovarian cancer continues to have high mortality rates. Understanding the multiple roles of surgery throughout the disease course is the focus of this review.