Preoperative prediction of suboptimal resection in advanced ovarian cancer based on clinical and CT parameters

A comparative study of [68Ga]Ga-FAPI-04 PET/MR and [18F]FDG PET/CT in the diagnostic accuracy and resectability prediction of ovarian cancer

PURPOSE

To provide a theory for guiding clinical treatment by comparing the clinical application value of [18F]fluorodeoxyglucose ([18F]FDG) PET/CT and [68Ga]Ga-FAPI (fibroblast activating protein inhibitor) PET/MR in the diagnosis and evaluation of resectability of ovarian cancer.

METHODS

Thirty patients with high clinical suspicion of ovarian malignancies were enrolled from July 2021 to October 2022 and underwent [18F]FDG PET/CT and [68Ga]Ga-FAPI-04 PET/MR within 5 days. Twenty patients underwent [18F]FDG PET/MR at once completing [18F]FDG PET/CT for consistency checking. Images were analysed for comparing SUVs and for judging incomplete resectability according to the peritoneal cancer index (PCI) and SUIDAN scoring system. The expression of FAP, HK2 and Ki67 was analysed by immunohistochemistry staining.

RESULTS

There was no significant difference between PET/MR and PET/CT in SUVs-FDG at different locations (p > 0.05), and their diagnostic accuracies were similar. The diagnostic accuracy of [68Ga]Ga-FAPI-04 PET/MR had advantages for peritoneal metastasis since SUVsFAPI were higher (p < 0.01). The sensitivity of [68Ga]Ga-FAPI-04 PET/MR in the diagnosis of peridiaghragmatic metastases was higher because SUVmax in the liver was decreased (p < 0.001). [68Ga]Ga-FAPI-04 PET/MR might have advantages in diagnosing gastrointestinal invasion. In PCI score analysis, [68Ga]Ga-FAPI-04 PET/MR could partially correct missing or underestimated scores by [18F]FDG PET/CT, but the matching probability between left peri-intestinal metastasis scores was low and easy to overestimate. Interestingly, diaphragmatic metastasis detected by [68Ga]Ga-FAPI-04 PET/MR had the greatest correlation with the prediction of incomplete resectability (logistic regression p = 0.02). Through immunohistochemistry, the expression of FAP had a strong correlation with SUVmax-FAPI (p < 0.001), while the expression of HK2 was correlated with SUVmax-FDG (p < 0.01). In addition, SUVmax-FDG with Ki67 ≥ 20% was significantly higher than that with Ki67 < 20% (p < 0.05).

CONCLUSIONS

[68Ga]Ga-FAPI-04 PET/MR had obvious advantages for metastases diagnosis and could more accurately assess tumour load and predict incomplete resectability. SUVmax-FDG was conducive to evaluating the degree of tumour malignancy.

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

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

Peroperative extent of peritoneal metastases affects the surgical outcome and survival in advanced ovarian cancer

OBJECTIVE

Determining whether cytoreductive surgery (CRS) is feasible in patients with advanced ovarian cancer and whether extensive surgery is justified is challenging. Accurate patient selection for CRS based on pre- and peroperative parameters will be valuable. The aim of this study is to assess the association between the extent of peritoneal metastases as determined during surgery and completeness of interval CRS and survival.

METHODS

This single-center observational cohort study included consecutive patients with newly diagnosed stage III-IV epithelial ovarian cancer who received neoadjuvant chemotherapy and underwent interval CRS. The 7 Region Count (7RC) was recorded during surgical exploration to systematically quantify the extent of peritoneal metastases. Logistic regression analysis was performed to predict surgical outcomes, and Cox regression analysis was done for survival outcomes.

RESULTS

A total of 316 patients were included for analyses. The median 7RC was 4 (interquartile range: 2-6). Complete CRS was performed in 58%, optimal CRS in 30%, and incomplete CRS in 12% of patients. A higher 7RC was independently associated with lower odds of complete or optimal CRS in multivariable analysis (odds ratio [OR] = 0.45, 95% confidence interval [CI]: 0.33-0.63, p < 0.001). Similarly, a higher 7RC was independently associated with worse progression-free survival (hazard ratio [HR] = 1.17, 95% CI 1.08-1.26, p < 0.001) and overall survival (HR = 1.14, 95% CI 1.04-1.25, p = 0.007).

CONCLUSION

The extent of peritoneal metastases, as expressed by the 7RC during surgery, is an independent predictor for completeness of CRS and has independent prognostic value for progression-free survival and overall survival in addition to completeness of CRS.

The BUMPy road of peritoneal metastases in ovarian cancer

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

Development and External Validation of a Novel Model for Predicting Postsurgical Recurrence and Overall Survival After Cytoreductive R0 Resection of Epithelial Ovarian Cancer

Purpose

Treatment of epithelial ovarian cancer is evolving towards personalization and precision, which require patient-specific estimates of overall survival (OS) and progression-free survival (PFS).

Patients and Methods

Medical records of 1173 patients who underwent debulking surgery in our center were comprehensively reviewed and randomly allocated into a derivation cohort of 879 patients and an internal validation cohort of 294 patients. Five hundred and seventy-seven patients from the other three cancer centers served as the external validation cohort. A novel nomogram model for PFS and OS was constructed based on independent predictors identified by multivariable Cox regression analysis. The predictive accuracy and discriminative ability of the model were measured using Harrell’s concordance index (C-index) and calibration curve.

Results

The C-index values were 0.82 (95% CI: 0.76–0.88) and 0.84 (95% CI: 0.78–0.90) for the PFS and OS models, respectively, substantially higher than those obtained with the FIGO staging system and most nomograms reported for use in epithelial ovarian cancer. The nomogram score could clearly classify the patients into subgroups with different risks of recurrence or postoperative mortality. The online versions of our nomograms are available at https://eocnomogram.shinyapps.io/eocpfs/ and https://eocnomogram.shinyapps.io/eocos/.

Conclusion

A externally validated nomogram predicting OS and PFS in patients after R0 reduction surgery was established using a propensity score matching model. This nomogram may be useful in estimating individual recurrence risk and guiding personalized surveillance programs for patients after surgery, and it could potentially aid clinical decision-making or stratification for clinical trials.

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

Objective

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

Materials and Methods

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

Results

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

Conclusion

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

Factors determining ultra-short-term survival and the commencement of active treatment in high-grade serous ovarian cancer: a case comparison study

Background

Despite improvements in median survival some patients with advanced ovarian cancer die within 100 days of diagnosis; the reasons for which remain poorly understood.

Here we investigate if ultra short-term survival can be explained by patient characteristics or treatment pathways.

Methods

A nested case comparison study was used to examine differences between patients with high grade serous ovarian/fallopian tube cancer who died within 100 days (n = 28) compared to a comparison group of patients matched for histology and including any survival greater than 100 days (n = 134).

Results

Cases and comparison patients had similar ages, BMI, ACE-27, deprivation indices, and distribution of disease on CT. There were no significant delays in time to diagnosis or treatment (p = 0.68) between the groups.

However, cases had lower serum albumin, haemoglobin and higher platelet counts than matched comparison patients (p < 0.0001) and a worse performance score (P = 0.006).

Conclusion

Patients who die rapidly after a diagnosis of ovarian cancer are only slightly older and have similar pre treatment frailty compared to patients whose survival approaches the median. However they do appear to undergo greater physiological compromise as a result of their disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08019-9.

Propensity score matching confirms that primary surgery or neoadjuvant chemotherapy result in equivalent survival within a comprehensive cohort of patients with high-grade serous ovarian cancer

OBJECTIVE

Our objective was to investigate whether trial evidence showing that neoadjuvant chemotherapy is non inferior to primary surgery for the primary treatment of advanced ovarian cancer could be extrapolated to groups of patients that were not included in the trials.

METHODS

Using a detailed retrospective cohort of all patients managed through a single tertiary hospital we carried out a propensity score analysis, principal component analysis, and cox proportional hazard analysis to compare survival in matched cohorts.

RESULTS

A propensity score analysis showed that for at least 41% of all patients with advanced high-grade serous cancer neoadjuvant chemotherapy is non inferior to primary surgery (median survival primary surgery: 38 months, neoadjuvant chemotherapy: 35 months. P = 0.39). However, principal component analysis, supported by cox modelling, suggests that for some subgroups, including patients with subdiaphragmatic nodal disease, primary surgery may be associated with improved survival (HR 0.11, CI 0.026-0.48).

CONCLUSIONS

We have shown that the findings of previous trials can be extrapolated to a wider population and that statistical modelling can be used to identify groups or patients who benefit from specific modalities of treatment.

Prognostic relevance of high pretreatment CA125 levels in primary serous ovarian cancer

The objective of the present study was to analyze the prognostic relevance of pretreatment serum CA125 ≥500 U/ml and its role as a non-invasive factor for estimating optimal cytoreduction (≤1 cm) in primary serous ovarian cancer. Clinicopathological parameters and CA125 levels prior to primary cytoreductive surgery were retrospectively evaluated in all 261 consecutive patients with primary epithelial ovarian cancer from a single centre. Inclusion criteria were existing preoperative CA125 level, serous ovarian cancer and performed full primary treatment (surgery/platinum-based chemotherapy). A total of 136 patients met the criteria. Among them, 74 patients had CA125 ≥500 U/ml. The other 62 patients that met the aforementioned criteria and had CA125 <500 U/ml were defined as controls. The present study tested cut-off CA125 values to detect subgroups affecting prognosis. The goal was to evaluate patients with optimal cytoreduction (R≤1 cm). Univariate analyses were performed with PASW to identify clinicopathological parameters associated with the pretreatment CA125 level. For survival analyses, a cut-off-value of CA125 ≥500 U/ml was used to identify the association between preoperative CA125 levels, resection status and prognosis. To test significant differences between examined groups, Student's t-test and the Mann-Whitney test were used. P<0.05 was considered to indicate a statistically significant difference. Significantly worse prognosis in terms of overall survival (P=0.023) and progression-free survival (P=0.011) was detected in the CA125 ≥500 U/ml group of optimally cytoreduced patients compared with in the CA125 <500 U/ml group. The complete cytoreduction rate was higher in CA125 <500 U/ml (33.9%) vs. CA125 ≥500 U/ml (21.6%). A CA125 level >1,404 U/ml had a higher rate of suboptimal cytoreduction (32.4%) compared with lower CA125 levels. A pretreatment CA125 level ≥500 U/ml had significantly worse prognostic impact after optimal cytoreduction compared with CA125 <500 U/ml. The higher the CA125 level the higher the suboptimal cytoreduction rate. Patients with CA125 ≥500 U/ml may be candidates for an initial laparoscopic approach to specify resectability and to determine how to proceed. Overall, CA125 levels appear to be helpful in predicting suboptimal cytoreductive surgery for patients with primary ovarian cancer, but should be interpreted together with clinical and radiologic findings. This may improve defining the optimal treatment strategy in these patients.

Predictive significance of preoperative CT findings for suboptimal cytoreduction in advanced ovarian cancer: a meta-analysis

Background

Computed tomography (CT) has been extensively used in predicting suboptimal cytoreduction (SCR) in advanced ovarian cancer (OC). However, disagreements remain in literatures on the predictive value of CT findings for SCR. This meta-analysis was designed to determine the ability of eight preoperative CT findings to predict SCR in advanced OC.

Materials and methods

A comprehensive literature search was conducted for eligible studies to identify the association between the eight preoperative CT findings and SCR in advanced OC. The predictive performances of preoperative CT findings were expressed in terms of sensitivity, specificity, positive likelihood ratio (PLR), negative likelihood ratio (NLR) and diagnostic odds ratio (DOR) with pooled proportion.

Results

A total of 10 studies and 1,614 patients were included in this meta-analysis. Large volume ascites had the highest sensitivity (64%, CI 56–71%), with a PLR of 1.3 (CI 1.1–1.5) and an NLR of 0.73 (0.59–0.90), while lymph node involvement had the highest specificity (89%, CI 79–94%). The highest DOR of 3 (CI 2–4) was achieved in peritoneal involvement and large bowel mesentery involvement. The other CT findings had poorer predictive performance.

Conclusion

Preoperative CT findings have a poor discriminative capacity to predict SCR in advanced OC. Preoperative CT predictors should be used with caution amid clinical decision-making.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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