Prediction Models for Complete Resection in Secondary Cytoreductive Surgery of Patients With 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.

Consensus on the management of platinum-sensitive high-grade serous epithelial ovarian cancer in Lebanon

Ovarian cancer is the most lethal gynecologic cancer. The high grade serous epithelial (HGSE) subtype is the most aggressive and it often presents at advanced stages, while screening programs have not proven beneficial. Management of the advanced stages (FIGO III and IV), which constitute the majority of diagnoses, usually consists of platinum-based chemotherapy and cytoreductive surgery (primary or interval) followed by maintenance therapy. Currently, the standard-of-care for advanced newly diagnosed HGSE ovarian cancer, as per international medical societies, starts with upfront cytoreductive surgery, followed by platinum-based chemotherapy (mostly carboplatin and paclitaxel) and/or anti-angiogenic agent bevacizumab, then maintenance therapy with a poly(ADP-ribose) polymerase (PARP) inhibitor with/without/or bevacizumab (continued). PARP inhibitor use depends on the patient's genetic signature, mainly the breast cancer gene (BRCA) mutation and the homologous recombination deficiency (HRD) status. Therefore, genetic testing is recommended at diagnosis to inform treatment and prognosis. In line with the evolving standard-of-care for ovarian cancer, a panel of experts in treating advanced ovarian cancer convened to lay down practical recommendations on the management of advanced ovarian cancer in Lebanon; since the currently applicable guidelines by the Lebanese Ministry of Public Health for cancer treatment have not been updated yet to reflect the treatment paradigm shift brought upon by the development and approval of PARP inhibitors. The current work reviews the leading clinical trials on PARP inhibitors (as maintenance for newly diagnosed advanced and platinum-sensitive relapsed ovarian cancer), presents international recommendations, and proposes treatment algorithms for optimal local practice.

The current role of secondary cytoreductive surgery for recurrent ovarian cancer

Ovarian cancer represents worldwide the second most frequent and the most fatal gynecological malignancy, with approximately two thirds of the patients presenting with advanced disease. Cytoreductive surgery, primary or after neoadjuvant chemotherapy, in combination with platinum-based chemotherapy is the standard of care for these patients. Despite the improvement in quality of cytoreductive surgery as well as development of novel drugs and chemotherapy regimens, still most women with ovarian cancer will ultimately develop recurrent disease and die of their disease. In contrast to the management of primary disease, the standard treatment of patients with recurrent ovarian cancer remains a topic of debate. While platinum-based or second line systemic chemotherapy, depending on the time after last platinum treatment, is standard of care, the role of secondary cytoreductive surgery has been a controversial issue for the last decades. Potential outcome benefit must be also weighed against the risk of severe surgical morbidity, impairment of quality of life and costs. In platinum-resistant recurrent disease, i.e., relapse after less than 6 months from the last platinum-based chemotherapy for primary disease, secondary cytoreduction seems generally not to be indicated due to its aggressive biological behavior and the absence of effective systemic treatment. In this comprehensive review, the current role of cytoreductive surgery in platinum-sensitive recurrent ovarian cancer is discussed thoroughly in view of the results of most recent randomized trials and a meta-analysis. There seems to be definitely a role for secondary cytoreductive surgery in selected patients with ovarian cancer recurrence in whom complete resection of macroscopic disease is feasible. However, its role should be continuously reviewed due to the changing systemic treatment of patients with ovarian cancer recurrence over time.