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Risum, S. et al. Prediction of suboptimal primary cytoreduction in primary ovarian cancer with combined positron emission tomography/computed tomography-a prospective study. Gynecol. Oncol. 108, 265-270

Department of Oncology, The Finsen Center, Rigshospitalet, Copenhagen University Hospital, Denmark.
Gynecologic Oncology (Impact Factor: 3.69). 02/2008; 108(2):265-70. DOI: 10.1016/j.ygyno.2007.11.002
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ABSTRACT To prospectively identify combined PET/CT predictors of incomplete/suboptimal primary cytoreduction in advanced ovarian cancer.
From September 2004 to March 2007, 179 patients with a Risk of Malignancy Index (RMI) >150 based on serum CA-125, ultrasound examinations and menopausal state, underwent PET/CT within 2 weeks prior to standard surgery/debulking of a pelvic tumor. Ten PET/CT features were identified and evaluated as predictors of cytoreduction in 54 patients with advanced ovarian cancer.
Complete cytoreduction (no macroscopic residual disease) was achieved in 35% and optimal cytoreduction (<1 cm residual disease) was achieved in 56%. Using univariate analysis, predictors of incomplete cytoreduction were large bowel mesentery implants (LBMI) (P<0.003), pleural effusion (P<0.009), ascites (P<0.009) and peritoneal carcinosis (P<0.01). LBMI (P<0.03) and ascites (P<0.05) were also predictors of suboptimal cytoreduction. Using multivariate analysis, LBMI was the only independent predictor of incomplete cytoreduction (P=0.004) and no predictor of suboptimal cytoreduction was found.
PET/CT predictors of cytoreduction were found. But they should not be used to withhold patients form primary cytoreductive surgery. We suggest PET/CT as a supplementary image modality prior to surgery in primary OC patients whenever accurate and comprehensive preoperative evaluation of primary tumor and metastases is desired.

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    • "This might suggest that a larger population is needed to detect differences in survival. Optimal cytoreduction, as already reported by other authors [24], was reached in a significant lower proportion of patients with PET/CT stage IV disease, despite the surgical effort being similar in all patients and not influenced by the spread of the disease. We acknowledge that, in patients with a preoperative diagnosis of metastatic disease, surgeons might have been unconsciously less inclined to perform an aggressive surgery, and this might be an explanation of the significant difference observed. "
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    ABSTRACT: the introduction of 18-FDG-PET/CT during preoperative evaluation of patients with epithelial ovarian cancer (EOC) has led to an increase of the detection of extra-abdominal metastases. However, the clinical impact of this upstage remains unclear. patients with suspected advanced EOC underwent 18-FDG-PET/CT within two weeks prior to debulking surgery. between 2006 and 2011 95 patients met the inclusion criteria. Based on the concordance or the discrepancy of clinical and PET/CT stage, patients were divided in 3 groups (A: clinical and PET III; B: clinical III and PET IV; C: clinical and PET IV). Twenty-five patients were upstaged from FIGO stage III to stage IV by PET/CT. The proportion of patients who achieved a residual tumor<1cm in group B and C was similar, whereas it was significantly lower compared to group A. Similarly, complete response to adjuvant chemotherapy was achieved more frequently in patients in group A. PFS was similar in the three groups (17, 17 and 12months in group A, B and C), as well as OS (51, 41 and 35months). PET/CT is able to detect distant metastases in EOC patients. The presence of extra-abdominal disease probably indicates a more aggressive disease which also shows a lower response to standard chemotherapy. However, upstaged patients has a similar prognosis compared to stage III patients, probably because intra-abdominal disease is more likely to lead patients to death. This might also explain why residual tumor is the most important prognostic factor for advanced EOC patients.
    Gynecologic Oncology 09/2013; 131(3). DOI:10.1016/j.ygyno.2013.09.024 · 3.69 Impact Factor
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    • "Pomel and Dauplat [131] demonstrated three independent factors that reduce the likelihood of achieving complete cytoreduction: 1) diffuse small bowel involvement extending into the mesentery; 2) infiltrative disease of the porta hepatis (gross infiltration in general precludes complete resection); and 3) diffuse involvement of the right hemi diaphragm at the level of the suprahepatic vessels resulting in infiltration and fixation of the liver. Several studies have demonstrated that surgical outcomes of incomplete/suboptimal cytoreduction could be predicted by preoperative assessment with serum CA-125 level [132] [133] [134], positron emission tomography/computed tomography (PET/CT) [135], CT, and MRI [129] [136] [137] [138]. Preoperative predictors of suboptimal primary cytoreduction include high serum CA-125 level, presence of pulmonary and liver metastases, and clinical evidence of massive ascites. "
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    ABSTRACT: Ovarian cancer is the third-most common cancer of the female reproductive tract, yet it has the highest case fa-tality ratio of all gynecologic malignancies. Approximately 60% of women diagnosed with epithelial ovarian cancer will die of the disease, because the majority of patients are diagnosed with advanced disease. Surgery followed by chemotherapy is the standard approach to the management of advanced epithelial ovarian cancer. The goal of the surgery is optimal cytoreduction prior to the initiation of chemotherapy. As significant survival benefit from optimal cytoreduction has also been shown for patients with advanced disease. The generally accepted definition of optimal cytoreduction today is a residual tumor diameter no greater than 1 cm. However, the surgeon should attempt to achieve complete cytoreduction to a level of no visible disease or microscopic disease. The surgical procedures required to achieve complete cytoreduction depend on the disease distribution. The most common areas of tumor involvement are the paracolic gutters, the small bowel serosal and mesentery surfaces, the diaphragmatic and pelvic peritoneum, the greater and lesser omentum with extension to the transverse colon, and the sigmoid colon af-fected by direct extension from the ovary. In cases of extensive tumor involvement, optimal cytoreduction may involve a radical en bloc resection of all involved pelvic viscera and associated peritoneum, bowel resection, splenectomy, and dia-phragmatic and liver resection. The benefit of such aggressive surgery outweighs the risk of morbidity in the vast majority of patients. This paper is a review of the recent information concerning the definition of optimal cytoreduction, surgical techniques for maximum cytoreduction, and the selection criteria for patients.
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