Tertiary cytoreductive surgery in recurrent ovarian cancer: selection criteria and survival outcome.
ABSTRACT Studies of tertiary cytoreductive surgery (TCS) in recurrent epithelial ovarian cancer are limited, and appropriate patient selection remains a clinical challenge. We sought to evaluate the impact of TCS on survival and to determine predictors of optimal tertiary resection.
Between January 1997 and July 2004, 47 women with recurrent epithelial ovarian cancer underwent TCS at two institutions. All patients received initial platinum and taxane-based chemotherapy following primary cytoreductive surgery. Clinico-pathologic factors and survival were retrospectively abstracted from medical records. Optimal TCS was defined as microscopic residual disease.
Thirty of 47 (64%) patients underwent optimal TCS. Size of tumor implants<5 cm on preoperative imaging was the only significant predictor of achieving optimal TCS. Overall survival after TCS was statistically longer in patients with microscopic versus macroscopic residual disease (24 versus 16 months, p=0.03). After controlling for age, time to progression and optimal TCS, only the presence of diffuse disease at tertiary exploration remained a significant poor predictor of survival. However, in a cohort of patients with limited disease implants, multivariate analysis indicated that optimal TCS retained prognostic significance as a positive predictor of survival. Twelve patients (26%) experienced severe postoperative complications, including six with pulmonary embolism, four with fistulae and two with postoperative myocardial infarctions.
Size of disease implants on preoperative imaging may guide the selection of candidates for TCS. In those patients with limited disease implants at laparotomy, optimal TCS is associated with improved survival.
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ABSTRACT: Ovarian cancer is the most lethal gynecological malignancy, with aggressive surgical debulking and adjuvant chemotherapy as the main treatment modalities. Optimal debulking during the primary surgery is significantly correlated with prolonged survival. As surgical techniques and chemotherapeutic agents improve, more patients with prolonged survival may face secondary and tertiary recurrences. The role of surgical debulking in secondary cytoreduction (SC) is not clearly defined and is based on retrospective series. The treatment of patients with primary or secondary recurrences generally consists of second-line chemotherapy, but may be performed on medically fit patients in certain circumstances. A limited number of studies concerning tertiary cytoreduction (TC) in cases of secondary recurrences have been published. In these studies, conventional prognostic factors for SC, including ascites, an advanced International Federation of Gynecology and Obstetrics (FIGO) stage and/or peritoneal carcinomatosis, did not apply to TC, but the post-operative residual tumor load was significant in determining the prognosis. A limited number of patients with completely-resectable tumors may have an opportunity for a maximal cytoreduction in these circumstances. TC appears to result in a favorable outcome and moderate complication rates. The surgery is an available option for patients with recurrence, in whom a complete tumor resection may be achieved.Oncology letters 09/2013; 6(3):642-647. · 0.24 Impact Factor
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ABSTRACT: Cytoreductive surgery combined with hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) has been proposed as treatment for advanced epithelial ovarian carcinoma (EOC). No consensus exists on when to administer CRS+HIPEC during the natural history of the disease, namely, as upfront therapy, at first recurrence, or at second or subsequent recurrence. We analyzed a series of patients with advanced EOC collected prospectively in an institution with a peritoneal malignant disease treatment program. Patients were treated with CRS+HIPEC upfront, at first recurrence, and at second or subsequent recurrence. We treated 42 patients: 15 upfront, 19 at first recurrence, and 8 at second or subsequent recurrence. Cytoreduction was complete (CC0) in 75% of cases; residual disease was <2.5 mm (CC1) in 25%. Severe morbidity (CTCAE v.3.0, grade 3-4) was 26%, and hospital mortality was 7%. After a median follow-up of 24 months, median overall survival was 77.8 months for patients treated upfront, 62.8 months for patients treated at first recurrence, and 35.7 months for patients treated at second or subsequent recurrence. Disease-free survival was 21.1 months, 18 months, and 5.7 months, respectively. Overall survival in the upfront and first recurrence groups was similar, and statistically significant differences with the second recurrence group were identified (p<0.03). Treatment of advanced EOC using CRS+HIPEC is promising in terms of overall survival and disease-free survival when administered as upfront and at first recurrence therapy. These results warrant further evaluation in a randomized trial.European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 07/2013; · 2.56 Impact Factor