Karam, A. K. et al. Tertiary cytoreductive surgery in recurrent ovarian cancer: selection criteria and survival outcome. Gynecol. Oncol. 104, 377-380
Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA. Gynecologic Oncology
(Impact Factor: 3.77).
02/2007; 104(2):377-80. DOI: 10.1016/j.ygyno.2006.08.037
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.
Available from: Jalid Sehouli
- "This paradigm shift that appears to occur in terms of loss of value of conventional prognostic and predictive factors is not new . In all six so far existing studies evaluating tertiary cytoreduction in EOC , there is clear evidence that otherwise established common clinical factors were not able to adequately predict surgical outcome after tertiary surgery ( Leitao et al , 2004 ; Karam et al , 2007 ; Gultekin et al , 2008 ; Shih et al , 2010a ; Fotopoulou et al , 2011a ; Hızlı et al , 2012 ) . This is probably attributed to the high patients ' selection that inevitably occurs in these advanced settings . "
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To evaluate surgical outcome and survival benefit after quaternary cytoreduction (QC) in epithelial ovarian cancer (EOC) relapse.
We systematically evaluated all consecutive patients undergoing QC in our institution over a 12-year period (October 2000-January 2012). All relevant surgical and clinical outcome parameters were systematically assessed.
Forty-nine EOC patients (median age: 57; range: 28-76) underwent QC; in a median of 16 months (range:2-142) after previous chemotherapy. The majority of the patients had an initial FIGO stage III (67.3%), peritoneal carcinomatosis (77.6%) and no ascites (67.3%). At QC, patients presented following tumour pattern: lower abdomen 85.7%; middle abdomen 79.6% and upper abdomen 42.9%. Median duration of surgery was 292 min (range: a total macroscopic tumour clearance could be achieved. Rates of major operative morbidity and 30-day mortality were 28.6% and 2%, respectively.Mean follow-up from QC was 18.41 months (95% confidence interval (CI):12.64-24.18) and mean overall survival (OS) 23.05 months (95% CI: 15.5-30.6). Mean OS for patients without vs any tumour residuals was 43 months (95% CI: 26.4-59.5) vs 13.4 months (95% CI: 7.42-19.4); P=0.001. Mean OS for patients who received postoperative chemotherapy (n=18; 36.7%) vs those who did not was 40.5 months (95% CI: 27.4-53.6) vs 12.03 months (95% CI: 5.9-18.18); P<0.001.Multivariate analysis indentified multifocal tumour dissemination to be of predictive significance for incomplete tumour resection, higher operative morbidity and lower survival, while systemic chemotherapy subsequent to QC had a protective significant impact on OS. No prognostic impact had ascites, platinum resistance, high grading and advanced age.
Even in this highly advanced setting of the third EOC relapse, maximal therapeutic effort combining optimal surgery and chemotherapy appear to significantly prolong survival in a selected patients 'group'.
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ABSTRACT: To evaluate the impact of tertiary cytoreductive surgery (TCS) on patient survival and to determine predictors of optimal TCS.
Twenty patients with recurrent epithelial ovarian carcinoma who had TCS at Hacettepe University Hospital during 1992-2004 were retrospectively reviewed.
Tertiary cytoreductive attempt was successful (optimal defined as <2 cm residual) in 12 patients and suboptimal in the remaining eight patients. Seven patients had no macroscopic residual, five patients had <2 cm gross residual and remaining 8 patients had >or=2 cm gross residual disease. Of these alive patients, 10 patients were alive with metastatic disease and only three patients were alive without any evidence of disease. Three patients had operative morbidity (15%), all of which were mild-moderate degree. Multivariate analysis could not differentiate a unique significant factor to have a possible predictor effect of optimal TCS. Multivariate survival analysis also could not differentiate any factor to have significant effect upon patient survival, neither the outcomes of primary, secondary or tertiary cytoreductive surgeries nor the usage of preoperative or postoperative chemotherapies.
TCS may not be helpful for patient survival. Neither of the clinical factors predicted an optimal TCS. Further larger series are needed for a definite conclusion.
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