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

The most advanced epithelial ovarian cancer develops recurrent disease despite maximal surgical cytoreduction and adjuvant platinum-based chemotherapy. Treatment with secondary cytoreductive surgery (SCS) combined with chemotherapy or with chemotherapy alone for patients with platinum-sensitive recurrent ovarian cancer (ROC) is currently under heated discussion. Encouragingly, the results of the AGO DESKTOP III Study and the SOC1/SGOG-OV2 trial, which have been published recently, showed a striking advantage in terms of overall survival (OS) and progression-free survival (PFS) of ROC patients undergoing SCS compared to chemotherapy alone; moreover, a benefit of SCS exclusively for patients with complete gross resection (CGR) was particularly highlighted. CGR is considered the ultimate goal of SCS, on condition that the balance between maximal survival gain and minimal operative morbidity is maintained. Several models have been proposed to predict the rate of CGR, such as the MSK criteria, the AGO score, and the Tian model, over the last 15 years. This summary is mainly about the several previously published prediction models for CGR in SCS of ROC patients and discusses the effectiveness and limitations of these prediction models.

Performance validation of the Mayo triage algorithm applied to individualize surgical management of advanced epithelial ovarian cancer.

OBJECTIVE: To externally validate the performance of the Mayo triage algorithm applied to treatment strategy management in advanced epithelial ovarian cancer (AEOC) patients. METHODS: AEOC patients who underwent primary debulking surgery (PDS) were included and were divided into two groups based on the Mayo triage algorithm: "high risk" and "triage appropriate". The surgery outcomes and complications of the patients were compared between the two groups. RESULTS: 179 consecutive AEOC patients were enrolled for analysis, including 32 patients in the high-risk group and 147 patients in the triage-appropriate group. The results showed that patients in the high-risk group were older, had worse physical status and had lower preoperative serum albumin than those in the triage-appropriate group (P<0.01). The high-risk group had a lower proportion of women who underwent intermediate/high complexity surgery (38% vs. 72%, P<0.01) as well as a lower proportion of women who underwent optimal resection (50% vs. 71%, P<0.05). Furthermore, the incidence of 30-day complications (28% vs. 5%, P<0.01) and the proportion of patients who were unable to undergo adjuvant chemotherapy after PDS (22% vs. 2%, P<0.01) were both significantly higher in the high-risk group than in the triage-appropriate group. In addition, compared to the triage-appropriate group, the 90-day mortality rate in the high-risk group was also notably higher, but the difference was not statistically significant (6% vs. 1%, P=0.15). CONCLUSION: The validity of the Mayo triage algorithm for treatment decision-making in AEOC was externally confirmed in this study. This short-term complication assessment tool could be effectively used for the individualized primary management of high-risk AEOC patients. The feasibility of the Mayo triage algorithm for use in long-term management should be further explored.

Does the method of primary treatment affect the pattern of first recurrence in high-grade serous ovarian cancer?

PURPOSE: To determine if the primary treatment approach (primary debulking surgery (PDS) versus neoadjuvant chemotherapy and interval debulking surgery (NACT-IDS)) influences the pattern of first recurrence in patients with completely cytoreduced advanced high-grade serous ovarian carcinoma (HGSOC). MATERIALS AND METHODS: This retrospective study included 178 patients with newly diagnosed stage IIIC-IV HGSOC, complete gross resection during PDS (n = 124) or IDS (n = 54) from January 2008-March 2013, and baseline and first recurrence contrast-enhanced computed tomography scans. Clinical characteristics and number of disease sites at baseline were analyzed for associations with time to recurrence. In 135 patients who experienced recurrence, the overlap in disease locations between baseline and recurrence and the number of new disease locations at recurrence were analyzed according to the primary treatment approach. RESULTS: At univariate and multivariate analyses, NACT-IDS was associated with more overlapping locations between baseline and first recurrence (p ≤ 0.003) and fewer recurrences in new anatomic locations (p ≤ 0.043) compared with PDS. The same results were found in a subgroup that received intra-peritoneal adjuvant chemotherapy after either treatment approach. At univariate analysis, patient age, primary treatment approach, adjuvant chemotherapy route, and number of disease locations at baseline were associated with time to recurrence (p ≤ 0.009). At multivariate analysis, older patient age, NACT-IDS, and greater disease locations at baseline remained significant (p ≤ 0.018). CONCLUSION: The distribution of disease at the time of first recurrence varied with the choice of primary treatment. Compared to patients treated with PDS, patients who underwent NACT-IDS experienced recurrence more often in the same locations as the original disease.

Continuous improvement in primary Debulking surgery for advanced ovarian cancer: Do increased complete gross resection rates independently lead to increased progression-free and overall survival?

OBJECTIVES: To assess complete gross resection (CGR) rates and survival outcomes in patients with advanced ovarian cancer who underwent primary debulking surgery (PDS) during a 13-year period in which specific changes to surgical paradigm were implemented. METHODS: We identified all patients with stage IIIB-IV high-grade ovarian carcinoma who underwent PDS at our institution, with the intent of maximal cytoreduction, from 1/2001-12/2013. Patients were categorized by year of PDS based on the implementation of surgical changes to our approach to ovarian cancer debulking (Group 1, 2001-2005; Group 2, 2006-2009; Group 3, 2010-2013). RESULTS: Among 978 patients, 78% had stage IIIC disease and 89% had disease of serous histology. Carcinomatosis was found in 81%, and 60% had bulky upper abdominal disease (UAD). Compared to Group 1, those who underwent PDS during the latter 2 time periods had higher ASA scores (p < 0.001), higher-stage disease (p < 0.001), and more often had carcinomatosis (p = 0.015) and bulky UAD (p = 0.009). CGR rates for Groups 1-3 increased from 29% to 40% to 55%, respectively (p < 0.001). Five-year progression-free survival (PFS) rates increased over time (15%, 16%, and 20%, respectively; p = 0.199), as did 5-year overall survival (OS) rates (40%, 44%, and 56%, respectively; p < 0.001). On multivariable analysis, CGR was independently associated with PFS (p < 0.001) and OS (p < 0.001). CONCLUSIONS: Despite higher-stage disease and greater tumor burden, CGR rates, PFS and OS for patients who underwent PDS increased over a 13-year period. Surgical paradigm shifts implemented specifically to achieve more complete surgical cytoreduction are likely the reason for these improvements.

A comparative analysis of prediction models for complete gross resection in secondary cytoreductive surgery for ovarian cancer.

OBJECTIVE: We sought to examine compliance and outcomes using Memorial Sloan Kettering "(MSK) criteria" to predict complete gross resection (CGR) and compare them with the validated Tian and AGO models. METHODS: Patients who underwent SCS for recurrent platinum-sensitive ovarian cancer from 5/2001-6/2014 were identified. The AGO and Tian models were applied to the study population; appropriate statistical tests were used to determine ability to predict CGR. RESULTS: 214 SCS cases were identified. Since the implementation of MSK criteria, the CGR rate has been 86%. The AGO model had a 49% accuracy rate in predicting CGR, and predicted gross residual disease (RD) in 51%; however, CGR was achieved in 86%. The Tian model had an 88% accuracy rate. Of the 4% scored as Tian high risk for gross RD, 33% achieved a CGR. Comparing models, McNemar's p-value was 0.366 between the Tian and MSK models and <0.001 between AGO and MSK criteria. Median PFS was 21.3 (95%CI, 18.2-24.5), 22.5 (95%CI, 19.4-25.3), and 14.1months (95%CI, 9.7-22.1) for the entire cohort, for those achieving CGR, and for those left with RD, respectively (p=0.013). OS was 82.2 (95%CI, 60.2-123.3), 95.6 (95%CI, 63.6-NE), and 57.5months (95%CI, 27.5-113.9), respectively (p=0.014). CONCLUSION: CGR during SCS is associated with extended PFS and OS. We report a high rate of CGR using MSK criteria. There was good concordance between the Tian and MSK models; however, the latter has fewer variables and is more user-friendly. Tian criteria may be applied to intermediate MSK cases for further stratification.