Secondary analyses from a randomized clinical trial: age as the key prognostic factor in endometrial carcinoma.

OBJECTIVE: The purpose of this study was to explore in greater depth the outcomes of the Italian randomized trial investigating the role of pelvic lymphadenectomy in clinical early stage endometrial cancer. In the attempt to identify the patients with poorer prognosis, the impact of age and body mass index were also thoroughly investigated by cancer-specific survival (CSS) analyses. STUDY DESIGN: Survival outcomes of trial patients were analyzed in relation to age (≤65 years and >65 years) in the 2 arms (lymphadenectomy and no lymphadenectomy) and in the whole population of the trial. RESULTS: Univariate and multivariable analyses of CSS and overall survival (OS) of patients showed that age >65 years is a strong independent poor prognostic factor (5-y OS 92.1% and 78.4% in ≤65 years and >65 years patients, respectively, P < .0001; 5-y CSS 93.8% and 83.5% in ≤65 years and >65 years patients, respectively, P = .003). Among women ≤65 years, node negative patients had 94.4% 5-y OS and 96.3% 5-y CSS vs 74.3% 5-y OS and 74.3% 5-y CSS for node positive patients (P = .009 and P = .002, respectively), while among women >65 y, node negative patients had 75.7% 5-y OS and 83.6% 5-y CSS vs 74.1% 5-y OS and 83.3% 5-y CSS for node positive patients (P = .55 and P = .58, respectively). Univariate and multivariable survival analyses in the whole trial population showed that older age, and higher tumor grade and stage were significantly associated to a worse prognosis. CONCLUSION: Older women faced an intrinsic poorer survival whether or not they underwent lymphadenectomy, and, unexpectedly, irrespective of the presence of nodal metastasis. Only in older patients was obesity (body mass index >30) significantly associated with scarce prognosis.

Conservative treatment of microinvasive adenocarcinoma of uterine cervix: long-term follow-up.

UNLABELLED: OBIECTIVE: This study aimed to evaluate the safety of conservative treatment in women desiring preservation of fertility with stage IA adenocarcinoma of the cervix. MATERIALS AND METHODS: Clinical report of all women with stage IA adenocarcinoma of the cervix, endocervical subtype, with clear margins on cone biopsy, diagnosed in our cancer center inclusive between January 1995 and December 2007, were evaluated, after either conservative therapy or hysterectomy. All diagnoses were reviewed by a pathologist expert in gynecologic oncology. Follow-up methods include at least cervical cytology, colposcopy with direct biopsy if indicated, and cervical curettage. RESULTS: Of 783 laser cone biopsy specimens, 7 were diagnostic for microinvasive adenocarcinoma, endocervical subtype (6 stage IA1 lesions and 1 stage IA2 lesion) with clear margins. No lymphovascular space invasion was seen. No residual invasive disease was observed in the specimens of 2 patients treated with hysterectomy after conization. Five women treated with laser cone biopsy only are free of invasive disease at 44, 66, 72, 86 and 100 months; 1 patient was found to have persistent adenocarcinoma in situ on endocervical cytology. CONCLUSIONS: Cone biopsy as definitive therapy is safe in women with stage IA1 adenocarcinoma of the cervix, endocervical subtype, with clear margins and no lymphovascular space invasion. Because of the low reliability of follow-up techniques (cytology, colposcopy, and endocervical curettage), conservative treatment should be reserved only for women strongly desiring to preserve fertility and accepting the risk of recurrent disease.

Small primary adenocarcinoma in adenomyosis with nodal metastasis: a case report.

BACKGROUND: Malignant transformation of adenomyosis is a very rare event. Only about 30 cases of this occurrence have been documented till now. CASE PRESENTATION: The patient was a 57-year-old woman with a slightly enlarged uterus, who underwent total hysterectomy and unilateral adnexectomy. On gross inspection, the uterine wall displayed a single nodule measuring 5 cm and several small gelatinous lesions. Microscopic examination revealed a common leiomyoma and multiple adenomyotic foci. A few of these glands were transformed into a moderately differentiated adenocarcinoma. The endometrium was completely examined and tumor free. The carcinoma was, therefore, considered to be an endometrioid adenocarcinoma arising from adenomyosis. Four months later, an ultrasound scan revealed enlarged pelvic lymph nodes: a cytological diagnosis of metastatic adenocarcinoma was made. Immunohistochemical studies showed an enhanced positivity of the tumor site together with the neighbouring adenomyotic foci for estrogen receptors, aromatase, p53 and COX-2 expression when compared to the distant adenomyotic glands and the endometrium. We therefore postulate that the neoplastic transformation of adenomyosis implies an early carcinogenic event involving p53 and COX-2; further tumor growth is sustained by an autocrine-paracrine loop, based on a modulation of hormone receptors as well as aromatase and COX-2 local expression. CONCLUSION: Adenocarcinoma in adenomyosis may be affected by local hormonal influence and, despite its small size, may metastasize.

UGT1A1*28 polymorphism in ovarian cancer patients.

(Uridino-diphosphate)glucuronosyl-transferase enzyme 1A1 isoform (UGT1A1) is involved in glucuronidation of antineoplastic drugs such as SN38, the active metabolite of irinotecan, as well as estrogens and their metabolites. UGT1A1*28 polymorphism decreases UGT1A1 expression and could alter estrogens disposition influencing tumour growth in hormone sensitive tissues. The UGT1A1*28 distribution among an ovarian cancer patient (OCP) population of 217 mono-institutional individuals was investigated to clarify its possible involvement in the pathogenesis and chemotherapy of ovarian cancer. Data were compared with those of 205 female healthy blood donors. In 160 patients also the tumour tissue was genotyped to describe the occurrence of loss of heterozygosity (LOH). A PCR based assay followed by automated fragment analysis was used. Odds ratios (OR), and 95% confidence intervals (95% CI), were computed by a multiple logistic regression model using as dependent variable in a case-control or in a case-case approach the histological classification. No significant prevalence of the polymorphism was observed in the cases versus controls. In a case-case approach, a higher frequency of the polymorphism was observed in patients with mucinous tumours (6/11, 54.6%) compared to non-mucinous (30/206, 14.6%) (p=0.009, OR=7.20; 95% CI 2.06-25.19). LOH was observed in 12 cases out of 160 (7.5%) and was associated with non-mucinous tumours, 10 (83.3%) cases determined a retention of the wild-type allele. In conclusion, the prevalence of UGT1A1*28 found in mucinous OCP could suggest a role in the development of specific histologic sub-groups and could become a marker to be considered when planning ovarian cancer chemotherapy.

Amsterdam criteria II and endometrial cancer index cases for an accurate selection of HNPCC families.

Endometrial carcinoma (EC) is the second most common tumor in hereditary nonpolyposis colorectal cancer (HNPCC), with an incidence rate of 60% by the age of 70 in mutation carriers. The International Collaborative Group on HNPCC revised the Amsterdam criteria and proposed a new, wider definition including extracolonic cancers. The aim of our study was to evaluate the accuracy of a new definition called Amsterdam criteria II. We updated, reclassified and compared the pedigrees of 29 women, already reported as being affected by EC and having a colorectal cancer familial background, according to the two clinical diagnostic criteria for HNPCC (Amsterdam criteria I, ACI, and Amsterdam criteria II, ACII) after two periods of observation (1990-1995 and 1995-2000). According to ACII the frequency of HNPCC in the population under study increased from 0.9% to 3.7% in the period 1990-1995 and from 3.2% to 3.7% in the period 1995-2000. ACII allowed early detection of HNPCC families and thus made it possible to provide them with a suitable surveillance program and genetic testing.

Prognostic role of bowel involvement in optimally cytoreduced advanced ovarian cancer: a retrospective study.

BACKGROUND: Optimal debulking surgery is postulated to be useful in survival of ovarian cancer patients. Some studies highlighted the possible role of bowel surgery in this topic. We wanted to evaluate the role of bowel involvement in patients with advanced epithelial ovarian cancer who underwent optimal cytoreduction. METHODS: Between 1997 and 2004, 301 patients with advanced epithelial cancer underwent surgery at Department of Gynecological Oncology of Centro di Riferimento Oncologico (CRO) National Cancer Institute Aviano (PN) Italy. All underwent maximal surgical effort, including bowel and upper abdominal procedure, in order to achieve optimal debulking (R < 0.5 cm). PFS and OS were compared with residual disease, grading and surgical procedures. RESULTS: Optimal cytoreduction was achieved in 244 patients (81.0%); R0 in 209 women (69.4.%) and R < 0.5 in 35 (11.6%). Bowel resection was performed in 116 patients (38.5%): recto-sigmoidectomy alone (69.8%), upper bowel resection only (14.7%) and both recto-sigmoidectomy and other bowel resection (15.5%). Pelvic peritonectomy and upper abdomen procedures were carried out in 202 (67.1%) and 82 (27.2%) patients respectively. Among the 284 patients available for follow-up, PFS and OS were significantly better in patients with R < 0.5. Among the 229 patients with optimal debulking (R < 0.5), 137 patients (59.8%) developed recurrent disease or progression. In the 229 R < 0.5 group, bowel involvement was associated with decreased PFS and OS in G1-2 patients whereas in G3 patients OS, but not PFS, was adversely affected. In the 199 patients with R0, PFS and OS were significantly better (p < 0.01) for G1-2 patients without bowel involvement whereas only significant OS (p < 0.05) was observed in G3 patients without bowel involvement versus G3 patients with bowel involvement. CONCLUSIONS: Optimal cytoreduction (R < 0.5 cm and R0) is the most important prognostic factor for advanced epithelial ovarian cancer. In the optimally cytoreduced (R < 0.5 and R0) patients, bowel involvement is associated with dismal prognosis for OS both in patients with G1-2 grading and in patients with G3 grading. Bowel involvement in G3 patients, carries instead the same risk of recurrence for PFS.

What sampling device is the most appropriate for vaginal vault cytology in gynaecological cancer follow up?

BACKGROUND: In women with cancer-related hysterectomy, the vaginal vault cytology has a low efficacy - when performed by conventional methods - for the early detection of vaginal recurrence. The amount of exfoliated cells collected is generally low because of atrophy, and the vaginal vault corners can be so narrow that the commonly used Ayres spatula cannot often penetrate deeply into them. This prospective study aimed at identifying the advantages obtained in specimens collection using the cytobrush, as compared to the Ayres's spatula. PATIENTS AND METHODS.: 141 gynaecologic cancer patients were studied to compare samplings collected with Ayre's spatula or with cytobrush. In a pilot setting of 15 patients, vaginal cytology samples obtained by both Ayre's spatula and cytobrush were placed at the opposite sites of a single slide for quali-quantitative evaluation. Thereafter, the remaining 126 consecutive women were assigned to either group A (spatula) or B (cytobrush) according to the order of entry. The same gynaecologist performed all the procedures. RESULTS: In all 15 pilot cases, the cytobrush seemed to collect a higher quantity of material. The comparative analysis of the two complete groups indicated that the cytobrush technique was more effective than the spatula one. The odds ratio (OR) for an optimal cytology using the cytobrush was 2.8 (95% confidence interval -C.I. 1.3-6.2; chi-square test, p=0.008). CONCLUSIONS: Vaginal vault cytology with cytobrush turned out to better perform than the traditional Ayre's spatula to obtain an adequate sampling in gynecological cancer patients.

Polymorphic thymidylate synthase gene impacts on overall survival of patients with epithelial ovarian cancer after platinum-based chemotherapy.

AIM: High levels of TS have been associated with a worse clinical outcome in several cancers including epithelial ovarian cancer (EOC). The TS gene (TYMS) is highly polymorphic and has an effect on mRNA/protein expression. MATERIALS & METHODS: Six TYMS polymorphisms were investigated for overall survival (OS) in 216 EOC patients: TYMS 1494ins/del, TSER (variable number of tandem repeats of 28 bp), TSER G>C, TYMS 1053C>T, TYMS IVS6-68C>T and TYMS 1122A>G. RESULTS: In a multivariate analysis, TYMS 1494 del/del genotype was associated with a significant increased OS compared with the ins/ins genotype (hazard ratio: 0.36; 95% CI: 0.16-0.82, p = 0.01). Similar results were obtained for the mutant genotypes TYMS 1053TT and TYMS IVS6-68TT. The event-free survival was significantly higher in TYMS 1053TT patients compared with wild-type patients (p = 0.05). CONCLUSION: TYMS 1494ins/del, 1053C>T and IVS6-68C>T polymorphisms can be prognostic markers for OS in patients with EOC, independently from stage at diagnosis, median age and tumor histotype.

Serum S100A6 concentration predicts peritoneal tumor burden in mice with epithelial ovarian cancer and is associated with advanced stage in patients.

BACKGROUND: Ovarian cancer is the 5th leading cause of cancer related deaths in women. Five-year survival rates for early stage disease are greater than 94%, however most women are diagnosed in advanced stage with 5 year survival less than 28%. Improved means for early detection and reliable patient monitoring are needed to increase survival. METHODOLOGY AND PRINCIPAL FINDINGS: Applying mass spectrometry-based proteomics, we sought to elucidate an unanswered biomarker research question regarding ability to determine tumor burden detectable by an ovarian cancer biomarker protein emanating directly from the tumor cells. Since aggressive serous epithelial ovarian cancers account for most mortality, a xenograft model using human SKOV-3 serous ovarian cancer cells was established to model progression to disseminated carcinomatosis. Using a method for low molecular weight protein enrichment, followed by liquid chromatography and mass spectrometry analysis, a human-specific peptide sequence of S100A6 was identified in sera from mice with advanced-stage experimental ovarian carcinoma. S100A6 expression was documented in cancer xenografts as well as from ovarian cancer patient tissues. Longitudinal study revealed that serum S100A6 concentration is directly related to tumor burden predictions from an inverse regression calibration analysis of data obtained from a detergent-supplemented antigen capture immunoassay and whole-animal bioluminescent optical imaging. The result from the animal model was confirmed in human clinical material as S100A6 was found to be significantly elevated in the sera from women with advanced stage ovarian cancer compared to those with early stage disease. CONCLUSIONS: S100A6 is expressed in ovarian and other cancer tissues, but has not been documented previously in ovarian cancer disease sera. S100A6 is found in serum in concentrations that correlate with experimental tumor burden and with clinical disease stage. The data signify that S100A6 may prove useful in detecting and/or monitoring ovarian cancer, when used in concert with other biomarkers.

Risk analysis of colorectal cancer in women with endometrial carcinoma.

Endometrial carcinoma (EC) and colorectal cancer (CRC) are closely linked in a well-documented, predominantly inherited cancer syndrome known as hereditary non-polyposis colorectal cancer (HNPCC). Epidemiological studies report that women with EC have a 1.5- to 3-fold increased risk of developing CRC. However, this elevated risk could be the consequence of genetic confounding. In order to plan a proper CRC prevention program, we sought to verify and quantify this risk, first estimating it in 697 women with EC who received treatment and follow-up in one health care district between 1986 and 2000. The standardised incidence ratio (SIR), which compares observed with expected cases of CRC in the general population, was calculated. Multiple logistic regression analysis was used to estimate the odds ratio and 95% confidence interval of a dependent variable, second primary CRC, as a function of clinical and pathological features. Multiple primary tumours were observed in 6.7% of the patients, with CRC being the second most frequently occurring type of cancer. The estimated overall risk for CRC was slightly higher than that observed in the general population, but was nonetheless not statistically significant. Multivariate analysis revealed a family history of CRC to be a risk factor for developing the disease as a second primary cancer. A BMI ≤25 and the pathological spectrum of EC were clinical and pathological features associated with CRC development, but were without statistical significance. MSH2 and MLH1 mutational screening confirmed genetic involvement in most of the CRCs observed in the cohort. Overall, the data show that women with EC have a CRC risk similar to that of the general population, and should therefore be screened on the basis of risk factors for CRC.

Systematic pelvic lymphadenectomy vs. no lymphadenectomy in early-stage endometrial carcinoma: randomized clinical trial.

BACKGROUND: Pelvic lymph nodes are the most common site of extrauterine tumor spread in early-stage endometrial cancer, but the clinical impact of lymphadenectomy has not been addressed in randomized studies. We conducted a randomized clinical trial to determine whether the addition of pelvic systematic lymphadenectomy to standard hysterectomy with bilateral salpingo-oophorectomy improves overall and disease-free survival. METHODS: From October 1, 1996, through March 31, 2006, 514 eligible patients with preoperative International Federation of Gynecology and Obstetrics stage I endometrial carcinoma were randomly assigned to undergo pelvic systematic lymphadenectomy (n = 264) or no lymphadenectomy (n = 250). Patients' clinical data, pathological tumor characteristics, and operative and early postoperative data were recorded at discharge from hospital. Late postoperative complications, adjuvant therapy, and follow-up data were collected 6 months after surgery. Survival was analyzed by use of the log-rank test and a Cox multivariable regression analysis. All statistical tests were two-sided. RESULTS: The median number of lymph nodes removed was 30 (interquartile range = 22-42) in the pelvic systematic lymphadenectomy arm and 0 (interquartile range = 0-0) in the no-lymphadenectomy arm (P < .001). Both early and late postoperative complications occurred statistically significantly more frequently in patients who had received pelvic systematic lymphadenectomy (81 patients in the lymphadenectomy arm and 34 patients in the no-lymphadenectomy arm, P = .001). Pelvic systematic lymphadenectomy improved surgical staging as statistically significantly more patients with lymph node metastases were found in the lymphadenectomy arm than in the no-lymphadenectomy arm (13.3% vs 3.2%, difference = 10.1%, 95% confidence interval [CI] = 5.3% to 14.9%, P < .001). At a median follow-up of 49 months, 78 events (ie, recurrence or death) had been observed and 53 patients had died. The unadjusted risks for first event and death were similar between the two arms (hazard ratio [HR] for first event = 1.10, 95% CI = 0.70 to 1.71, P = .68, and HR for death = 1.20, 95% CI = 0.70 to 2.07, P = .50). The 5-year disease-free and overall survival rates in an intention-to-treat analysis were similar between arms (81.0% and 85.9% in the lymphadenectomy arm and 81.7% and 90.0% in the no-lymphadenectomy arm, respectively). CONCLUSION: Although systematic pelvic lymphadenectomy statistically significantly improved surgical staging, it did not improve disease-free or overall survival.

Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial.

BACKGROUND: The role of systematic aortic and pelvic lymphadenectomy in patients with optimally debulked advanced ovarian cancer is unclear and has not been addressed by randomized studies. We conducted a randomized clinical trial to determine whether systematic aortic and pelvic lymphadenectomy improves progression-free and overall survival compared with resection of bulky nodes only. METHODS: From January 1991 through May 2003, 427 eligible patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB-C and IV epithelial ovarian carcinoma were randomly assigned to undergo systematic pelvic and para-aortic lymphadenectomy (n = 216) or resection of bulky nodes only (n = 211). Progression-free survival and overall survival were analyzed using a log-rank statistic and a Cox multivariable regression analysis. All statistical tests were two-sided. RESULTS: After a median follow-up of 68.4 months, 292 events (i.e., recurrences or deaths) were observed, and 202 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for first event was statistically significantly lower in the systematic lymphadenectomy arm (hazard ratio [HR] = .75, 95% confidence interval [CI] = 0.59 to 0.94; P = .01) than in the no-lymphadenectomy arm, corresponding to 5-year progression-free survival rates of 31.2 and 21.6% in the systematic lymphadenectomy and control arms, respectively (difference = 9.6%, 95% CI = 1.5% to 21.6%), and to median progression-free survival of 29.4 and 22.4 months, respectively (difference = 7 months, 95% CI = 1.0 to 14.4 months). The risk of death was similar in both arms (HR = 0.97, 95% CI = 0.74 to 1.29; P = .85), corresponding to 5-year overall survival rates of 48.5 and 47%, respectively (difference = 1.5%, 95% CI = -8.4% to 10.6%), and to median overall survival of 58.7 and 56.3 months, respectively (difference = 2.4 months, 95% CI = -11.8 to 21.0 months). Median operating time was longer, and the percentage of patients requiring blood transfusions was higher in the systematic lymphadenectomy arm than in the no-lymphadenectomy arm (300 versus 210 minutes, P<.001, and 72% versus 59%; P = .006, respectively). CONCLUSION: Systematic lymphadenectomy improves progression-free but not overall survival in women with optimally debulked advanced ovarian carcinoma.

Abdominal recurrence of ovarian cancer: value of abdominal MR in patients with positive CA125 and negative CT.

PURPOSE: To evaluate the role of abdominal MR in the diagnosis of ovarian cancer recurrence in patients with increasing serum Ca-125 levels and negative abdomino-pelvic CT scan. MATERIALS AND METHODS: In a period of about 30 months, 22 patients in follow-up for ovarian carcinoma (stages II, III-IV) with increasing levels of Ca-125 and negative abdomino-pelvic CT scan were studied with abdomino-pelvic MR. All patients had a disease-free interval of at least 6 months after cytoreductive surgery and chemotherapy. MR examinations were performed with T1- and T2-weighted SE and FSE sequences in the axial and coronal planes, before and after Gadolinium administration. Tumour recurrence was confirmed at surgery, percutaneous biopsy and by monitoring progression or remission of the disease with clinical examination, Ca-125 serum levels and integrated imaging (CT and MR) during and after medical therapy. RESULTS: MR imaging demonstrated recurrence of the disease in 16 of the 22 patients, 3 of the remaining 6 patients were true negatives, whereas 3 patients were false negatives (in one case the CT and MR studies missed the peritoneal seeding found at surgery performed 1 month after the MR; in 2 cases both the CT and MR scans became positive for abdominal recurrence after 3 and 4 months respectively). The sensitivity and diagnostic accuracy of MRI were 84% (16/19) whereas specificity was 100% (3/3). The positive predictive value was 100% (16/16) whereas the negative predictive value was 50% (3/6). CONCLUSIONS: In a selected population of women with increasing serum Ca-125 levels and negative abdominal CT, MR imaging could supply earlier information about the presence and location of recurrences with a high impact on further decisions regarding the choice of therapeutic options (surgical or medical). The limited number of patients requires additional studies to confirm these resuts.

Comparison of ultrasonography, hysteroscopy, and biopsy in the diagnosis of endometrial lesions in postmenopausal tamoxifen-treated patients.

BACKGROUND: At present, no proven recommendations can be made for the surveillance of tamoxifen-treated women. The aim of the present study was to evaluate ultrasonography and hysteroscopy in this setting. METHODS: Three hundred and ten postmenopausal patients using tamoxifen underwent vaginal ultrasonography, hysteroscopy, and endometrial biopsy; 274 were asymptomatic and 49 had abnormal bleeding. Ultrasonographic endometrial thickness and echotexture were recorded. Hysteroscopic endometrial appearance, presence of focal endometrial lesions and polyps were also recorded. General or selective endometrial biopsy was performed. Ultrasonographic and hysteroscopic follow up was provided. RESULTS: At ultrasonography, mean endometrial thickness was 10.8 mm. At hysteroscopy, cystic atrophy and suspect focal lesions were detected in 49.2% and 5.3% of women, respectively. Polyps were present in 44.8% of women; 38.9% of these polyps were missed at ultrasonography, whereas 11.4% were suspected but were not found at hysteroscopy. At biopsy, non-atypical hyperplasia and atypical changes were found in 4.8% and 1.3% of patients, respectively. Three carcinomas were found, all in asymptomatic women. Logistic regression analysis showed that only suspect focal lesions at hysteroscopy were significantly associated with abnormal histology. With a 6-mm cut-off value for endometrial thickness, negative and positive predictive values for ultrasonography in detecting hyperplastic or neoplastic changes were 96% and 8%, respectively; the corresponding values for hysteroscopy were 96% and 65%. No additional carcinoma was found at follow up. CONCLUSIONS: No single ultrasonographic feature (echotexture and borders) is significantly associated with the detection of endometrial hyperplasia or carcinoma; hysteroscopy, although not predictive unless revealing a focal lesion, is more accurate in detecting polyps and hyperplastic changes.

Surgical treatment of recurrent endometrial carcinoma.

BACKGROUND: Surgery does not have a definite role in the treatment of patients with recurrent endometrial carcinoma, except for those with central pelvic recurrences. The authors describe their experience with surgery in patients with abdominal endometrial recurrences. METHODS: Between 1988 and 2000, 75 patients with abdominal and pelvic endometrial recurrences underwent secondary rescue surgery. Patients were classified according to the presence or absence of residual tumor after surgery. Therapy after rescue surgery was undertaken at the discretion of the medical oncologist. The progression-free interval and overall survival were defined as the time from secondary rescue surgery to the specific event and were evaluated by the Kaplan-Meier method and the log-rank test. A Cox proportional hazards regression model was used to compare survival with covariates. RESULTS: Fifty-six patients (74.7%) underwent optimal debulking. Major surgical complications were observed in 23 patients (30.7%). Only 1 postoperative death was observed, although the mortality rate for surgical complications after the postoperative period was 8%. Patients who underwent optimal debulking had a significantly better cumulative survival rate compared with patients who had residual disease (36% vs. 0% at 60 months; P < 0.05). Residual disease, chemotherapy after rescue surgery, and central pelvis-vagina as the only site of recurrence were associated significantly with survival. CONCLUSIONS: The authors found that this approach was very challenging in terms of the procedures involved, the incidence of major surgical complications, and the high mortality rate. It was useful in increasing overall survival, provided that patients were free of macroscopic disease. Careful selection of patients is needed to minimize mortality.