Ultra-radical surgery versus standard-radical surgery for the primary cytoreduction of advanced epithelial ovarian cancer; long-term tertiary center experiences.

OBJECTIVE: To compare overall survival (OS) and morbidity outcomes in patients with advanced epithelial ovarian/tubal/peritoneal cancer undergoing standard-radical (SR) and ultra-radical (UR) surgical procedures based on NICE classification. STUDY DESIGN: This retrospective study analyzed data from 282 patients with 2014 FIGO stage III-IV epithelial ovarian cancer operated on between January 2006 and January 2019. The study compared OS, progression-free survival (PFS), and morbidity between SR and UR surgeries. Parameters influencing OS, including preoperative, postoperative, and post-adjuvant chemotherapy CA-125 values, surgical procedures, post-surgical residual tumor, histopathological grade, and FIGO surgical stage, were assessed. RESULTS: Out of 282 patients, 256 met the inclusion criteria. SR surgery was performed in 48 %, and UR surgery in 52 %. The mean preoperative CA-125 value was 1200 ± 1914.83, decreasing to 240.32 ± 373.87 postoperatively. The mean follow-up period was 63.01 ± 47.56 months. UR surgery correlated with significantly higher postoperative complications (p < 0.001), histopathological grade (p = 0.023), FIGO stage (p < 0.001), three-year death rates, and overall mortality rates (p = 0.035). FIGO stage and total metastatic lymph nodes emerged as independent prognostic factors for overall and PFS. CONCLUSION: In the treatment of epithelial ovarian cancer, evaluating the extent of the tumor before the surgery and showing maximal effort to minimize the residual tumor volume instead of applying UR procedures as the first choice seems to be the most important factor that can affect survival.

Survival Dynamics in Advanced Ovarian Cancer: R2 Resection Versus No-Surgery Paths Explored.

BACKGROUND: Cytoreductive surgery is critical for optimal tumor clearance in advanced epithelial ovarian cancer (EOC). Despite best efforts, some patients may experience R2 (>1 cm) resection, while others may not undergo surgery at all. We aimed to compare outcomes between advanced EOC patients undergoing R2 resection and those who had no surgery. METHODS: Retrospective data from 51 patients with R2 resection were compared to 122 patients with no surgery between January 2015 and December 2019 at a UK tertiary referral centre. Progression-free survival (PFS) and overall survival (OS) were the study endpoints. Principal Component Analysis and Term Frequency - Inverse Document Frequency scores were utilized for data discrimination and prediction of R>2 cm from computed tomography pre-operative reports, respectively. RESULTS: No statistical significance was observed, except for age (73 vs 67 years in the no- surgery vs R2 group, P: .001). Principal Components explained 34% of data variances. Reasons for no surgery included age, co-morbidities, patient preference, refractory disease, patient deterioration or disease progression, and absence of measurable intra- abdominal disease). The median PFS and OS were 12 and 14 months for no-surgery, vs 14 and 26 months for R2 (P: .138 and P: .001, respectively). Serous histology and performance status independently predicted PFS in both no-surgery and R2 cohorts. In the no-surgery cohort, serous histology independently predicted OS, while in the R2 cohorts, both serous histology and adjuvant chemotherapy were independent prognostic features for OS. The bi-grams "abdominopelvic ascites" and "solid omental" were amongst those best discriminating between R>2 cm and R1-2 cm. CONCLUSIONS: R2 resection and no-surgery cohorts displayed unfavourable prognosis with a notable degree of uniformity. When cytoreduction results in suboptimal results, the survival benefit may still be higher compared to those who underwent no surgery.

The study examined outcomes in advanced epithelial ovarian cancer (EOC) patients who underwent either R2 (suboptimal) surgical resection or received no surgery at all at a UK tertiary referral center. Sophisticated machine learning methodolgies were used to analyze data patterns and predict the extent of resection (>2 cm) from pre-operative CT reports. Reasons for not undergoing surgery included older age, presence of other medical conditions, patient preference, progressive disease, patient decline, or lack of detectable intra-abdominal disease. Factors like serous histology and performance status iinfluenced the risk of recurrence in both groups, while serous histology and adjuvant chemotherapy predicted the risk of death in the R2 group. Word sequences like "omental disease" and "reduced bulk" helped differentiate between R>2 cm and less extensive resections (R1-2 cm). In summary, both R2 resection and no-surgery groups had poor outcomes, but patients who underwent R2 resection generally had better survival compared to those who received no surgery, even when complete tumor removal was not achieved.

Ovarian Carcinoma - A Single Centre Case-Series Descriptive Analysis of Surgical Procedures.

Background: Ovarian surface epithelial cancer (OSEC) are an entity in which, according to genomics and pathology data accumulated in the last couple of decades, several different nosological entities with distinct etiologies are aggregated. In ovarian cancer, surgery is the pivot of treatment, to which medical oncological treatment is added by recommendation in most cases. Material and Methods: This is a single centre sample of 263 cases with OSEC operated from January 2014 until December 2021 with a 28-month period of follow-up, until 30th April 2024. OSEC surgical procedures in stages IIB to III and IV of the disease are complex interventions in order to have the R0/optimal cytoreduction achieved, so we summarised and coded them as follows: 1 = biopsy (of the tumour/peritoneum); 2 = bilateral/unilateral adnexectomy (BA/UA) total hysterectomy (TH) omentectomy +- peritoneal biopsies; 3 = (2) with total hysterectomy with bilateral adnexectomy (THBA) +- by extraperitoneal/subperitoneal route+peritonectomies (exclusively diaphragmatic) and electrocauterization of peritoneal carcinomatous lesions; 4 = (3) with visceral (multiple) resections +- stoma; 5 = (4) with diaphragmatic peritonectomies/stripping/partial resection of the diaphragm; 6 = palliative surgery. Results: Debulking surgery (DS) was carried out for n = 182 patients with no residual tissue = R0 being registered in n = 41. Results for patients with residual tissue (n = 141) after DS recorded the following findings: 1 cm (49% cases), 1.1-2 cm (29%) and 2 cm (22%). Recorded results for endometrial ovarian carcinoma (EC) n = 27 shown a tumour free survival probability estimate (%) at 60 months of 66% as both surgery and platinum based chemotherapy are efficient. For clear cell ovarian carcinoma (CCC) n = 7 recorded results shown a tumour free estimate (%) at 60 months of 14%, being known the controversy as to whether or not paclitaxel is an active drug for CCC. Major complications were recorded in 25 patients with a fatality ratio of 5/25. Conclusion: Considering OSEC is a relatively rare disease and the importance of collecting substantial numbers of samples by histotypes to further knowledge about ovarian cancer it comes crucial to establish collaborative endeavour of tertiary centers with standardised and quality control strategies.

Postoperative Complications of Upfront Ovarian Cancer Surgery and Their Effects on Chemotherapy Delay.

BACKGROUND: Extensive surgery on advanced-stage epithelial ovarian cancer is associated with increased postoperative morbidity, which may cause a delay in or omission of chemotherapy. We examined postoperative complications and their effects on adjuvant treatment in patients undergoing primary debulking surgery (PDS). METHODS: Stage IIIC-IV epithelial ovarian cancer patients who underwent PDS between January 2013 and December 2020 were included. Patients were divided into two groups according to the radicality of the operation, i.e., extensive or standard surgery, and their outcomes were compared. RESULTS: In total, 172 patients were included; 119 underwent extensive surgery, and 53 had standard surgery. Clavien-Dindo grade 3-5 (CDC 3+) complications were detected in 41.2% of patients after extensive operations and in 17% after standard surgery (p = 0.002). The most common CDC 3+ complication was pleural effusion. Despite the difference in the complication rates, the delay in chemotherapy did not differ between the extensive and standard groups (p = 0.98). CONCLUSIONS: Complications are common after PDS. Extensive surgery increases the complication rate, but most complications can be treated effectively; therefore, a delay in adjuvant treatment is rare.

Ovarian Carcinoma: A Single-Centre Eight-Year Case-Series Study with Survival Analysis.

Introduction: This research describes an eight-year case-series of ovarian carcinoma by surgical (pTNM) staging and surgical procedure, explores the characteristics of ovarian surface epithelial cell (OSEC) tumours by histopathological type in a single centre of reference. Material and Methods: survival analysis with overall survivor probabilities for n=263 patients for 12 months and 60-month tumour free survival status (TFS). Results by staging (pTNM stage classification), histotype and for poor surgical candidate (PSC) status are shown. Histotype high grade serous carcinoma (HGSC) was the most frequently diagnosed type (63%). Results: 12-month survivor probabilities according to histotype, rank as follows: clear cell carcinoma (CCC) - 14%; rare carcinoma (RC) - 15%; carcinosarcoma (CS) - 29%; HGSC - 46%; low grade serous carcinoma (LGSC) - 74%; endometrioid carcinoma (EC) - 79%; mucinous carcinoma (MC) - 80% and borderline tumours (BLT) - 94%. At 60 months results are: RC and MC - 0%; CCC - 14%; HGSC - 16%; CS - 29%; LGSC - 62%; EC - 66%; and BLT - 94%. Overall median survival time is 26 months (CI95% 15 to 37); and 20 months when BLT excluded (CI95% CI 15 to 25). Conclusions: These results may guide further research for the OSEC pathology and its histotypes.

Impact of molecular testing on the surgical management of advanced epithelial ovarian cancer.

Ovarian carcinoma remains the most lethal gynaecologic malignancy. Half of all high-grade serous ovarian cancers (HGSOCs) have a homologous recombination deficiency (HRD) with regard to the repair of double-strand DNA breaks and are candidate to receive maintenance treatment with PARP inhibitors. While a wealth of literature exists regarding the therapeutic guidance of patients from a medical standpoint, the influence of the HRD status on the surgical outlook has been comparatively limited. In this review, the clinical and biological features of advanced ovarian cancers with BRCA1/2 mutation and/or HRD status are considered with particular reference to their impact on the surgical management and on the medico-surgical sequence. The modification of the surgical indications according to the results of molecular testing in first-line and recurrent settings are discussed.

Bowel Resection Outcomes in Ovarian Cancer Cytoreductive Surgery by Surgeon Specialty.

Importance: Extensive bowel surgery is often necessary to achieve complete cytoreduction in patients with epithelial ovarian cancer. Regardless of who performs the surgery, it has been well documented that bowel resections are a high-risk procedure and an anastomotic leak is a severe complication that can occur. There are few studies addressing whether surgeon type impacts surgical outcomes in this patient population. Objective: To compare surgical outcomes between gynecologic oncologist, general surgeons, and a 2-surgeon team approach for patients with advanced epithelial ovarian cancer who underwent bowel surgery during cytoreductive debulking. Design, Setting, Participants: This retrospective cohort study used the American College of Surgeons' National Surgical Quality Improvement Program datasets from 2012 through 2020. The aforementioned years of the dataset were analyzed from March 2022 to March 2023 and reanalyzed in May 2024 for quality assurance. Analysis of cytoreductive surgeries performed by a gynecologic oncologist, a general surgeon, or a 2-surgeon team approach for patients with ovarian cancer recorded in National Surgical Quality Improvement Program datasets was included. The 2-surgeon team approach included any combination of the aforementioned surgical specialties. Main outcome and measure: The primary outcome of interest was anastomotic leak after bowel surgery during ovarian cancer debulking. Results: A total of 1810 patients were included in the study; in the general surgery cohort, mean (SD) patient age was 65.1 (11.1) years and mean (SD) body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) was 26.9 (7.4); in the gynecologic oncology cohort, mean (SD) patient age was 63.5 (11.7) years and mean BMI (SD) was 27.7 (6.5); and in the 2-surgeon team cohort, mean (SD) patient age 62.4 (12.1) years and mean (SD) BMI was 28.1 (7.0). Gynecologic oncologists performed 1217 cases (67.2%), general surgery performed 97 cases (5.4%), and 496 cases had 2-surgeon teams involved (27.4%). Bivariate analysis revealed an anastomotic leak rate of 3.6% for gynecologic oncologists, 5.2% for general surgeons, and 0.4% for cases that had 2 surgical teams involved (P < .001). By multivariable analysis, the adjusted odds ratio for anastomotic leak was 1.53 (95% CI, 0.59-3.96) for the general surgeon group (P = .38) vs an adjusted odds ratio of 0.11 (95% CI, 0.03-0.47) for the 2-surgeon team approach (P = .003) with the referent being gynecologic oncology. Conclusion and Relevance: In this study, the anastomotic leak rate was found to be lower when 2 surgeons participated in the case, regardless of the surgical specialty. These results suggest that team-based care improves surgical outcomes.

Lymph node metastasis in grossly apparent early-stage epithelial ovarian cancer: A retrospective clinical study at a tertiary institute.

OBJECTIVE: This study aimed to evaluate the incidence and predict the risk factors of lymph node (LN) metastasis among patients with grossly apparent early-stage epithelial ovarian cancer (EOC). METHODS: We retrospectively reviewed the clinicopathologic data and follow-up information of 266 patients who underwent LN dissection for apparent early-stage EOC between January 2018 and September 2022 at the Obstetrics and Gynecology Hospital of Fudan University. RESULTS: Among 266 patients, 44 (16.5%) showed LN metastasis, of which 65.9% and 59.1% presented in the pelvic region and para-aortic region, respectively. Univariate analysis revealed higher LN positivity in patients with high-grade serous carcinoma (HGSC), preoperative imaging suggestive of LN metastasis, bilateral adnexal involvement, lymphovascular space invasion (LVSI), positive peritoneal cytology, and clinical stage IIA. LN metastases were identified in 7.9%, 10.2%, and 39.7% of clinical stage IA/B, IC, and IIA disease cases, respectively. Multivariate analysis confirmed significantly higher LN positivity rates in patients with HGSC, LVSI, and clinical stage IIA. In clinical stage IIA EOC, the 3-year progression-free survival (PFS) rates were 65.8% and 77.4% (P = 0.360) for LN-negative and LN-positive groups, respectively. In clinical stage I EOC, the 3-year PFS rates were 93.5% and 59.4% (P < 0.001) for LN-negative and LN-positive groups, respectively. CONCLUSIONS: High-grade serous histology, LVSI, and clinical stage IIA disease are predictive factors for LN involvement in early-stage EOC. In addition, LN metastasis appears to be associated with worse PFS in clinical stage I EOC compared with clinical stage IIA EOC.

The Significance of Lymph Node Dissection in Patients with Early Epithelial Ovarian Cancer.

AIM: This study aimed to investigate the impact of lymph node dissection on the prognosis of early epithelial ovarian cancer and to assess the factors associated with lymph node metastasis. METHODS: In this retrospective study, we collected and analyzed the demographic characteristics, clinical pathological data, and perioperative adverse events in newly diagnosed early epithelial ovarian cancer (EOC) patients, Federation International of Gynecology and Obstetrics (FIGO) stage IA-IIA. The patients underwent surgical treatment at the First, Second, and Third Affiliated Hospitals of Wenzhou Medical University in Zhejiang Province, China, between June 2012 and June 2022. The survival analysis was performed. RESULTS: We enrolled 284 patients in this study, including 246 stage I, 28 stage II, and 10 stage III patients after surgery. Among them, 42 patients did not undergo lymph node dissection, 113 underwent pelvic lymph node dissection only, and 129 underwent pelvic plus para-aortic lymph node dissection. Among the lymph node dissection group, only 8 patients had lymph node metastasis (8/242, 3.3%), including 6 with pelvic lymph node metastasis and 2 with pelvic plus para-aortic lymph node metastasis. The median follow-up duration was 63 months. The systematic lymph node dissection group significantly prolonged the median operation duration and increased intraoperative blood loss and postoperative complications (p < 0.05). Postoperative multivariate Cox regression analysis revealed FIGO stage III as an independent risk factor for Progression-Free-Survival (PFS) and Overall Survival (OS) (p < 0.05). Furthermore, the preoperative cancer antigen 125 (CA125) level was observed as an independent factor affecting lymph node metastasis. CONCLUSIONS: Systematic lymph node dissection showed minimal effect on the survival rate of patients with clinically apparent early epithelial ovarian cancer and increased the postoperative complications of patients.

Preoperative neutrophil/lymphocyte ratio as prognostic factor in epithelial ovarian cancer / Cociente neutrófilos/linfocitos preoperatorio como factor pronóstico en el cáncer epitelial de ovario.

Objectives: To determine if there is an association between the neutrophil to lymphocyte ratio (NLR) and prognosis in patients with epithelial ovarian cancer (EOC) diagnosed and treated in a Spanish population. Material and methods: Retrospective cohort of patients with epithelial ovarian cancer who had neutrophil and lymphocyte values in complete blood count before the histopathological diagnosis and survival of at least three months, in an intermediate complexity hospital. Convenience sampling. Measured variables included age, menopausal stage, parity, International Federation of Gynecology and Obstetrics (FIGO) stage, treatment type, residual tumor, lymph node involvement, presence of ascites, cytology, histologic type, differentiation grade, and CA-125 values. Additionally, outcomes, overall survival, disease/progression-free survival were also measured. Bivariate inferential and Cox regression analyses were performed. Results: Out of 78 candidates, 60 women with EOC were included. Of them, 24 (40%) had a low NLR (≤ 2,9) while 36 (60%) had a high NLR (> 2,9). An association was found between high NLR levels and suboptimal cytoreductive surgery. High NLR ratios were associated with lower overall survival (Hazard ratio (HR): 4.1; 95% CI: 1.4-11.8) and lower 5-year disease-free survival (HR: 2.6; 95% CI: 1.2-5.7). Conclusions: A plasma neutrophil to lymphocyte ratio of more than 2.9 was associated with poor prognosis in patients with epithelial ovarian cancer in our setting. There is a need to establish the optimal cut-off point and conduct prospective studies with larger patient numbers in order to support this information.

Objetivos: evaluar si hay asociación entre los valores del cociente plasmático neutrófilos/ linfocitos (NLR) y el pronóstico en pacientes con cáncer epitelial de ovario (CEO) diagnosticadas y tratadas en una población española. Materiales y métodos: cohorte retrospectiva de pacientes con cáncer epitelial de ovario que tuvieran un recuento de neutrófilos y linfocitos en hemograma previo al diagnóstico histopatológico en un hospital de nivel medio de complejidad y posterior sobrevida de, al menos, 3 meses. Muestreo por conveniencia. Se midieron: edad, estado menopáusico, paridad, estadio Federación International de Ginecología y Obstetricia (FIGO), tipo de tratamiento, tumor residual, afectación ganglionar, presencia de ascitis, citología, tipo histológico, grado de diferenciación y cifras de CA-125; como desenlaces, sobrevida global y sobrevida libre de enfermedad o progresión. Análisis inferencial bivariado y por regresión de Cox. Resultados: de 78 candidatas, ingresaron 60 mujeres con CEO. De ellas, 24 (40%) presentaron un NLR bajo (≤ 2,9) y 36 (60 %) elevado (> 2,9). Se encontró asociación entre los niveles altos de NLR y cirugía citoreductora subóptima. Los niveles altos de NLR se asociaron a menor sobrevida global (Hazard ratio (HR): 4,1; IC 95%: 1,4-11,8) y menor sobrevida libre de enfermedad a los 5 años (HR:2,6; IC 95 %: 1,2-5,7). Conclusiones: un cociente plasmático neutrófilos/linfocitos mayor de 2,9 se asoció a un mal pronóstico en pacientes con cáncer epitelial de ovario en nuestro medio. Se necesita determinar el punto de corte óptimo y realizar estudios prospectivos con mayor número de pacientes que avalen esta información.

Does neoadjuvant chemotherapy reduce surgical complexity in patients with advanced-stage epithelial ovarian cancer?

BACKGROUND: This study aimed to determine the effect of neoadjuvant chemotherapy (NACT) on the complex surgical procedures required in addition to staging surgery for the need to achieve a residual tumor 1 cm or less in a population of stage IIIC-IV epithelial ovarian cancer patients. METHODS: Patients were referred for NACT if preoperative imaging and/or intraoperative evaluation confirmed that it was not possible to achieve a residual tumor size of 1 cm or less with cytoreductive surgery or if the patient had a poor performance status and a high American Society of Anesthesiologists (ASA) score. Surgical complexity was defined as complex or non-complex. RESULTS: One hundred and twenty-six patients with stage IIIC-IV ovarian cancer were included in the study. Primary cytoreductive surgery was performed in 67 patients, and interval cytoreductive surgery was performed in 59 patients after NACT. At least one complex surgery was performed in 74.6% of the patients in the primary cytoreductive surgery group and in 61% of the patients in the NACT group, with no statistically significant difference between the groups. However, the NACT group showed significantly decreased rates of low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy. CONCLUSIONS: The analyses showed no reduction in the requirement for at least one complex surgical procedure in the group of patients who underwent NACT. Nevertheless, this group exhibited a significant decrease in low-rectal resection, diaphragmatic peritoneal stripping, and peritonectomy due to their effectiveness in reducing peritoneal disease.

Cytoreductive surgery plus chemotherapy versus chemotherapy alone for recurrent epithelial ovarian cancer.

OBJECTIVES: This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the benefits and harms of secondary CRS and chemotherapy in comparison to chemotherapy alone for women with platinum-sensitive recurrent epithelial ovarian cancer.

Oncological outcomes of fertility-sparing surgery versus radical surgery in stage - epithelial ovarian cancer: a systematic review and meta-analysis.

BACKGROUND: The oncological outcomes of fertility-sparing surgery (FSS) compared to radical surgery (RS) in patients with stage I epithelial ovarian cancer (EOC) remain a subject of debate. We evaluated the risk ratios (RRs) for outcomes in patients with stage I EOC who underwent FSS versus RS. METHODS: We conducted a systematic search of PubMed, Web of Science, and Embase for articles published up to November 29, 2023. Studies that did not involve surgical procedures or included pregnant patients were excluded. We calculated the RRs for disease-free survival, overall survival, and recurrence rate. The quality of the included studies was assessed using the Cochrane Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I) tool. The meta-analysis was registered on PROSPERO (CRD42024546460). RESULTS: From the 5,529 potentially relevant articles, we identified 83 articles for initial screening and included 12 articles in the final meta-analysis, encompassing 2,906 patients with epithelial ovarian cancer. There were no significant differences between the two groups in disease-free survival (RR [95% confidence interval {CI}], 0.90 [0.51, 1.58]; P = 0.71), overall survival (RR [95% CI], 0.74 [0.53, 1.03]; P = 0.07), and recurrence rate (RR [95% CI], 1.10 [0.69, 1.76]; P = 0.68). In sensitivity analyses, the significant difference was observed only for overall survival (before exclusion: RR [95% CI], 0.74 [0.53-1.03], P = 0.07; after exclusion: RR [95% CI], 0.70 [0.50-0.99]; P = 0.04). CONCLUSIONS: This is the first and only individual patient data meta-analysis comparing disease-free survival, overall survival, and recurrence rate of patients with early-stage epithelial ovarian cancer undergoing FSS and RS. FSS was associated with similar disease-free survival and risk of recurrence as RS. We hypothesized that the decreased overall survival in the FSS group could not be attributed to distant metastases from epithelial ovarian cancer.

The survival benefit associated with complete macroscopic resection in epithelial ovarian cancer is histotype specific.

BACKGROUND: Complete macroscopic resection is a key factor associated with prolonged survival in ovarian cancer. However, most evidence derives from high-grade serous ovarian carcinoma, and the benefit of complete macroscopic resection in other histotypes is poorly characterized. We sought to determine which histotypes derive the greatest benefit from complete macroscopic resection to better inform future decisions on radical cytoreductive efforts. METHODS: We performed multivariable analysis of disease-specific survival across 2 independent patient cohorts to determine the magnitude of benefit associated with complete macroscopic resection within each histotype. RESULTS: Across both cohorts (Scottish: n = 1622; Surveillance, Epidemiology, and End Results [SEER]: n = 18 947), complete macroscopic resection was associated with prolonged disease-specific survival; this was more marked in the Scottish cohort (multivariable hazard ratio [HR] = 0.44, 95% confidence interval [CI] = 0.37 to 0.52 vs HR = 0.59, 95% CI = 0.57 to 0.62 in SEER). In both cohorts, clear cell ovarian carcinoma was among the histotypes to benefit most from complete macroscopic resection (multivariable HR = 0.23 and HR = 0.50 in Scottish and SEER cohorts, respectively); high-grade serous ovarian carcinoma patients demonstrated highly statistically significant and clinically meaningful survival benefit, but this was of lower magnitude than in clear cell ovarian carcinoma and endometrioid ovarian carcinoma across both cohorts. The benefit derived in low-grade serous ovarian carcinoma is also high (multivariable HR = 0.27 in Scottish cohort). Complete macroscopic resection was associated with prolonged survival in mucinous ovarian carcinoma patients in the SEER cohort (multivariable HR = 0.65), but the association failed to reach statistical significance in the Scottish cohort. CONCLUSIONS: The overall ovarian cancer patient population demonstrates clinically significant survival benefit associated with complete macroscopic resection; however, the magnitude of benefit differs between histotypes.

Primary Cytoreduction and Survival for Patients With Less-Common Epithelial Ovarian Cancer.

This cohort study examines the association between primary cytoreduction status and survival for patients with less-common, advanced-stage epithelial ovarian carcinoma.

Preferences and considerations for interval cytoreductive surgery in advanced ovarian cancer: The patient's perspective.

OBJECTIVE: Treatment of advanced-stage ovarian cancer contains cytoreductive surgery (CRS) and chemotherapy. Achieving successful CRS (≤ 1 cm residual disease) is prognostically important, but may not be feasible peri-operatively while still risking complications. Therefore, patients' treatment expectations are important to discuss. We investigated patient considerations for interval CRS. METHODS: Patients with advanced-stage ovarian cancer planned for interval CRS completed a questionnaire about the impact of chance of successful CRS, survival benefit and becoming care-dependent on decision-making regarding CRS. The questionnaire included a vignette study, in which patients repeatedly chose between two treatment scenarios with varying levels for chance of successful CRS, survival benefit and risk of complications including stoma. Patient preferences were analyzed, including differences between patients aged < 70 and ≥ 70 years. RESULTS: Among 85 included patients, 31 (37%) patients considered interval CRS worthwhile irrespective of survival benefit and 33 (39%) irrespective of chance of successful surgery. However, 34 patients (41%) considered interval CRS only worthwhile if survival benefit was > 12 months, while 41 (49%) thought so if chance of successful surgery was ≥ 25%. Older patients considered these factors more important. Overall, 27% considered becoming permanently dependent of home care unacceptable. In the vignette study (n = 72) risk of complications and stoma were considered less important than chance of successful CRS and survival benefit. CONCLUSION: Survival benefit, chance of successful surgery and becoming care-dependent are important factors in patient's decision for interval CRS, while risk of complications and stoma are less important. Our results are useful in shared decision-making for interval CRS in ovarian cancer.

Diaphragmatic stripping in epithelial ovarian cancer at first diagnosis: Impact on morbidity and survival outcomes.

OBJECTIVES: Diaphragmatic stripping is a standard procedure that is performed in a significant proportion of patients undergoing surgical cytoreduction for advanced ovarian cancer. The objective of the present study is to evaluate morbidity and survival outcomes among patients offered diaphragmatic surgery for primary diagnosed optimally resected ovarian cancer. STUDY DESIGN: We conducted a retrospective cohort study, identifying patients that were offered surgery between 2016 and 2021 for primary diagnosis of ovarian cancer. Cases that had diaphragmatic stripping or partial diaphragmatic resection were selected and compared to cases that did not require this procedure. Kaplan-Meier and Cox-regression analyses were applied to evaluate survival outcomes. RESULTS: Overall, 61 patients that had diaphragmatic stripping were identified. Severe postoperative complications (Clavien-Dindo 3 + ) were noted in 19 patients (31 %). Survival analyses denoted that the stage of the disease at the time of diagnosis, as well as the timing of the surgical procedure (PDS vs IDS) and the completion of tumor debulking were factors that significantly affected the recurrence free and overall survival of patients. Severe postoperative morbidity was a significant predictor of the overall survival. Multivariate cox-regression analysis that was adjusted for the stage of the disease revealed that preoperative pleural effusion, optimal (compared to complete) tumor resection and the occurrence of postoperative complications significantly affected the overall survival of patients. Compared to patients that did not have diaphragmatic surgery, patients submitted to diaphragmatic stripping or resection had improved progression free and overall survival rates, irrespective of the stage of the disease at diagnosis or the adequacy of resection status. CONCLUSIONS: Diaphragmatic surgery is feasible in advanced ovarian cancer patients with acceptable morbidity that mainly refers to postoperative pleural effusion. Its positive impact on patients' survival requires further investigation.

Evaluating nutrition in advanced ovarian cancer: which biomarker works best?

BACKGROUND: Advanced epithelial ovarian cancer (OC) patients often present with malnutrition; however, the ideal nutritional evaluation tool is unclear. We aimed to evaluate the role of preoperative albumin, Prognostic Nutritional Index [PNI], neutrophil-to-lymphocyte ratio [NLR], and platelet-to-lymphocyte ratio [PLR] as independent predictors of severe postoperative complications and 90-day mortality in OC patients who underwent primary cytoreductive surgery to identify the ideal tool. METHODS: OC patients who underwent surgery at Mayo Clinic (2003-2018) were included; biomarkers were retrospectively retrieved and established cut-offs were utilized. Outcomes included severe complications (Accordion grade ≥ 3) and 90-day mortality. Univariate and multivariable logistic regression models were performed. Biomarkers were evaluated in separate models adjusted for age and American Society of Anesthesiologists (ASA) score for 90-day mortality, and adjusted for age, ASA score, stage, and surgical complexity for severe complications. RESULTS: Albumin <3.5 g/dL, PNI < 45, NLR > 6 and PLR ≥ 200 were univariately associated with 90-day mortality (all p < 0.05) in 627 patients that met inclusion criteria. Each marker remained significant in adjusted models with albumin having the highest OR: 6.04 [95% CI:2.80-13.03] and AUC (0.83). Univariately, PNI <45, NLR >6, and PLR ≥200 were significant predictors of severe complications(all p < 0.05), however failed to reach significance in adjusted models. Albumin was not associated with severe complications. CONCLUSION: All biomarkers were associated with 90-day mortality in adjusted models, with albumin being the easiest predictor to attain clinically; none with severe complications. Future research should focus less on methods of nutritional assessment and more on strategies to improve nutrition during OC tumor-directed therapy.