Prognostic factors of secondary cytoreductive surgery for patients with recurrent epithelial ovarian cancer

배재만,임명철,최재호,송용중,이경수,서상수,박상윤,강석범,서상수 대한부인종양학회 2009 Journal of Gynecologic Oncology Vol.20 No.2

Objective: The objective of this study was to identify the prognostic factors of secondary cytoreductive surgery on survival in patients with recurrent epithelial ovarian cancer. Methods: The medical records of all patients who underwent secondary cytoreductive surgery between May 2001 and October 2007 at the National Cancer Center, Korea were reviewed. Univariate and multivariate analyses were executed to evaluate the potential variables for overall survival. Results: In total, 54 patients met the inclusion criteria. Optimal cytoreduction to <0.5 cm residual disease was achieved in 87% of patients who had received secondary cytoreductive surgery. Univariate analysis revealed that site of recurrence (median survival, 53 months for the largest tumors in the pelvis vs. 24 months for the largest tumors except for the pelvis; p=0.007), progression free survival (PFS) (median survival, 43 months for PFS≥12 months vs. 24 months for PFS<12 months; p=0.036), and number of recurrence sites (median survival, 49 months for single recurred tumor vs 29 months for multiple recurred tumors; p=0.036) were significantly associated with overall survival. On multivariate analysis, prognostic factors that correlated with improved survival were site of recurrence (p=0.013), and PFS (p=0.043). Conclusion: In the author’s analysis, a significant survival benefit was identified for the recurred largest tumors within the pelvis and PFS≥12 months. Secondary cytoreductive surgery should be offered in selected patients and large prospective studies are needed to define the selection criteria for secondary cytoreductive surgery. Objective: The objective of this study was to identify the prognostic factors of secondary cytoreductive surgery on survival in patients with recurrent epithelial ovarian cancer. Methods: The medical records of all patients who underwent secondary cytoreductive surgery between May 2001 and October 2007 at the National Cancer Center, Korea were reviewed. Univariate and multivariate analyses were executed to evaluate the potential variables for overall survival. Results: In total, 54 patients met the inclusion criteria. Optimal cytoreduction to <0.5 cm residual disease was achieved in 87% of patients who had received secondary cytoreductive surgery. Univariate analysis revealed that site of recurrence (median survival, 53 months for the largest tumors in the pelvis vs. 24 months for the largest tumors except for the pelvis; p=0.007), progression free survival (PFS) (median survival, 43 months for PFS≥12 months vs. 24 months for PFS<12 months; p=0.036), and number of recurrence sites (median survival, 49 months for single recurred tumor vs 29 months for multiple recurred tumors; p=0.036) were significantly associated with overall survival. On multivariate analysis, prognostic factors that correlated with improved survival were site of recurrence (p=0.013), and PFS (p=0.043). Conclusion: In the author’s analysis, a significant survival benefit was identified for the recurred largest tumors within the pelvis and PFS≥12 months. Secondary cytoreductive surgery should be offered in selected patients and large prospective studies are needed to define the selection criteria for secondary cytoreductive surgery.

상피성 난소암에서 수술 전 혈청 CA-125 농도에 의한 일차 종양축소수술의 결과 예측에 관한 연구

박한뫼,김윤수,신은경,김미경,정경아,박미혜,전선희,안정자,김종일,김승철 대한부인종양 콜포스코피학회 2003 Journal of Gynecologic Oncology Vol.14 No.2

목적 : 상피성 난소암에서 수술 전 혈청 CA-125가 일차 종양축소수술의 결과를 예측할 수 있는지에 대해서 알아보고 최적의 민감도와 특이도를 보이는 혈청 CA-125 농도의 cutoff point를 알아보고자 하였다. 연구 방법 : 1997년 1월부터 2002년 8월까지 이대목동병원에 내원하여 상피성 난소암으로 진단받고 일차 종양축소수술을 시행받은 85명의 환자를 대상으로 후향적인 연구를 시행하였다. 모든 환자는 수술 전에 혈청 CA-125 농도를 측정하였으며 ROC법을 이용하여 종양축소수술의 결과를 예측할 수 있는 최적의 CA-125의 농도를 결정 하였다. 결과 : 모든 환자의 혈청 CA-125농도의 중앙값은 890.9 U/mL이었으며, 수술 전 혈청 CA-125는 조직형, 세포분화도, 병기, 복수 등과 통계적으로 유의한 관련이 있었다(p<0.05). 또한 수술 전 혈청 CA-125농도의 중앙값은 종양축소수술이 적절하게 시행된 환자와 그렇지 않은 환자간에 유의한 차이를 보였다(2584.8 U/mL vs. 524.8 U/mL, p<0.05). ROC법을 이용하여 수술 전 혈청 CA-125 농도가 1050 U/mL에서 종양축소수술의 결과를 가장 잘 예측할 수 있는 cutoff point임을 알 수 있었다(민감도 66.7%, 특이도 64.0%, 양성예측도 81.6%, 음성예측도 44.4%). 결론 : 본 연구에서 수술 전 혈청 CA-125농도는 종양축소수술의 결과 예측에 도움이 될 것으로 생각되나, 음성예측도가 낮아 수술 전 혈청 CA-125농도만을 이용하여 난소암 환자에서 복합 선행화학요법 대상자를 선정하는데는 한계가 있는 것으로 판단된다. 따라서 난소암 환자에서는 수술 전 여러 임상정보를 종합적으로 고려하여 복합선행화학요법이 결정되어야 할 것이다. Objective : To evaluate the ability of preoperative serum CA-125 level to predict the outcome of primary cytoreductive surgery in patients with epithelial ovarian carcinoma. Methods : We performed a retrospective chart review of 85 consecutive patients with epithelial ovarian carcinoma. All patients had preoperative serum CA-125 levels measured. We used a receiver operating characteristics curve (ROC) to determine the CA-125 level with the maximal power in predicting the outcome of primary cytoreductive surgery. Results : The median CA-125 level was 890.9 U/mL for all patients. Preoperative CA-125 level had significant correlations with histology, tumor grade, stage, and the presence of ascites (p<0.05). Also, preoperative CA-125 level showed significant difference between patients with suboptimal cytoreduction and those with optimal cytoreduction (2584.9 U/mL vs. 524.8 U/mL, p<0.05). Using the ROC, we found that preoperative CA-125 level of 1050 U/mL had the most powerful ability in predicting the outcome of primary cytoreductive surgery, but a poor negative predictive value (sensitivity 66.7%, specificity 64.0%, PPV 81.6%, NPV 44.4%). Optimal cytoreductive surgery was achieved in 81.6% (40/49) among patients with CA-125 <1050 U/mL, but 55.6% (20/36) among those with CA-125=1050 U/mL (p<0.05). Conclusion : We think that preoperative CA-125 level may be used for selection of candidates for neoadjuvant chemotherapy before primary cytoreductive surgery. But preoperative CA-125 level was a weak negative predictor of primary optimal cytoreductive surgery. Thus, preoperative CA-125 level could not be a primary predictor of the outcome of primary cytoreductive surgery and should be considered in the context of other preoperative features.

Long-Surviving Patients with Recurrent GIST after Receiving Cytoreductive Surgery with Imatinib Therapy

최원혁,Sungsoo Kim,형우진,유정식,박찬일,최승호,노성훈 연세대학교의과대학 2009 Yonsei medical journal Vol.50 No.3

In the treatment of recurrent or metastatic gastrointestinal stromal tumors (GIST), good prognoses may not be expected by surgery alone. Recently, imatinib has been applied for the treatment of GISTs, resulting in improved patient survival. However, long-term success is limited due to the development of resistance. Herein, we report two cases of long-surviving patients with recurrent GIST after receiving cytoreductive surgery with imatinib therapy. A 49 year-old man was diagnosed to a duodenal GIST with single hepatic metastasis, and an antrectomy including the duodenal lesion with intraoperative radiofrequency ablation were performed in April, 2002. After four months, a new metastatic hepatic lesion was identified. Percutaneous radiofrequency ablation was done, and imatinib therapy was started. A 56 year-old man underwent laparoscopic segmental resection of the distal ileum and partial excision of parietal peritoneum in March, 2001 to treat a malignant GIST of the distal ileum that was attached to parietal peritoneum. After six months, recurrence of GIST with peritoneal seeding and hepatic metastasis was found, and he underwent cytoreductive surgery including right hemicolectomy and wedge resection of liver. After surgery, there was no residual tumor grossly and imatinib therapy was started. In both cases, they were doing well with no evidence of recurrence for 5 years with imatinib therapy. Therefore, in patients with a recurrent GIST, improved survival can be expected with imatinib therapy after cytoreductive surgery.

Tertiary Cytoreduction for Recurrent Epithelial Ovarian Cancer: a Multicenter Study in Turkey

Arvas, Macit,Salihoglu, Yavuz,Sal, Veysel,Gungor, Tayfun,Sozen, Hamdullah,Kahramanoglu, Ilker,Topuz, Samet,Demirkiran, Fuat,Iyibozkurt, Cem,Bese, Tugan,Ozgu, Burcin Salman,Vatansever, Dogan,Tokgozoglu Asian Pacific Journal of Cancer Prevention 2016 Asian Pacific journal of cancer prevention Vol.17 No.4

Background: The purpose of this study was to determine the benefit of tertiary cytoreductive surgery (TC) for secondary recurrent epithelial ovarian cancer (EOC), focusing on whether optimal cytoreduction has an impact on disease-free survival, and whether certain patient characteristics could identify ideal candidates for TC. Materials and Methods: Retrospective analysis of secondary recurrent EOC patients undergoing TC at three Turkish tertiary institutions from May 1997 to July 2014 was performed. All patients had previously received primary cytoreduction followed by intravenous platinum-based chemotherapy and secondary cytoreduction for first recurrence. Clinical and pathological data were obtained from the patients' medical records. Survival analysis was caried out using the Kaplan Meier method. Actuarial curves were compared by the two tailed Logrank test with a statistical significance level of 0.05. Results: Median age of the patients was 49.6 years (range, 30-67) and thirty-eight (72%) had stage III-IV disease at initial diagnosis. Twenty six (49%) had optimal and 27 (51%) suboptimal cytoreduction during tertiary debulking surgery. Optimal initial cytoreduction, time to first recurrence, optimal secondary cytoreduction, time interval between secondary cytoreduction and secondary recurrence, size of recurrence, disease status at last follow-up were found to be significant risk factors to predict optimal TC. Optimal cytoreduction in initial and tertiary surgery and serum CA-125 level prior to TC were independent prognostic factors on univariate analysis. Conclusions: Our results and a literature review clearly showed that maximal surgical effort should be made in TC, since patients undergoing optimal TC have a better survival. Thus, patients with secondary recurrent EOC in whom optimal cytoreduction can be achieved should be actively selected.

A phase II trial of cytoreductive surgery combined with niraparib maintenance in platinum-sensitive, secondary recurrent ovarian cancer: SGOG SOC-3 study

Ting-Yan Shi,Sheng Yin,Jianqing Zhu,Ping Zhang,Jihong Liu,Libing Xiang,Yaping Zhu,Sufang Wu,Xiaojun Chen,Xipeng Wang,Yin-Cheng Teng,Tao Zhu,Aijun Yu,Yingli Zhang,Yanling Feng,He Huang,Wei Bao,Yanli Li 대한부인종양학회 2020 Journal of Gynecologic Oncology Vol.31 No.3

Background: In China, secondary cytoreductive surgery (SCR) has been widely used in ovarian cancer (OC) over the past two decades. Although Gynecologic Oncology Group-0213 trial did not show its overall survival benefit in first relapsed patients, the questions on patient selection and effect of subsequent targeting therapy are still open. The preliminary data from our pre-SOC1 phase II study showed that selected patients with second relapse who never received SCR at recurrence may still benefit from surgery. Moreover, poly(ADP-ribose) polymerase inhibitors (PARPi) maintenance now has been a standard care for platinum sensitive relapsed OC. To our knowledge, no published or ongoing trial is trying to answer the question if patient can benefit from a potentially complete resection combined with PARPi maintenance in OC patients with secondary recurrence. Methods: SOC-3 is a multi-center, open, randomized, controlled, phase II trial of SCR followed by chemotherapy and niraparib maintenance vs chemotherapy and niraparib maintenance in patients with platinum-sensitive second relapsed OC who never received SCR at recurrence. To guarantee surgical quality, if the sites had no experience of participating in any OC-related surgical trials, the number of recurrent lesions evaluated by central-reviewed positron emission tomography–computed tomography image shouldn't be more than 3. Eligible patients are randomly assigned in a 1:1 ratio to receive either SCR followed by 6 cycles of platinum-based chemotherapy and niraparib maintenance or 6 cycles of platinum-based chemotherapy and niraparib maintenance alone. Patients who undergo at least 4 cycles of chemotherapy and must be, in the opinion of the investigator, without disease progression, will be assigned niraparib maintenance. Major inclusion criteria are secondary relapsed OC with a platinum-free interval of no less than 6 months and a possibly complete resection. Major exclusion criteria are borderline tumors and non-epithelial ovarian malignancies, received debulking surgery at recurrence and impossible to complete resection. The sample size is 96 patients. Primary endpoint is 12-month non-progression rate. Trial Registration: ClinicalTrials.gov Identifier: NCT03983226

CT-Based Fagotti Scoring System for Non-Invasive Prediction of Cytoreduction Surgery Outcome in Patients with Advanced Ovarian Cancer

Kim Na Young,정대철,이정윤,Han Kyung Hwa,오영택 대한영상의학회 2021 Korean Journal of Radiology Vol.22 No.9

Objective: To construct a CT-based Fagotti scoring system by analyzing the correlations between laparoscopic findings and CT features in patients with advanced ovarian cancer. Materials and Methods: This retrospective cohort study included patients diagnosed with stage III/IV ovarian cancer who underwent diagnostic laparoscopy and debulking surgery between January 2010 and June 2018. Two radiologists independently reviewed preoperative CT scans and assessed ten CT features known as predictors of suboptimal cytoreduction. Correlation analysis between ten CT features and seven laparoscopic parameters based on the Fagotti scoring system was performed using Spearman’s correlation. Variable selection and model construction were performed by logistic regression with the least absolute shrinkage and selection operator method using a predictive index value (PIV) ≥ 8 as an indicator of suboptimal cytoreduction. The final CT-based scoring system was internally validated using 5-fold cross-validation. Results: A total of 157 patients (median age, 56 years; range, 27–79 years) were evaluated. Among 120 (76.4%) patients with a PIV ≥ 8, 105 patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the optimal cytoreduction rate was 90.5% (95 of 105). Among 37 (23.6%) patients with PIV < 8, 29 patients underwent primary debulking surgery, and the optimal cytoreduction rate was 93.1% (27 of 29). CT features showing significant correlations with PIV ≥ 8 were mesenteric involvement, gastro-transverse mesocolon-splenic space involvement, diaphragmatic involvement, and para-aortic lymphadenopathy. The area under the receiver operating curve of the final model for prediction of PIV ≥ 8 was 0.72 (95% confidence interval: 0.62–0.82). Conclusion: Central tumor burden and upper abdominal spread features on preoperative CT were identified as distinct predictive factors for high PIV on diagnostic laparoscopy. The CT-based PIV prediction model might be useful for patient stratification before cytoreduction surgery for advanced ovarian cancer.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy With Mitomycin C Used for Colorectal Peritoneal Carcinomatosis

노승재,박성찬,최재희,이준상,Dong Woon Lee,홍창원,한경수,박형철,손대경,오재환 대한대장항문학회 2020 Annals of Coloproctolgy Vol.36 No.1

Purpose: This study aimed to assess the evaluation of clinical outcomes and consequences of complications after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) for the peritoneal carcinomatosis (PC) from colorectal cancer. Methods: A total 26 patients underwent CRS and HIPEC for PC from colorectal cancer between March 2009 and April 2018. All the patients underwent CRS with the purpose of complete or near-complete cytoreduction. Intraoperative HIPEC was performed simultaneously after the CRS. Mitomycin C was used as chemotherapeutic agent for HIPEC. Results: Median disease-free survival was 27.8 months (range, 13.4–42.2 months). Median overall survival was 56.0 months (range, 28.6–83.5 months). The mean peritoneal cancer index (PCI) was 8.73 ± 5.54. The distributions thereof were as follows: PCI <10, 69.23%; PCI 10–19, 23.08%; and PCI ≥20, 7.69%. The completeness of cytoreduction was 96.2% of patients showed CC-0, with 3.8% achieved CC-1. The mean operation time was 8.5 hours, and the mean postoperative hospital stay was 21.6 days. The overall rate of early postoperative complications was 88.5%; the rate of late complications was 34.6%. In the early period, most complications were grades I–II complications (65.4%), compared to grades III–V (23.1%). All late complications, occurring in 7.7% of patients, were grades III–V. There was no treatment-related mortality. Conclusion: Although the complication rate was approximately 88%, but the rate of severe complication rate was low. In selective patients with peritoneal recurrence, more aggressive strategies for management, such as CRS with HIPEC, were able to be considered under the acceptable general condition and life-expectancy.

Optimal number of neoadjuvant chemotherapy cycles prior to interval debulking surgery in advanced epithelial ovarian cancer: a systematic review and meta-analysis of progression-free survival and overall survival

Camelia Alexandra Coada,Giulia Dondi,Gloria Ravegnini,Stella Di Costanzo,Marco Tesei,Enrico Fiuzzi,Marco Di Stanislao,Susanna Giunchi,Claudio Zamagni,Alessandro Bovicelli,Patrizia Hrelia,Sabrina Angel 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.6

Objective: Neoadjuvant chemotherapy (NACT) represents a treatment option in patients with advanced epithelial ovarian cancer (AEOC) who are not good candidates for primary debulking surgery. Usually, 3 cycles of chemotherapy before surgery have been considered the best option for patient survival, although quite often some patients receive more than 3 cycles. The aim of this systematic review and meta-analysis was to identify the optimal number of NACT cycles reporting better survival in AEOC patients. Methods: PubMed, Cochrane Library, and Scopus were searched for original articles that analyzed the relationship between the number of chemotherapy cycles and clinical outcomes in AEOC patients before interval debulking surgery (IDS). The main outcomes were progression-free survival (PFS) and overall survival (OS). Results: A total of 22 studies comprising 7,005 patients diagnosed with AEOC were included in our analysis. In terms of survival, the reviewed studies dividing the patients in ≤3 NACT cycles vs. >3, showed a trend for a decrease in PFS and a significant reduction in OS with an increasing number of cycles, while a difference in both PFS and OS was revealed if early IDS included patients with 4 NACT cycles. These results should be interpreted with caution due to the complex characteristics of AEOC patients. Conclusion: In conclusion, our review and meta-analysis revealed that there is not enough evidence to determine the optimal number of NACT treatments before surgery. Further research in the form of well-designed randomized controlled trials is necessary to address this issue.

An overview of the current debate between using minimally invasive surgery versus laparotomy for interval cytoreductive surgery in epithelial ovarian cancer

Lindsey Finch,Dennis S. Chi 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.5

The standard of care for treatment of advanced-stage epithelial ovarian cancer is primarily surgery followed by platinum-based chemotherapy, with the operative goal to achieve complete gross resection. Cytoreductive surgeries for epithelial ovarian cancer historically were performed via open laparotomy; however, as minimally invasive techniques became more widely accepted within gynecologic oncology, interest in employing this approach in the setting of cytoreductive surgery for epithelial ovarian cancer has grown. The purpose of this review was to examine the current debate between the use of minimally invasive surgery versus laparotomy as an approach to interval cytoreductive surgery in advanced epithelial ovarian cancer. While numerous retrospective and feasibility studies have found comparable outcomes with respect to complete gross residual disease, progression-free survival, and overall survival between minimally invasive and laparotomy approaches to interval cytoreductive surgery for epithelial ovarian cancer, methodological challenges limit the utility of these data. Given potential risks of underestimating disease burden and failing to achieve complete resection using a minimally invasive approach, further rigorous studies are needed to evaluate the safety and efficacy of minimally invasive surgery in this setting and to better define the subset of patients who would receive the greatest benefit from a minimally invasive approach.

Predictors of postoperative pancreatic fistula after splenectomy with or without distal pancreatectomy performed as a component of cytoreductive surgery for advanced ovarian cancer

Kyoko Nishikimi,Shinichi Tate,Ayumu Matsuoka,Satoyo Otsuka,Makio Shozu 대한부인종양학회 2022 Journal of Gynecologic Oncology Vol.33 No.3

Objective: Splenectomy with or without distal pancreatectomy is occasionally performed during cytoreductive surgery for advanced ovarian cancer. We investigated pre-, intra-, postoperative risk factors and predictors of clinically relevant postoperative pancreatic fistula (CR-POPF) in patients who underwent cytoreductive surgery for advanced ovarian cancer. Methods: We investigated 165 consecutive patients with ovarian, fallopian tube, and peritoneal carcinoma categorized as stage III/IV disease, who underwent splenectomy with or without distal pancreatectomy as a component of cytoreductive surgery performed as initial treatment at Chiba University Hospital. Patient characteristics, clinical factors, and surgical outcomes were compared between those with and without CR-POPF. Results: CR-POPF occurred in 20 patients (12%). There were no significant intergroup differences in the characteristics between patients with CR-POPF and patients without CR-POPF except for operative time, intraoperative blood loss, amylase (AMY) levels in drain fluid on postoperative day (POD)1 and POD3, and pancreatic stump thickness. Multivariate analysis showed that the POD3 drain fluid AMY level was the only significant risk factor and predictor of CR-POPF in patients who underwent cytoreductive surgery for advanced ovarian cancer. The receiver operating characteristic curve of the POD3 drain fluid AMY level, which predicted development of CR-POPF showed an area under the curve of 0.77, and the optimal cut-off value of AMY was 808 U/L. A pancreatic fistula did not occur in patients with POD3 drain fluid AMY levels <130 U/L. Conclusion: The POD3 drain fluid AMY level can be early diagnostic predictor CR-POPF after splenectomy with or without distal pancreatectomy for advanced ovarian cancer.