Interval debulking surgery: an alternative for primary surgical debulking?

Markers of Oxidative Stress and Inflammation in Ascites and Plasma in Patients with Platinum-Sensitive, Platinum-Resistant, and Platinum-Refractory Epithelial Ovarian Cancer

Diverse proinflammatory biomarkers and oxidative stress are strongly associated with advanced epithelial ovarian cancer (EOC). Objective. To determine the behavior of markers of oxidative stress and inflammation in plasma and ascites fluid in patients with platinum-sensitive, platinum-resistant, and platinum-refractory EOC. Methods. A prospective cohort study. The colorimetric method was used to determine levels of the markers 8-isoprostanes (8-IP), lipid peroxidation products (LPO), and total antioxidant capacity (TAC) in plasma and ascites fluid; and with ELISA, the levels of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α) were determined in patients with EOC. Results. In ascites fluid, a significant increase in 8-IP versus baseline plasma levels was found (p = 0.002). There was an important leakage of the TAC levels in ascites fluid versus baseline plasma levels (p < 0.001). The IL-6 was elevated in ascites fluid versus baseline plasma levels (p = 0.003), and there were diminished levels of TNF-α in ascites fluid versus baseline plasma levels (p = 0.001). Discussion. We hypothesize that the ascites fluid influences the behavior and dissemination of the tumor. Deregulation between oxidants, antioxidants, and the proinflammatory cytokines was found to vary among platinum-sensitive, platinum-resistant, and platinum-refractory patients.

WITHDRAWN: Adjuvant chemotherapy followed by interval debulking surgery versus upfront surgery followed by chemotherapy in advanced epithelial ovarian carcinoma

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"The impact of debulking surgery in patients with node-positive epithelial ovarian cancer: Analysis of prognostic factors related to overall survival and progression-free survival after an extended long-term follow-up period"

OBJECTIVE

to estimate the prognostic factors associated with survival and progression free survival (PFS) in patients with node-positive epithelial ovarian cancer (EOC) after an extended long-term follow-up period.

METHODS

Data was provided by the Tumor Registry of the Mayo Clinic, Scottsdale, Arizona on 116 node-positive EOC patients who underwent primary cytoreductive surgery observed over the period 1996-2014.

RESULTS

At censoring date, 21 patients were alive (18%), 95 dead (82%), 18 without evidence of disease (NED) (15 alive, 3 dead) and 76 with evidence of disease (ED) (2 alive, 74 dead). Twenty-nine ED patients (38.2%) experienced a recurrence within 2 years, 53 patients (69.7%) before 5 years. No recurrences were recorded after 10 years. The median follow-up in alive patients was 169.8 months (1.20-207.9 months), 34.9 months (0.30-196.2 months) in dead patients, 128.4 months for NED patients (72.8-202.5 months) and 34.6 months (0.1-106.9 months) in ED patients. Multivariate analysis showed an increased risk of dead in patients with age ≥ 60 years (HR: 3.20; p < 0.002), stage IVA/B (compared with stage IIIA1/2, HR: 4.31; p < 0.001 and stage IIIB/C, HR: 5.31; p < 0.010) and incomplete surgery (compared with complete surgery, HR: 3.10; 95% CI, 1.41-6.77; p < 0.003) and a decreased PFS in stage IVA/B (compared with stages IIIB/C; p = 0.003 and stage IIIA; p = 0.000) and residual volume after surgery >0.6 cm (compared with residual disease <0.5 cm; p < 0.023).

CONCLUSIONS

prognostic factors for an extended long-term PFS are similar as those for survival, because after 17-year follow-up period, the majority of alive patients are NED patients.

A rare case of ovarian cancer in pregnancy complicated by pulmonary embolus and myocardial infarction: management dilemmas

Malignant ovarian neoplasms diagnosed during pregnancy at advanced stages are very rare. The clinical course and prognosis of pregnant patients diagnosed with epithelial ovarian cancer is similar to that of non-pregnant patients. We describe our management of a woman diagnosed with FIGO IIIc ovarian cancer at Caesarean section. Immediately after surgery she suffered a pulmonary embolus and a myocardial infarction. She showed signs of a severe pulmonary hypertension (59 mmHg). Four weeks later the pulmonary hypertension was still moderate but, despite her critical status, she underwent primary debulking surgery (PDS). This was performed under extensive anaesthesiological monitoring. Through this rare case, we show that despite the complex initial status of a critically ill patient, PDS can still remain the mainstay of treatment in patients with advanced ovarian cancer as most patients are able to tolerate even extensive debulking surgery without the need for neoadjuvant chemotherapy.

CA125 kinetic parameters predict optimal cytoreduction in patients with advanced epithelial ovarian cancer treated with neoadjuvant chemotherapy

OBJECTIVE

To evaluate the different kinetic parameters of serum CA125 during neoadjuvant chemotherapy (NAC) to predict optimal interval debulking surgery (IDS).

METHODS

The present retrospective multicenter study included patients with advanced ovarian cancer treated with neoadjuvant platinum-based chemotherapy followed by IDS between 2002 and 2009. Demographic data, CA125 levels, radiographic data, chemotherapy and surgical-pathologic information were obtained. Univariate and multivariate analyses were performed to evaluate variables associated with complete IDS. ROC analysis was used to determine potential cut-off values to predict the likelihood of complete cytoreduction via IDS.

RESULTS

One hundred and forty-eight patients met the study criteria. Ninety-three patients (62.8%) had optimal cytoreduction with no residual macroscopic disease (CC-0) after IDS. In multivariate analyses, the CA125 level after the 3rd NAC was an independent predictor for optimal cytoreduction (odds ratio: 0.98 [0.97-0.99], p=0.04). The area under the ROC curve was 0.73. A threshold of 75 UI/ml displayed the most predictive power. The odds ratio to predict complete cytoreduction was 3.29 [1.56-7.10] (p=0.0008).

CONCLUSION

Our data indicate that for advanced ovarian cancer, a CA125 level less than 75 UI/ml after the 3rd NAC was an independent predictor factor for complete IDS.

Can the preoperative HE4 level predict optimal cytoreduction in patients with advanced ovarian carcinoma?

OBJECTIVE

Optimal surgical outcome has been proved to be one of the most powerful survival determinants in the management of ovarian cancer patients. Actually, for ovarian cancer patients there is no general consensus on the preoperatively establishment of cytoreducibility.

METHODS

Between January 2011 and June 2012 patients affected by suspicious advanced ovarian cancer, referred to the Department of Gynecology of Campus Biomedico of Rome were enrolled in the study. All patients had serum CA125 and HE4 measured preoperatively. After a complete laparoscopy to assess the possibility of optimal debulking surgery defined as no visible residual tumor after cytoreduction (RT=0), patients were submitted to primary cytoreductive surgery (Group A) or addressed to neoadjuvant chemotherapy (Group B).

RESULTS

After diagnostic open laparoscopy, 36 patients underwent optimal primary cytoreductive surgery (Group A) and 21 patients were addressed to neoadjuvant chemotherapy (Group B). In our population, based on ROC curve, the HE4 value of 262pmol/L is the best cut-off to identify patients candidates to optimal cytoreduction with a sensitivity of 86.1% and a specificity of 89.5% (PPV=93.9% and NPV=77%). In addition, CA125 has a sensitivity of 58.3% and a specificity of 84% at cut-off of 414 UI/mL (AUC is 0.68, 95% C.I.=0.620 to 0.861).

CONCLUSION

Our data indicate that preoperative HE4 is a better predictor for optimal cytoreduction compared to CA125. The best combination in predicting cytoreduction is HE4≤262 pmol/L and ascites <500mL with a sensitivity of 100% and a specificity of 89.5% (PPV=94% and NPV=100%).

Can the preoperative Ca-125 level predict optimal cytoreduction in patients with advanced ovarian carcinoma? A single institution cohort study

BACKGROUND

Preoperative Ca-125 level has been used as a predictor of optimal cytoreduction in advanced ovarian carcinoma. Yet, controversy exists regarding the ability of the tumor marker to predict optimal debulking and moreover of the proper cut-off limit to do so.

METHODS

The preoperative Ca-125 levels of 426 patients with Stage III/IV ovarian carcinoma from a single institution were correlated with surgical outcome. Optimal was considered the cytoreduction if the largest residual tumor was < or equal to 1 cm in diameter. Receiver operation characteristic (ROC) curve data were combined with interval likelihood ratios at various Ca-125 levels to determine the cut-off level with the maximum prognostic power. Sensitivity, specificity, positive and negative predictive values and accuracy were also calculated.

RESULTS

Preoperative Ca-125 proved to be a reliable predictor for optimal cytoreduction. The area under curve of the ROC curve was 0.89, 98% C.I.=[0.828-0.952], indicating very good discriminating capability. The level of 500 IU/ml was found to have the most predictive power. The sensitivity of Ca-125 at that level was 78.5%, the specificity 89.6%, the positive predictive value 84.2%, the negative predictive value 85.4% and its accuracy 85%. Furthermore, the likelihood ratio for correct discrimination between optimal and sub-optimal cytoreduction, dropped sharply from 6.33, 95% C.I. [5.19-10.91] at the level of 500 IU/ml to 0.58, 95% C.I. [0.21-1.63] at the level of 600 IU/ml.

CONCLUSIONS

Our data indicate that preoperative Ca-125 is a good predictor for optimal cytoreduction. the best threshold for this prediction proved to be 500 IU/ml. These patients may be candidates for neo-adjuvant chemotherapy treatment. Nevertheless, all clinical and radiological findings must be co-evaluated.

Preoperative predictors for residual tumor after surgery in patients with ovarian carcinoma

OBJECTIVES

Suboptimal debulking (>1 cm residual tumor) results in poor survival rates for patients with an advanced stage of ovarian cancer. The purpose of this study was to develop a prediction model, based on simple preoperative parameters, for patients with an advanced stage of ovarian cancer who are at risk of suboptimal cytoreduction despite maximal surgical effort.

METHODS

Retrospective analysis of 187 consecutive patients with a suspected clinical diagnosis of advanced-stage ovarian cancer undergoing upfront debulking between January 1998 and December 2003. Preoperative parameters were Karnofsky performance status, ascites and serum concentrations of CA 125, hemoglobin, albumin, LDH and blood platelets. The main outcome parameter was residual tumor >1 cm. Univariate and multivariate logistic regression was employed for testing possible prediction models. A clinically applicable graphic model (nomogram) for this prediction was to be developed.

RESULTS

Serum concentrations of CA 125 and blood platelets in the group with residual tumor >1 cm were higher in comparison to the optimally cytoreduced group (p < 0.0001 and <0.01, respectively). Serum albumin and hemoglobin levels were lower in the group with residual tumor (p < 0.0001 and <0.05, respectively). The frequency of preoperative ascites was higher in the group with residual tumor (p < 0.0005). The prediction model, consisting of CA 125 and albumin, for remaining with residual tumor showed an area under the receiver operating characteristics curve of 0.79. A nomogram for probability of residual tumor >1 cm based on serum levels of CA 125 and albumin was established.

CONCLUSION

Postoperative residual tumor despite maximal surgical effort can be predicted by preoperative CA 125 and serum albumin levels. With a nomogram based on these two parameters, probability of postoperative residual tumor in each individual patient can be predicted. This proposed nomogram may be valuable in daily routine practice for counseling and to select treatment modality.

[Survival reflecting the effectiveness of primary operation in patients with epithelial ovarian cancer]

INTRODUCTION

Primary operation of ovarian cancer patients has a great implication in treatment. The survival of patients operated on optimally is better than in those patients, who have tumor residuum after the operation. The optimal result is more frequent in operations performed by gynecologist oncologists as is in surgery administered by general gynecologists or general surgeons.

AIM

Authors evaluated the data of 83 epithelial ovarian cancer patients treated by first-line paclitaxel-carboplatin chemotherapy in Gynecological Oncology Department, at National Institute of Oncology between 2000-2002 through a 35 months follow-up period.

MATERIAL AND METHODS

Average age of patients was as 59 +/- 9.8 years. Primary optimal surgery was done in 45, non-optimal operations were administered in 38 patients. Distribution of patients according to the stages was similar in both groups. Evaluation of progression free interval was calculated according to the product limit method of Kaplan-Meier.

RESULTS

Progression free interval was 35 and 35 months in the optimal and non-optimal surgery groups and 36 and 35 months in the groups operated on by skillful or less practiced gynecologists in radical surgery. Gynecologist oncologists' first operations showed an optimal result in 76% of patients, contrary to other surgeons' group resulting in only a 43% first optimal surgery. A better progression free interval was observed in the patients having optimal surgery by the interval laparotomy in contrary to those patients, who had no optimal second operation (36 vs 25 months), however, the difference showed no statistical significance.

CONCLUSION

Authors believe the similar survival data could be caused by the short follow-up (35 months) and the small numbers in the patient-groups as well as the greater rate of advanced stage patients in the authors' department, in contrary to the partner municipal hospitals (23/29 = 80% versus 33/54 = 61%) resulting in worse survival chances. Proving the efficiency of radical surgery the survey is carried on.

The neoadjuvant approach in the treatment of patients with advanced epithelial ovarian carcinoma

AIMS

Ovarian cancer has a very poor prognosis, with 5-year survival rates of 5-20% for advanced-stage disease. This work was designed to verify whether the neoadjuvant approach had an effect on survival in patients with advanced-stage ovarian cancer.

MATERIALS AND METHODS

Patients with stage III or IV disease who received neoadjuvant platinum-based chemotherapy (group 1) were compared with a group of conventionally treated patients (group 2).

RESULTS

Most of the patients in group 1 (76%) had partial tumoral responses after chemotherapy. Patients from group 1 (n = 42) had a median survival that was not different from that in patients from group 2 (n = 348). Patients who received platinum-based chemotherapy with taxanes had the same survival of patients who received no taxanes.

CONCLUSIONS

Our results showed similar responses and survival rates for patients with stage III or IV ovarian cancer treated with neoadjuvant platinum-based chemotherapy, when compared with patients who underwent primary suboptimal cytoreductive surgery. Our data therefore support the ongoing trials to determine the optimum timing of surgery for ovarian cancer.

Delaying the primary surgical effort for advanced ovarian cancer: a systematic review of neoadjuvant chemotherapy and interval cytoreduction

OBJECTIVE

To summarize the existing data on interval cytoreductive surgery and neoadjuvant chemotherapy as alternative treatment strategies for patients with advanced-stage ovarian cancer.

METHODS

All investigational studies with evaluable survival data on interval cytoreductive surgery and neoadjuvant chemotherapy for ovarian cancer reported in the English language literature between 1989 and 2006 were systematically reviewed.

RESULTS

Three randomized trials and six non-randomized studies of interval cytoreduction following suboptimal initial surgery were identified. Twenty-six studies, including a total of 1336 patients, reporting on neoadjuvant chemotherapy administered in lieu of primary cytoreductive surgery were analyzed according to the survival outcome achieved, the degree of surgical effort or success, and the particular selection criteria employed to justify deferring an attempt at primary cytoreductive surgery.

CONCLUSIONS

Interval surgery following a concerted but suboptimal attempt at up-front cytoreduction does not appear to have an appreciable impact on survival outcome. Maximal primary cytoreductive surgery remains the standard of care for the majority of women with suspected advanced ovarian cancer. Neoadjuvant chemotherapy represents a viable alternative management strategy for the limited number of patients felt to be optimally unresectable by an experienced ovarian cancer surgical team; however, currently available data suggest that the survival outcome achievable with initial chemotherapy is inferior to successful up-front cytoreductive surgery. Additional research is needed to devise universal selection criteria for neoadjuvant chemotherapy, determine the most efficacious treatment program, and characterize the appropriate proportion of patients in which an attempt at primary surgery should be abandoned in favor of initial chemotherapy.

Diagnostic open laparoscopy in the management of advanced ovarian cancer

OBJECTIVE

Optimal primary cytoreductive surgery (OPCS) plus adjuvant chemotherapy (AC) represents the standard management for patients with advanced ovarian cancer (AOC). Recently, some authors have suggested the use of neoadjuvant chemotherapy (NACT) followed by interval debulking surgery (IDS) in patients with unresectable AOC. This study has been started to evaluate the role of diagnostic open laparoscopy (DOL) in predicting who are the best candidates to OPCS.

METHODS

All patients newly diagnosed as affected by AOC were submitted to DOL in order to establish the possibility of OPCS considered as no residual tumor left after operation. Patients considered not susceptible of OPCS were submitted to three cycles of NACT, administered every 3 weeks (Carboplatin, targeted AUC = 6, plus paclitaxel 175 mg/mq), followed by IDS and adjuvant chemotherapy.

RESULTS

From January 2000 to March 2004, 87 patients with AOC underwent DOL. Fifty-three patients (61%) were judged operable and therefore submitted to primary cytoreductive surgery (Group A). Optimal debulking rate in this group of patients was 96%. Thirty-four patients were judged affected by disease not cytoriducible to absent residual tumor and therefore scheduled for NACT-IDS-AC (Group B). Twenty-five patients were judged with partial clinical response and were therefore scheduled for IDS and AC. Optimal debulking rate (no residual tumor ) in Group B patients was 80%. No major perioperative complications, due to laparoscopy, occurred. All Group B patients received the first cycle of chemotherapy the day after DOL. In 34 patients (39%), an explorative laparotomy was avoided. With a median follow-up of 22 months (range 2-49 months), the proportions surviving were 87% and 60% in Group A and Group B patients, respectively.

CONCLUSION

DOL could be considered a valid diagnostic tool in evaluating the extent of disease in AOC. Our data suggest that the use of DOL leads to decrease the rate of primary cytoreductive surgery for AOC; on the other hand, a higher optimal debulking rate (no residual tumor) at primary surgery is achieved.

Neoadjuvant chemotherapy versus primary surgery in advanced ovarian carcinoma

Background

Patients with advanced ovarian cancer should be treated by radical debulking surgery aiming at complete tumor resection. Unfortunately about 70% of the patients present with advanced disease, when optimal debulking can not be obtained, and therefore these patients gain little benefit from surgery. Neoadjuvant chemotherapy (NACT) has been proposed as a novel therapeutic approach in such cases. In this study, we report our results with primary surgery or neoadjuvant chemotherapy as treatment modalities in the specific indication of operable patients with advanced ovarian carcinoma (no medical contraindication to debulking surgery).

Patients and methods

A total of 59 patients with stage III or IV epithelial ovarian carcinomas were evaluated between 1998 and 2003. All patients were submitted to surgical exploration aiming to evaluate tumor resectability. Neoadjuvant chemotherapy was given (in 27 patients) where optimal cytoreduction was not feasible. Conversely primary debulking surgery was performed when we considered that optimal cytoreduction could be achieved by the standard surgery (32 patients).

Results

Optimal cytoreduction was higher in the NACT group (72.2%) than the conventional group (62.4%), though not statistically significant (P = 0.5). More important was the finding that parameters of surgical aggressiveness (blood loss rates, ICU stay and total hospital stay) were significantly lower in NACT group than the conventional group. The median overall survival time was 28 months in the conventional group and 25 months in NACT group with a P value of 0.5. The median disease free survival was 19 months in the conventional group and 21 months in NACT group (P = 0.4). In multivariate analysis, the pathologic type and degree of debulking were found to affect the disease free survival significantly. Overall survival was not affected by any of the study parameters.

Conclusion

Primary chemotherapy followed by interval debulking surgery in select group of patients doesn't appear to worsen the prognosis, but it permits a less aggressive surgery to be performed.

Systemic therapy for gynecological neoplasms: ovary, cervix and endometrium

Early-stage endometrial carcinomas should be treated by total abdominal hysterectomy and bilateral salpingo-oophorectomy. In a small subset of patients, who wish to have children, conservative treatment (hormonal therapy) could be considered. The most effective agents for palliation of advanced disease are doxorubicin plus cisplatin.

Does systematic lymphadenectomy have a benefit on survival of suboptimally debulked patients with stage III ovarian carcinoma? A DEGOG* Study

BACKGROUND AND OBJECTIVES

The aim of this study was to investigate whether systematic lymphadenectomy is necessary in suboptimally cytoreduced patients with stage III ovarian carcinoma.

METHODS

Prognostic significance and the effect on survival of systematic pelvic and para-aortic lymphadenectomy were investigated retrospectively in 61 suboptimally debulked patients with stage III ovarian carcinoma. All patients received platinum-based chemotherapy after surgery; 51 patients had been followed for > or =1 year, or until death. Survival curves were calculated according to the Kaplan-Meier method and were evaluated by log-rank test.

RESULTS

Most patients had stage IIIC disease (60.7%), poorly differentiated tumor (45.9%), and serous histological type (59%). Systematic pelvic and para-aortic lymphadenectomy was performed in 29 patients (47.5%). Lymph node metastases were found in 17 (58.6%) patients; the median number of metastatic nodes was 7 (5-10). Lymph node metastasis was significantly higher in patients with residual disease of >2 cm (P < 0.05). Both univariate and multivariate analyses showed that systematic pelvic and para-aortic lymphadenectomy was not a significant prognostic factor (P > 0.05). In lymph node-dissected patients, survival was significantly longer in patients with minimal residual tumor than in those with residual tumor size >2 cm (P = 0.005).

CONCLUSIONS

Lymphadenectomy seems not to have an evident prognostic value and a benefit on survival in suboptimally debulked patients with stage III ovarian carcinoma.

Can serum CA-125 levels predict the optimal primary cytoreduction in patients with advanced ovarian carcinoma?

OBJECTIVE

The aim of this study was to investigate the predictive value of serum CA-125 levels to ability of optimal primary cytoreduction in patients with advanced epithelial ovarian carcinoma.

METHODS

Preoperative serum CA-125 levels were determined by a commercial enzyme immunoassay kit in a series of 92 patients with stage IIIC epithelial ovarian carcinoma. The abilities of various cutoff value of CA-125 to predict suboptimal cytoreductive surgery were determined. A receiver operating characteristic curve was used to find the most clinically useful CA-125 cutoff value.

RESULTS

Optimal cytoreduction was obtained in 48 patients (52%) using the diameter of the largest residual tumor nodule less than 1 cm. Receiver operating characteristic curve showed that the most clinically suitable CA-125 cutoff value was 500 U/ml. Forty-seven patients (51%) had preoperative serum CA-125 levels below 500 U/ml. Of these patients, optimal cytoreductive surgery was performed in 36 (77%). Of the 45 patients with serum CA-125 levels greater than 500 U/ml, optimal cytoreductive surgery was achieved in 12 (27%). True- and false-positive rates were 73 and 23%, respectively.

CONCLUSIONS

Although our results showed that preoperative serum CA-125 levels might predict the optimal resectable patients, larger prospective studies are needed to prove its predictivity. Gynecologic oncologists should evaluate the sum of all criteria until more data are available.

Neoadjuvant chemotherapy followed by tumor debulking prolongs survival for patients with poor prognosis in International Federation of Gynecology and Obstetrics Stage IIIC ovarian carcinoma

BACKGROUND

Patients with advanced ovarian carcinoma of International Federation of Gynecology and Obstetrics (FIGO) Stage IIIC should be treated by radical surgical tumor debulking with the goal of complete tumor resection. Prolonged median survival can be achieved in those patients entirely free of tumor after surgery by the administration of postsurgical platinum/taxane-based chemotherapy regimens. However, residual tumor is present in the majority of patients, which limits survival prognosis. Different therapy approaches should be utilized to improve prognosis in these patients. Neoadjuvant chemotherapy could induce "downstaging" of the tumor and thus improve operability. Here, evidence of large ascites volume (>500 mL) can be used to identify those patients who could benefit from neoadjuvant chemotherapy.

METHODS

In a prospective, nonrandomized Phase II study, 31 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received 3 cycles of platinum/taxane-based combination chemotherapy, followed by tumor debulking surgery and 3 additional cycles of platinum/taxane-based combination chemotherapy. During the same period, 32 patients with advanced FIGO Stage IIIC ovarian carcinoma and large ascites volume (>500 mL) received conventional therapy (tumor debulking surgery followed by 6 cycles of platinum/taxane-based combination chemotherapy). The two groups were investigated and compared with respect to tumor resection rates, blood transfusion requirements, morbidity, and mortality during surgery, duration of surgery, and median survival.

RESULTS

The tumor resection rate in the patient group receiving neoadjuvant chemotherapy was significantly higher (P = 0.04) than that of the conventionally treated group; the median survival time of 42 months versus 23 months also was significantly longer (P = 0.007). Time spent in surgery, blood transfusion requirements, morbidity, and mortality during surgery were not significantly different.

CONCLUSIONS

Patients with advanced ovarian carcinoma of FIGO Stage IIIC who will benefit only marginally from conventional therapy can be identified by evidence of large ascites volume. Higher tumor resection rates and longer median survival can be achieved in these patients by the use of neoadjuvant chemotherapy. A prospective randomized multicenter study currently is being performed by the Society for Gynecological Oncology in Germany to confirm these findings.