Total rectosigmoidectomy versus partial rectal resection in primary debulking surgery for advanced ovarian cancer

Clinical Progression of Colorectal Resection in Gynecologic Cancer Patients: Does the Risk of Anastomotic Leakage Increase after Surgery?

OBJECTIVES

This research aimed to examine the clinicopathological results of colorectal resection in patients with advanced gynecological cancers.

METHODS

We retrospectively reviewed the medical records of 104 patients with gynecological cancer who underwent colorectal resection from December 2008 to August 2020 at a single hospital (PNUYH). Using descriptive statistics, variables for risk factors and surgical complications were compared. We eliminated instances with malignancies originating from organs other than the female genitalia, benign gynecological illnesses, primary stoma formation, and any other bowel procedures outside colon resection.

RESULTS

The average age of 104 patients was determined to be 62.0 years. The most prevalent gynecological cancer was ovarian cancer (85 patients, 81.7%), and the most frequent procedure was low anterior resection (80 patients, 76.9%). There were postoperative problems in 61 patients (58.7%), while there was anastomotic leaking in just 3 patients (2.9%). Among the risk factors, only preoperative albumin was statistically significant (p=0.019).

CONCLUSION

Our findings imply that colorectal resection can be performed safely and effectively on individuals with advanced gynecological cancer.

Rectosigmoid sparing en bloc pelvic resection for fixed ovarian tumors: Surgical technique and perioperative and oncologic outcomes

Purpose

Patients with advanced ovarian cancer often undergo en bloc rectosigmoid resection with total hysterectomy to completely debulk the pelvis. We describe a unique rectosigmoid sparing en bloc pelvic resection technique for fixed ovarian tumors infiltrating the colon wall.

Methods

From July 2020 to June 2021, 20 patients with advanced epithelial ovarian cancer (EOC) underwent rectosigmoid sparing en bloc pelvic resection successfully at our institution. We summarized our surgical technique and the peri-operative and oncological outcomes.

Results

Twenty cases with bowel infiltration achieved en bloc pelvic resection with rectosigmoid tumorectomy in a centripetal fashion. Only two patients required mucosal repair. None of the patients experienced any complications associated with en bloc resection. No pelvic recurrence occurred within the median follow-up time of 12 months.

Conclusion

Rectosigmoid sparing en bloc pelvic resection may be feasible for select patients with fixed ovarian tumors infiltrating the colon wall.

Risks factors for anastomotic leakage in advanced ovarian cancer: A systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis aimed to summarise the available evidence on the pre- and intra-operative risk factors for anastomotic leakage (AL) after bowel resection and anastomosis for ovarian cancer (OC).

STUDY DESIGN

We searched online databases from Pubmed, Scopus, ScienceDirect, and Cochrane Library from inception to October 2020. Pre- and intra-operative risk factors for AL were considered as the primary outcomes. Research heterogeneity and bias were evaluated by I² and by the Newcastle Ottawa scale, respectively. The study was registered with PROSPERO, CRD42018095225.

RESULTS

The overall AL rate after OC surgery (median ± SD) was 5.3 ± 12% (277 AL on 5178 anastomoses). Thirteen non-randomised studies were included in the meta-analysis enrolling a total of 3274 patients. Pre albumin level ≤ 3 gr/dl, multiple bowel resections and primary cytoreductive surgery were associated with a significantly high risk of AL with a pooled OR of 5.29 (95% CI: 1.51-18.59), OR = 4.4 (95% CI: 1.19-16.66) and OR = 1.71 (95% CI: 1.05-2.77), respectively. Optimal cytoreduction, ASA score, ascites, and protective stoma were not associated with an increased risk of AL.

CONCLUSION

Based on the best available evidence, preoperative albumin level <3 gr/dl, multiple bowel resections and primary cytoreductive surgery were associated with an increased risk for AL after bowel surgery for OC.

Clinical Phenotypes of Tumors Invading the Rectosigmoid Colon Affecting the Extent of Debulking Surgery and Survival in Advanced Ovarian Cancer

We classified clinical phenotypes based on tumor separability from the rectosigmoid colon and then evaluated the effect of these clinical phenotypes on surgical outcomes and prognosis of advanced ovarian cancer. We collected data of patients with stage IIIB-IVB disease who either underwent visceral segmental serosectomy (VSS) or low anterior resection (LAR) during maximal debulking surgery. All patients were divided into the following, according to the resection types of tumors involving the rectosigmoid colon: the focal (tumor-involved length <18 cm) and separable (FS) group that received VSS, the focal and inseparable (FI) that received LAR, or the diffuse (tumor-involved length ≥18 cm) group (D) that also received LAR. A total of 83 patients were included in FS (n=44, 53%), FI (n=18, 21.7%), and D (n=24, 25.3%) groups. FS and D groups with more extensive tumors were related to wider extent of surgery and more tumor infiltration except for bowels, whereas FI and D groups with more invasive tumors were associated with wider extent of surgery, more tumor infiltration to bowels, longer operation time, more blood loss, more transfusion, longer hospitalization, and higher surgical complexity scores. Moreover, FS and FI groups showed better progression-free survival than D group, whereas FS group demonstrated better overall survival than FI and D groups. Clinical phenotypes based on tumor separability from the rectosigmoid colon may depend on tumor invasiveness and extensiveness in advanced ovarian cancer. Moreover, these clinical phenotypes may affect surgical outcomes and survival.

Clinical Significance of Mesenteric Lymph Node Involvement in the Pattern of Liver Metastasis in Patients with Ovarian Cancer

BACKGROUND

Mesenteric lymph node (MLN) involvement is often observed in ovarian cancer (OC) with rectosigmoid invasion. This study aimed to investigate the clinical significance of MLN involvement in the pattern of liver metastasis in patients with OC.

METHODS

We included 85 stage II-IV OC patients who underwent primary or interval debulking surgery. Twenty-seven patients underwent rectosigmoid resection, whose status of MLN involvement was judged from hematoxylin and eosin (H&E) staining of resected specimens. The prognostic significance of clinicopathological characteristics, including MLN involvement, was evaluated using univariate and multivariate analyses.

RESULTS

MLN involvement was detected in 14/85 patients with stage II-IV OC. Residual tumor status, cytology of ascites, and MLN involvement were independent prognostic factors for progression-free survival (PFS; p = 0.033, p = 0.014, and p = 0.008, respectively). When patients were classified into three groups (no MLN, one MLN, two or more MLNs), the number of MLNs involved corresponded to three distinct groups in PFS (p = 0.001). The 3-year cumulative incidence of liver metastasis of patients with MLN involvement was significantly higher than that of patients without MLN involvement (61.1% vs. 8.9%, p < 0.001). MLN involvement was significantly associated with liver metastasis of hematogenous origin (p < 0.001) compared with peritoneal disseminated origin.

CONCLUSION

MLN involvement is an important prognostic factor in OC, predicting poor prognosis and liver metastasis of hematogenous origin.

Management of postoperative chylous ascites after surgery for ovarian cancer: a single-institution experience

Postoperative chylous ascites is a rare complication from operative trauma to the cisterna chyli or lymphatic vessels in the retroperitoneum. In the present study, we aimed to identify the incidence of postoperative chylous ascites in patients treated for ovarian cancer and to describe its management. We retrospectively reviewed all patients submitted to surgery for ovarian cancer at our Institution from October 2016 to November 2018. We analyzed the clinicopathological features, including the primary tumor histology, stage, grade, surgical procedure, median number of harvested pelvic and para-aortic lymph nodes. We described our experience in the diagnosis and management of chylous ascites. Five hundred and forty-six patients were submitted to surgery for ovarian cancer and 298 patients received pelvic and/or para-aortic lymphadenectomy. Chylous ascites occurred in 8 patients with an incidence of 1.4% in the overall population and a 2.68% among patients receiving lymphadenectomy. All patients received total parenteral nutrition (TPN) with Olimel N4E 2000 mL (Baxter^®) and somatostatin therapy with 0.2 mL per 3 times/day for a median of 9 days (range 7-11). Median hospital stay was 15 days (range 7-16). All patients were successfully managed conservatively and none required surgical correction. Conservative management of chylous ascites with TPN, somatostatin and paracentisis is feasible and effective. These data should be confirmed by prospective multicentric studies.

[Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).

Sarcopenia in Ovarian Cancer Patients, Oncologic Outcomes Revealing the Importance of Clinical Nutrition: Review of Literature

INTRODUCTION

Ovarian cancer is the leading cause of death among gynecological malignancies. Its usual clinical manifestation is at advanced stages, with nutritional impairment, weight loss, and a consequent decline in skeletal muscle mass and strength (defined as sarcopenia). The relationship between sarcopenia and decreased survival was demonstrated not only in ovarian cancer but also in other cancer types, such as hepatocellular, pancreatic, lung, colon, cervical, metastatic breast, and renal cancer. The aim of this study is to review the current evidence regarding the relationship between sarcopenia and the surgical and oncological outcomes in ovarian cancer patients.

METHODS

The systematic search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) statement. The terms "SARCOPENIA" AND "OVARIAN CANCER" were systematically used to search PubMed and Scopus databases. Original reports in English language were identified, with the purpose to include all relevant papers regarding the role of sarcopenia and indicators of skeletal muscle quality assessment in gynecological ovarian cancer.

RESULTS

A total of 9 studies were considered eligible for the present review. The strength of recommendation was moderate and the level of evidence was low in all selected articles. No prospective studies were conducted and most of the papers were case-control series comparing ovarian cancer sarcopenic population vs. non sarcopenic population.

CONCLUSIONS

Sarcopenia appears to have an important role in oncological outcomes of ovarian cancer patients. However, sarcopenia occurrence during disease history and mechanisms underlying the possible impairment in prognosis should be better investigated. Prospective trials are awaited in order to obtain a better insight in this topic.

Survival impact of low anterior resection in patients with epithelial ovarian cancer grossly confined to the pelvic cavity: a Korean multicenter study

Objective

To evaluate survival impact of low anterior resection (LAR) in patients with epithelial ovarian cancer (EOC) grossly confined to the pelvis.

Methods

We retrospectively reviewed 397 patients who underwent primary staging surgery for treatment of 2014 International Federation of Gynecology and Obstetrics (FIGO) stage II–IIIA EOC: 116 (29.2%) IIA, 212 (53.4%) IIB, and 69 (17.4%) IIIA. Patients with grossly enlarged retroperitoneal lymph nodes positive for metastatic carcinoma were excluded. Of 92 patients (23.2%) with gross tumors at the rectosigmoid colon, 68 (73.9%) underwent tumorectomy and 24 (26.1%), LAR for rectosigmoid lesions. Survival outcomes between patients who underwent tumorectomy and LAR were compared using Kaplan-Meier curves.

Results

During the median follow-up of 55 months (range, 1–260), 141 (35.5%) recurrences and 81 (20.4%) deaths occurred. Age (52.8 vs. 54.5 years, p=0.552), optimal debulking (98.5% vs. 95.0%, p=0.405), histologic type (serous, 52.9% vs. 50.0%, p=0.804), FIGO stage (p=0.057), and platinum-based adjuvant chemotherapy ≥6 cycles (85.3% vs. 79.2%, p=0.485) were not different between groups. No significant difference in 5-year progression-free survival (PFS; 57.9% vs. 62.5%, p=0.767) and overall survival (OS; 84.7% vs. 63.8%, p=0.087), respectively, was noted between groups. Postoperative ileus was more frequent in patients subjected to LAR than those who were not (4/24 [16.7%] vs. 11/373 [2.9%], p=0.001). The 5-year PFS (60.3% vs. 57.9%, p=0.523) and OS (81.8% vs. 87.7%, p=0.912) between patients who underwent tumorectomy and those who did not were also similar.

Conclusion

Survival benefit of LAR did not appear to be significant in EOC patients with grossly pelvis-confined tumors.

Morbidity of rectosigmoid resection in cytoreductive surgery for ovarian cancer. Risk factor analysis

AIM

Rectosigmoid resection is often performed during cytoreductive surgery for ovarian cancer, to achieve the goal of no residual tumour. Here, we evaluated the morbidity associated with rectosigmoid resection and the underlying risk factors.

METHODS

We retrospectively assessed consecutive patients managed with rectosigmoid resection during cytoreductive surgery for ovarian cancer at our centre in Paris, France, between 2005 and 2013. All previously identified risk factors were analysed. Major complications were defined as grade III-IV in the Clavien-Dindo classification.

RESULTS

Of 228 patients, 116 had primary and 112 interval surgery; 43/228 [18.9%]; experienced major complications, and these were more common after primary surgery [24.1% vs. 13.4%, p = .04]. The 69 patients who had rectosigmoid resection [33 primary vs. 36 interval surgery, p = .32] had a higher morbidity rate compared to the other patients [30.4% vs. 14.6%, p = .006]. The anastomotic leakage rate was 2.89%. By multivariate logistic regression, independent risk factors for morbidity were postmenopausal status [adjusted odds ratio (aOR), 13.7; 95% confidence interval (95%CI), 1.2;161.9], surgery after neoadjuvant chemotherapy [aOR, 4.4; 95%CI, 1.1;18.8], and peritoneal stripping of the left; paracolic gutter [aOR, 11.3; 95%CI, 2.3;54.3].

CONCLUSION

The morbidity of rectosigmoid resection during cytoreductive surgery for ovarian cancer seems acceptable. Ileostomy does not seem associated with a lower risk of major complications or adjuvant bevacizumab with a higher complication rate.

Partial Cystectomy for Atypical Isolated Recurrence of Ovarian Adenocarcinoma - A Case Report and Literature Review

BACKGROUND

Most cases with advanced-stage epithelial ovarian malignancies will experience recurrent disease at a certain moment of their evolution, even if maximal cytoreductive surgery has been performed at the moment of initial diagnosis. However, it seems that the best therapeutic strategy, in case of relapse, remains aggressive re-resection, with complete cytoreduction being the most efficient way to improve survival.

MATERIALS AND METHODS

We present the case of a 55-year-old patient diagnosed with an isolated pelvic recurrence after stage IIIC surgically-treated ovarian cancer three years after primary cytoreduction.

RESULTS

Intraoperatively, the diagnosis of an isolated pelvic recurrence invading the urinary bladder was confirmed. The recurrent tumor was resected en bloc with partial cystectomy. The postoperative course was uneventful, while histopathological studies confirmed the presence of a poorly differentiated epithelial ovarian recurrent adenocarcinoma. At two year follow-up, the patient is free of any recurrent disease.

CONCLUSION

Isolated pelvic recurrences after surgically-treated ovarian adenocarcinomas can be safely removed and might improve survival.