Neo-adjuvant chemotherapy does not increase the rate of complete resection and does not significantly reduce the morbidity of Visceral–Peritoneal Debulking (VPD) in patients with stage IIIC–IV ovarian cancer

Cardiophrenic lymph node metastasis as the sole presentation of high grade serous ovarian carcinoma

Key Clinical Message

Cardiophrenic metastasis is typically a late stage manifestation of ovarian high grade serous carcinoma. Here we present a case where this was the sole presentation of this disease. This case challenges our current understanding of the natural course of ovarian high grade serous carcinoma.

Abstract

Ovarian cancer is typically described to spread from its primary site within the fallopian tubes or ovaries into the peritoneal cavity and beyond with cardiophrenic lymph node involvement being considered a late stage disease process. Here we present the case of a lady in her 60s where increased metabolic activity of the cardiophrenic lymph node was picked up in the investigation of an adenocarcinoma of the lung. Post-thoracoscopic resection histopathological analysis of this lymph node showing an epithelial structure with positive immunohistochemical markers PAX8, WT1, ER, and p16 with a p53 wild type-pattern were the sole presenting features of a high grade serous ovarian carcinoma, that was otherwise undetectable by radiological or hematological screening. Only histopathological analysis after modified radical hysterectomy in gynae-oncological fashion were able to identify a 4 mm lesion within the left fallopian tube. This case questions our current understanding of the natural history of ovarian carcinomas.

Feasibility of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer: the ULTRA-LAP trial pilot study

OBJECTIVE

A non-randomized prospective clinical trial (ULTRA-LAP) was registered to test safety, side effects and efficacy of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer (OC). A pilot study was designed to identify which OC patients are suitable to undergo L-VPD.

METHODS

Between March 2016 and October 2021, all consecutive patients with OC underwent exploratory laparoscopy (EXL). All patients whose disease was deemed amenable for a complete resection (CR) at imaging review and EXL, underwent VPD. In all patients a consistent attempt was made at completing L-VPD.

RESULTS

Two hundred and eight OC had EXL in the study period: 121 underwent interval VPD and 87 up-front VPD. Overall, 158 patients had VPD by laparotomy (75.9%) and 50 (24.1%) had L-VPD, of which 34 patients as interval (iL-VPD) and 16 as up-front (uL-VPD). Intra- and post-operative morbidity was very low in the L-VPD group. CR rate was 98% in L-VPD group and 94% in VPD. Most common reason for conversion was diaphragmatic disease extending dorsally.

CONCLUSION

In the pilot study of ULTRA-LAP, L-VPD was completed in 24,1% of OC. Initial analysis supports the feasibility of L-VPD in 2 groups of OC: those with no gross disease at interval surgery and those with gross visible disease at upfront or interval surgery, but limited to: pelvis (including recto-sigmoid), gastro colic omentum, peritoneum and diaphragm, the latter not requiring dorsal liver mobilization. Both groups had 100% feasibility and have been thus forth recruited to ULTRA-LAP.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05862740.

Peritonectomy and resection of mesentery during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer: A phase I-II trial

OBJECTIVE

To describe the surgical technique, assess feasibility, efficacy, and safety of peritonectomy and/or resection of mesentery (P-Rme) during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC).

METHODS

In April 2009 we registered a protocol study on the safety and feasibility of P-Rme. In the period April 2009-December 2022, 687 patients with FIGO stage IIIC-IV ovarian cancer underwent VPD. One hundred and twenty-nine patients (18.7%) had extensive disease on the mesentery and underwent P-Rme. Feasibility was assessed as the number of procedures completed. Efficacy was measured as the rate of Complete Resection (CR). Safety was defined by the intra- and post-operative morbidity rate specifically associated with these procedures.

RESULTS

In all patients P-Rme was successfully completed. P-me was performed in 82 patients and R-me in 47, both procedures in 23 patients. CR was achieved in all 129 patients with an efficacy of 100%. Intra-operatively 5 patients out of 129 experienced small bowel loop surgical devascularization. They required small bowel resection and anastomosis. The procedure specific morbidity was 3.8%. No post-operative complication was related to P-Rme. At 64 months median follow-up, survival outcomes in the study group were similar to patients in the control group.

CONCLUSION

Overall, almost 20% of the VPD patients needed P-Rme to obtain a CR. P-Rme was a safe and effective step during VPD. The rate of CR in the study group was 100% achieved thanks to the addition of the P-Rme. No procedure specific post-operative complications occurred but 3.8% of the patients had unplanned additional surgery related to these procedures.

Cytoreduction Plus Hyperthermic Intraperitoneal Chemotherapy in Primary and Recurrent Ovarian Cancer: A Single-Center Cohort Study

Epithelial ovarian cancer (EOC) is the most frequent cause of death among women with gynecologic malignant tumors. Primary debulking surgery (PDS) with maximal surgical effort to reach completeness of cytoreduction, followed by chemotherapy, has become the standard of care; moreover, some experiences have shown that a comprehensive treatment approach of surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) could improve the prognosis of ovarian cancer. We carried out a retrospective analysis of all consecutive sixty-six patients diagnosed with primary advanced or recurrent ovarian cancer who underwent debulking surgery plus HIPEC in a single center between September 2005 and October 2020. For 33 patients with primary EOC, with a median follow-up period of 70 months, the median overall survival was 56 months (range: 48.1–96.9); and the median disease-free survival (DFS) was 13 months (range: 19.9–53.7). In the recurrent population, the median follow-up period was 78 months, the median overall survival (OS) was 82 months (range: 48.1–96.9), and the median DFS was 17 months (range: 19.7–53.0). In our study, we have found that CRS plus HIPEC is feasible, with very low rates of major complications and good results in terms of overall survival.

Computed tomographic enterography (CTE) in evaluating bowel involvement in patients with ovarian cancer

PURPOSE

To explore the utility of CTE in the evaluation of bowel invasion in patients with primary ovarian, fallopian tube, and peritoneal cancer.

METHODS

This observational study included 73 patients who received CTE before operation between September 2019 and December 2021. Two radiologists reviewed CTE images, focusing on the sites and depth of bowel involvement. Based on the findings during surgical exploration, we evaluated the diagnostic power, like sensitivity, specificity, accuracy, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (+ LR), and negative likelihood ratio (- LR) of CTE. Additionally, the characteristic images of bowel involvement on CTE corresponding to surgical findings were shown in the study.

RESULTS

The rate of macroscopic bowel invasion in this cohort was 49.31% (36/73), of which eight patients had small bowel involvement, 17 patients had colon involvement and 27 patients had sigmoid-rectum involvement. CTE detected bowel invasion in the small intestine with a sensitivity, specificity, PPV, NPV, and accuracy of 87.50%, 92.31%, 58.33%, 98.36%, 91.78%; for colon, the statistics were 58.82%, 96.43%, 83.33%, 88.52%, 87.67% and for sigmoid-rectum 62.96%, 82.61%, 68.00%, 79.17%, 75.34%, respectively.

CONCLUSION

CTE appeared a preferable diagnostic power on the small bowel and colon invasion in patients with primary ovarian, fallopian tube, and peritoneal cancer.

Surgery in Advanced Ovary Cancer: Primary versus Interval Cytoreduction

Primary debulking surgery (PDS) has remained the only treatment of ovarian cancer with survival advantage since its development in the 1970s. However, survival advantage is only observed in patients who are optimally resected. Neoadjuvant chemotherapy (NACT) has emerged as an alternative for patients in whom optimal resection is unlikely and/or patients with comorbidities at high risk for perioperative complications. The purpose of this review is to summarize the evidence to date for PDS and NACT in the treatment of stage III/IV ovarian carcinoma. We systematically searched the PubMed database for relevant articles. Prior to 2010, NACT was reserved for non-surgical candidates. After publication of EORTC 55971, the first randomized trial demonstrating non-inferiority of NACT followed by interval debulking surgery, NACT was considered in a wider breadth of patients. Since EORTC 55971, 3 randomized trials-CHORUS, JCOG0602, and SCORPION-have studied NACT versus PDS. While CHORUS supported EORTC 55971, JCOG0602 failed to demonstrate non-inferiority and SCORPION failed to demonstrate superiority of NACT. Despite conflicting data, a subset of patients would benefit from NACT while preserving survival including poor surgical candidates and inoperable disease. Further randomized trials are needed to assess the role of NACT.

The surgical outcomes and perioperative complications of bowel resection as part of debulking surgery of advanced ovarian cancer patients

Background

To review the utilization of bowel resection in ovarian cancer surgery in our institution.

Methods

All ovarian cancer patients who received bowel resection between 2006/01 and 2018/12 were identified. Postoperative morbidities were assessed according to the Clavien–Dindo classification (CDC).

Results

There were 182 patients in the anastomosis group and 100 patients in the ostomy group, yielding a total of 282 patients. The median age was 57 years, and most patients had high-grade serous histology (88.7%). Forty-nine (17.3%) patients received neoadjuvant chemotherapy. During the operation, 78.7% of patients had ascites, and the median volume was 800 mL. Extensive bowel resection (at least two-segment) and upper abdominal operation were performed in 29 (10.2%) and 69 (24.4%) patients, respectively. The rectosigmoid colon was the most commonly resected (83.8%) followed by right hemicolectomy (5.9%) and small bowel resection (2.8%). No macroscopic residual disease was observed in 42.9% of the patients, whereas 87.9% had residual disease ≤ 1 cm. Among the entire cohort, 23.0% (65/282) experienced different complications. Severe complications (CDC 3–5) accounted for 9.2% of complications and were mostly categorized as pleural effusion requiring drainage (3.5%) followed by wound dehiscence requiring delayed repair in the operating room (1.8%). Nine patients experienced anastomotic leakage (AL): one in the ostomy group with extensive bowel resection and eight in the anastomosis group. The overall AL rate was 4.2% (9/212) per anastomosis.

Conclusions

The execution of bowel resection as part of debulking surgery in patients with newly diagnosed ovarian cancer resulted in a severe morbidity rate of 9.2%.

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.

Surgical outcomes of diaphragmatic resection during cytoreductive surgery for advanced gynecological ovarian neoplasia: A randomized single center clinical trial - DRAGON

INTRODUCTION

Ovarian cancer (OC) represent nearly 4% of gynecologic malignancies and it is often diagnosed at advanced stage. Diaphragmatic surgery, a fundamental step of advanced stage ovarian cancer (ASOC) debulking surgery, is associated with a high post-operative complication incidence, which is supposedly reduced with thoracostomy tube placement. We assessed the role of intra-operative thoracostomy tube placement, as a prevention measure for post-operative complications, after diaphragmatic resection.

METHODS

This was a single center prospective randomized trial. Ovarian cancer patients, who underwent mono-lateral diaphragmatic resection, were randomized 1:1 into two arms. Arm A included patients receiving intra-operative thoracostomy tube placement (TP); Arm B patients did not receive thoracostomy tube placement (NTP). After surgery, all patients underwent seriate chest x-ray and ultrasound to record thoracic complications. Statistical analysis included uni- and multivariable logistic regression model (proportional odds model).

RESULTS

Three hundred seventy-one patients were screened and 88 patients were enrolled: 44 in arm A and B, respectively. No statistically significant differences for intra-operative (p = 0.291) and any grade of post-operative complication (p = 0.072) were detected, while 6.8% of patients in arm A and 22.7% in arm B experienced severe respiratory symptoms (p = 0.035); 18.2% of patients in arm A had a moderate/large pleural effusion versus 65.9% in arm B (p < 0.0001). At multivariable analysis, results confirmed that the NTP-group had a higher risk to receive post-operative thoracostomy tube placement due to pleural effusion than the TP-group (odds ratio [95% Confidence Interval] = 14.5 [3.7-57.4]).

CONCLUSIONS

Thoracostomy intra-operative tube placement after diaphragmatic resection is effective to prevent post-operative thoracic complications. The extension of resection does not influence outcomes and the risk of post-operative thoracentesis or TP remain elevated.

Feasibility of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer

OBJECTIVE

To describe the surgical technique and evaluate the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC).

METHODS

This report is part of a Service Evaluation Protocol (Trust number 3267) on laparoscopy in patients with OC following neo-adjuvant chemotherapy. Between April 2015 and November 2017, all patients underwent to exploratory laparoscopy and a selected court was offered laparoscopic VPD. Laparoscopic diaphragmatic surgery was considered if there was no full thickness involvement. Primary endpoints of this part of the study were the safety, feasibility and efficacy of laparoscopic diaphragmatic peritonectomy. We report the surgical technique and outcomes.

RESULTS

Ninety-six patients underwent diaphragmatic surgery during the study period. Fifty patients (52.1%) had intra-operative exclusion criteria and/or full thickness diaphragmatic resection, 46 (47.9%) had peritonectomy and were included in the study. Laparoscopic diaphragmatic peritonectomy was performed in 21 patients (45.4%, group 1), while in 25 patients (54.6%, group 2) laparotomy was necessary. Extent of disease and complexity of surgery were similar. Reasons for conversions were disease coalescing the liver to the diaphragm preventing safe mobilization (22 patients) and accidental pleural opening (3 patients). Overall, intra- and post-operative morbidity was lower in group 1 and pulmonary specific morbidity was very low.

CONCLUSION

Diaphragmatic peritonectomy can be safely accomplished by laparoscopy in almost half of the patients with OC whose disease is limited to the diaphragmatic peritoneum.

Residual Tumor Diameter Predicts Progression After Primary Debulking Surgery of Ovarian Clear Cell Carcinoma (OCCC): Clinicopathologic Study of Stage II-IV OCCC Patients from a Single Institution

Introduction

Ovarian clear cell carcinoma (OCCC) is a subtype of ovarian cancer characterized by highly aggressive and poor prognosis. However, it is unclear what factors are associated with OCCC recurrence and death. The study aimed to evaluate whether residual tumor diameter after primary debulking surgery, or other clinicopathological features play roles in predicting survival outcome in stage II–IV OCCC patients.

Material and Methods

We present a retrospective study of OCCC patients with stage II–IV in our department from 2010 to 2015. Kaplan–Meier method was used to draw a survival curve. Survival analysis was performed using Log-rank test for univariate analysis and COX proportional risk regression model for multivariate analysis.

Results

In this cohort of 78 patients who underwent primary debulking surgery, 47 patients had disease recurrence and 32 cases died. On univariate analysis, FIGO stage, residual tumor diameter and ascites were significant predictors of 3-year PFS (P values<0.05) and OS (P values<0.05). On multivariate analysis, the residual tumor diameter was an independent prognostic factor for 3-year PFS and OS (P values<0.05). The outcomes of patients in residual-free group were significantly better than those in the residual tumor diameter 0–1cm and >1cm group (PFS: P=0.000, OS: P=0.001), but there was no significant difference in prognosis between 0–1cm and > 1cm group (P values >0.05). Greater residual tumor diameter predicted progression on cox analysis in patients with stage III, but not for patients with stage IV.

Conclusion

Residual tumor diameter is prognostic after surgery for OCCC. Achieving no residual disease will significantly improve the prognosis in advanced OCCC patients.

[Epithelial ovarian cancers and minimally invasive cytoreductive surgery after neoadjuvant chemotherapy: A systematic review]

INTRODUCTION

Advanced epithelial ovarian cancer (EOC) is associated with high mortality and often managed first with neoadjuvant chemotherapy (NACT) followed by debulking surgery. Laparoscopic surgery with or without robotic assistance (Minimally Invasive Surgery (MIS)) may represent a beneficial option for these patients. The objective of this literature review is to clarify the place of MIS in the management of advanced EOC for selected patients.

METHOD

Pubmed, Cochrane and Clinicaltrials.gov online databases were used for this review, to select English or French published articles.

RESULTS

We selected 11 original articles published between 2015 and 2020, 6 of which compared MIS and laparotomy. Among these 11 studies, 8 were retrospective cohorts, 2 were phase II trials, and one was a case-control study. In total, there were 3721 patients, of which 854 (23%) were treated with MIS. The robotic assistance was used with 224 patients (26%) of those MIS patients. Looking specifically at MIS patients, the laparoconversion rate was 9.5%, the rate of complete resection (CC-0) was 83.4%. Finally, the MIS complication rate was 1% intraoperatively and 12% postoperatively. The rate of complete resection, postoperative complication, as well as overall survival (OS) were comparable between patients treated with MIS or laparotomy. One study found an improved disease-free survival (DFS) in MIS versus laparotomy (18 months versus 12 months; P=0.027).

CONCLUSION

MIS seems feasible, effective, and reliable in comparison to laparotomy for the completion of cytoreductive surgery after NACT without compromising oncological safety. Prospective randomized controlled trials are needed to confirm the role of MIS in advanced EOC.

Gynecological cancers and urinary dysfunction: a comparison between endometrial cancer and other gynecological malignancies

The purpose of this paper is to provide a narrative overview of the available literature about voiding dysfunction in women with gynecological cancer before and after surgical, chemo- and radiotherapy treatments. Radical surgery, radiotherapy, and chemotherapy may cause lower urinary tract dysfunction such as stress and urge urinary incontinence, and voiding difficulties. However, nerve-sparing radical hysterectomy may be a valid surgical approach in order to reduce bladder innervation impairment and maintain normal urinary function. Also, newer radiotherapy techniques significantly reduce the number of adverse effects, including bladder dysfunction. Pelvic floor muscle physiotherapy and training with biofeedback and urethral bulking agents represent some additional therapies that can be used in oncologically treated patients with urinary symptoms in order to improve a significant aspect of their quality of life. Considering the important impact on the patients' quality of life, a full urogynecological evaluation should be considered as an important part of oncological treatment and follow-up.

A prospective study on the diagnostic pathway of patients with stage IIIC-IV ovarian cancer: Exploratory laparoscopy (EXL) + CT scan VS. CT scan

OBJECTIVE

To compare the diagnostic power of CT scan to a combination of exploratory laparoscopy (EXL) and CT scan in patients with stage IIIC-IV Ovarian Cancer (OC) by anatomic areas. To investigate if adding EXL to CT can reduce unnecessary laparotomy.

METHODS

In the period 2009-2017, 350 consecutive patients with FIGO Stage IIIC-IV OC underwent CT and EXL prior to Visceral-Peritoneal debulking (VPD) and were included in the study. Radiologist and surgeons filled an ad-hoc form to report CT scan and EXL of eleven key anatomic areas. The decision to proceed to EXL was based on the CT scan and the decision to proceed to laparotomy (LPT) on CT and EXL. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity, and accuracy of CT, EXL and CT + EXL were calculated. We broke down the diagnostic outcomes by anatomic areas and determined the rate of unnecessary laparotomy avoided with the findings of EXL.

RESULTS

Median time for the EXL was 14 min (SD +/- 3). No complication related to EXL occurred. At EXL, 325 out of 350 patients (93%) proceeded to LPT and 25 patients (7.1%) did not because of exclusion criteria. In 307 patients out of 325 (94.4%) EXL was followed by VPD. Eighteen patients had exclusion criteria found at LPT and had no VPD. EXL reduced the rate of unnecessary/futile laparotomy from 12.2% to 5.1%. CT + EXL showed a significantly higher sensitivity for all anatomic areas except for the lymph nodes. Specificity was not significantly improved. PPV was significantly improved for small bowel, porta hepatis and stomach. NPV displayed a statistical improvement in all anatomic areas except lymph nodes, stomach, and liver.

CONCLUSION

The combination CT + EXL has a higher diagnostic power than CT alone, particularly on diaphragm, small bowel serosa and mesentery. The rate of unnecessary laparotomy decreased by almost 60%.

Clear cell degeneration associated with endometriosis of abdominal wall after cesarean section: A case report and systematic review of literature

AIM

The scar of cesarean section (CS) is the most common site of abdominal wall endometriosis (AWE), whose tumor degeneration has been reported in an increasing number of cases; the most frequent histological type is clear cell carcinoma (CCC).

METHODS

We conducted a systematic research of the literature, collecting data regarding the evidence on tumor degeneration from AWE after CS. Moreover, we reported a case of clear cell borderline tumor (CCBT) originating from AWE.

RESULTS

We included data of 37 patients with diagnosis of CCC. The average time between the last CS and the diagnosis of CCC was around 15 years. Overall, 26.0% and 73.9% patients received exclusive local abdominal resection of the lesion and additional surgery, respectively. Lymph nodes involvement was detected in 26.0 % patients and adjuvant chemotherapy was administered in 52.0 % cases. During follow-up period, 15.2% patients died of disease, 32.6% had no evidence of disease, and 17.4% recurred. We diagnosed a CCBT arose in a patients with AWE and a personal history of several surgical procedures for endometriosis, a CS and a subsequent transverse laparotomy. We performed an open bilateral ovariectomy and a large excision of the endometriotic abdominal lesion.

CONCLUSION

Tumor degeneration from AWE seems to be a real occurrence with an increasing number of events. Considering the lack of risk factors and diagnostic instruments for tumor degeneration, the removal of AWE localization could be advisable, even though there was long average time between the trigger surgery and the tumor finding.

Rectosigmoid resection during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer: morbidity of gynecologic oncology vs. colorectal team

Objective

This study investigates the specific morbidity of rectosigmoid resection (RSR) during Visceral-Peritoneal Debulking (VPD) in a consecutive series of patients with stage IIIC-IV ovarian cancer and compares the results of the colo-rectal vs. the gynaecologic oncology team.

Methods

All patients with the International Federation of Gynecology and Obstetrics (FIGO) stage IIIC–IV ovarian cancer who had VPD and RSR were included in the study. Between 2009 and 2013 all operations were performed by the gynecologic oncology team alone (group 1). Since 2013 the RSR was performed by the colorectal team together with the gynecologic oncologist (group 2). All pre-operative information and surgical details were compared to exclude significant bias. Intra- and post-operative morbidity events were recorded and compared between groups.

Results

One hundred and sixty-two patients had a RSR during VPD, 93 in group 1 and 69 in group 2. Groups were comparable for all pre-operative features other than: albumin (1<2) hemoglobin (2<1) and up-front surgery (1>2). Overall morbidity was 33% vs. 40% (p=0.53), bowel specific morbidity 11.8% vs. 11.5% (p=0.81), anastomotic leak 4.1% vs. 6.1% (p=0.43) and re-operation rate 9.6% vs. 6.1% (p=0.71) in groups 1 and 2, respectively. None of them were significantly different. The rate of bowel diversion was 36.5% in group 1 vs. 46.3% in group 2 (p=0.26).

Conclusions

Our study failed to demonstrate any significant difference in the morbidity rate of RSR based on the team performing the surgery. These data warrant further investigation as they are interesting with regards to education, finance, and medico-legal aspects.

Extra-abdominal ovarian cancer presenting with breast metastases at diagnosis: Case report and literature review

OBJECTIVE

Malignant ovarian tumours are diagnosed at an advanced stage in the majority of cases. However, only a small percentage present as extra-abdominal, non-lymph-node solid metastases, as in the breast, and they are usually cases of relapse. The discovery of mono- or bilateral breast lesions with peritoneal carcinosis and/or abdomino-pelvic lesions can be cumbersome in the differential diagnosis of primary tumours. This article aims to summarize current evidence on the detection of breast metastases at diagnosis of ovarian cancer.

STUDY DESIGN

A systematic review of the literature in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including case reports and case series, was undertaken. Data regarding study features; population characteristics; clinical, radiological and histological assessment of the disease; treatment and follow-up were collected. In addition, a case report of a patient managed at the authors' centre is provided.

RESULTS

According to the search strategy, 16 articles (18 patients) were included in this review. Serous ovarian, fallopian tube or primary peritoneal cancer was detected in 61% of cases, while another type or a non-specified type of epithelial ovarian cancer was detected in 27.7% of cases; there was one case with granulosa cell tumour of the ovary and one case with mucinous ovarian tumour of low malignant potential. Breast metastases were mainly monolateral (66.6%), with other extra-abdominal sites of disease in the majority of the cases. A minority of patients (16.6%) received treatment for primary breast cancer with a subsequent diagnosis of ovarian cancer. Concomitant breast and abdominal surgery can be an option. PAX8, WT1 and CA125 immunohistochemical staining can aid in differential diagnosis.

CONCLUSION

Breast metastases of malignant ovarian tumours must be promptly recognized to ensure proper treatment. Specific immunohistochemical analysis can be a decisive assessment in uncertain cases.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for ovarian cancer recurrence: systematic review and meta-analysis

Background

Ovarian cancer is the first cause of death among gynecological malignancies with a high incidence of recurrence. Different treatment options are suitable to prolong the survival rate of these patients. Over the last years, one of the most intriguing methods, adopted in different oncologic centers worldwide, is the hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods

A meta-analysis was performed to value the role of HIPEC for ovarian cancer recurrence. Search strategy was conducted with a combination of the following keywords: "ovarian recurrence, ovarian cancer recurrence, peritoneal cancer recurrence, ovarian recurrence AND HIPEC, secondary cytoreduction HIPEC". Seven studies were selected for analysis.

Results

In women with recurrent ovarian cancer (ROC), the use of HIPEC in addition to cytoreductive surgery and chemotherapy significantly improved 1-year overall survival (OS) when compared to protocols without HIPEC (OR 2.42; 95% CI, 1.06-5.56; P=0.04; I²=4%). The improvement in OS was maintained significant also after 2, 3 and 5 years respectively (OR 3.33; 95% CI, 1.81-6.10; P<0.01; I²=0%), (OR 4.22; 95% CI, 2.07-8.60; P<0.01; I²=52%), (OR 5.17; 95% CI, 1.40-19.09; P=0.01; I²=82%).

Conclusions

HIPEC seems to have an effective role to prolong survival in patients affected by ROC.

Diagnostic flow-chart to identify bowel involvement in patients with stage IIIC-IV ovarian cancer: Can laparoscopy improve the accuracy of CT scan?

OBJECTIVE

This study investigates the diagnostic power of CT scan combined with exploratory laparoscopy (EXL) at identifying large bowel involvement in patients with stage IIIC-IV primary Epithelial Ovarian Cancer (EOC) by comparing with the macroscopic surgical findings at laparotomy.

METHODS

All patients with FIGO Stage IIIC-IV EOC who had Visceral Peritoneal Debulking (VPD) were included in the study. Results of CT scan, EXL and laparotomy (LPT) with regards to the bowel involvement were prospectively recorded in an ad hoc study form. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity and accuracy of CT and EXL were calculated. In addition, the diagnostic power of the combination CT scan + EXL was investigated.

RESULTS

Ninety-four out of 177 patients (53.2%) had a bowel resection during VPD. CT-scan alone had sensitivity, specificity, PPV, NPV and accuracy of 56.7%, 72.4%, 70.8%, 58.5% and 63.8% respectively. EXL alone 84.4%, 93.8%, 93.8%, 84.3%, 88.8%. CT combined with EXL detected bowel involvement with a sensitivity, specificity, PPV, NPV and accuracy of 87.5%, 70.4%, 77.8%, 82.6% and 79.6% and respectively. The combined tests showed a statistically significant improvement vs. CT scan alone (p < 0001) in sensitivity, NPV and accuracy, with non-significant difference in specificity and PPV.

CONCLUSIONS

CT-scan alone shows a limited diagnostic power at detecting large bowel involvement in patients with stage IIIC-IV EOC. The combination of CT scan with EXL increases the diagnostic power and enables to appropriately plan the bowel resection and consent the patients.

Tozzi classification of diaphragmatic surgery in patients with stage IIIC-IV ovarian cancer based on surgical findings and complexity

Objective

To introduce a systematic classification of diaphragmatic surgery in patients with ovarian cancer based on disease spread and surgical complexity.

Methods

For all consecutive patients who underwent diaphragmatic surgery during Visceral-Peritoneal debulking (VPD) in the period 2009–2017, we extracted: initial surgical finding, extent of liver mobilization and type of procedure. Combining these features, we aimed to classify the surgical procedures necessary to tackle different presentation of diaphragmatic disease. We also report histology, intra- and post-operative specific complication rate based on the classification.

Results

A total of 170 patients were included in this study, 110 (64.7%) had a peritonectomy, while 60 (35.3%) had a full thickness resection with pleurectomy. We identified 3 types of surgical procedures. Type I treated 28 out of 170 patients (16.5%) who only had anterior diaphragm disease, needed no liver mobilization, included peritonectomy and had no morbidity recorded. Type II pertained to 105 out of 170 patients (61.7%) who had anterior and posterior disease, needed partial and sometimes full liver mobilization, had a mix of peritonectomy and full thickness resection, and experienced 10% specific morbidity. Type III included 37 out of 170 patients (21.7%) who needed full mobilization of the liver, always had full thickness resection, and suffered 30% specific morbidity.

Conclusion

Diaphragmatic surgery can be classified in 3 types. The adoption of this classification can facilitate standardization of the surgery, comparison of data and define the expertise required. Finally, this classification can be a benchmark to establish the training required to treat diaphragmatic disease.

Morbidity of multiple bowel resection compared to single bowel resection after debulking surgery for ovarian cancer

OBJECTIVES

To assess the impact of multiple bowel resections on postoperative outcomes in stage IIIC-IV ovarian cancer (OC).

METHODS

From the Oxford OC database we retrieved consecutive patients who underwent bowel resection between January 2009 and November 2017. Patients were divided into two groups: single bowel resection (SBR) and MBR (≥2 bowel resections). The following outcomes were compared between the two groups: 30-day related and not related morbidity to bowel surgery, bowel diversion rate and time to start/restart adjuvant chemotherapy.

RESULTS

Thirty-five patients were in the MBR and 146 in the SBR group. The 30-day overall surgical-related complication and bowel specific complications rate was higher in MBR group than SBR group (54.3% vs. 23.9%, p < 0.001) and (25.7% vs. 10.5%, p = 0.035), respectively. The rate of bowel diversion was 97.7% in MBR vs. 26.7% in the SBR group (p = 0.021). Trend analysis showed a significant reduction in the rate of MBR after the introduction of NACT (p- for trend <0.001).

CONCLUSIONS

Our data show that MBR during OC surgery is associated with a higher rate of overall and bowel specific complication compared to SBR. The introduction of NACT is associated with a reduced rate of MBR.

Arterial-enteric fistula after pelvic lymphadenectomy in secondary cytoreductive surgery for recurrent ovarian cancer

In 6.2% of gynaecologic malignancies, vascular involvement is reported. Cytoreductive surgery presents in those cases a higher rate of major complications. Arterial-enteric fistula is a very rare post-surgical complication with serious repercussions on the patient's life due to intestinal haemorrhage and the overlapping sepsis. This is the first case report about iliac-colonic fistula formation in recurrent ovarian cancer with lymph-node metastasis after laparoscopic secondary cytoreductive surgery in a 75-year-old woman and its successful surgical management. A literature review about arterial-enteric fistula formation in gynaecologic cancer treatment, specifically ovarian cancer, is also reported, hypothesising the risk factors of this severe postoperative complication and possible surgical solutions.

Sexual function and quality of life of patients affected by ovarian cancer

INTRODUCTION

The sexual function (SF) in patients affected by malignancies represents an important aspect influencing the quality of life (QoL). The most frequent symptoms reported are the decreased sexual desire, dyspareunia, and/or problems with arousal or achieving orgasm. The present study is aimed at analyzing the available scientific evidence regarding the QoL and especially SF of patients affected by ovarian cancer who underwent surgical and medical treatment.

EVIDENCE ACQUISITION

A preliminary research was conducted using Pubmed database with specific keywords combinations regarding SF, QoL and ovarian cancer. The principal findings considered in the present review were: the study design, the number of patients included in each study, the information about the malignancy (histology and stage of disease), the questionnaires administered and the principal findings concerning SF and QoL.

EVIDENCE SYNTESIS

The studies selected were 5 prospective series and 3 case control cross-sectional studies. The scores used were focused on SF, QOL, fatigue and psychological aspects. All studies reported a decreased SF and QOL. Different factors coexist in the influence on outcomes such as physical, hormonal, psychological, self body image, and mechanic outcomes.

CONCLUSIONS

SF represents a fundamental aspect strictly related with QoL. Patients with ovarian cancer (as well all oncological patients) experience a reduction in their SF after diagnosis of malignancy and they should receive adequate counseling regarding this aspect.

Primary debulking surgery vs. interval debulking surgery for advanced ovarian cancer: review of the literature and meta-analysis

INTRODUCTION

Epithelial ovarian cancer (EOC) is the seventh most common cancer among women in the world and the leading cause of death from gynecological malignancies. The standard treatment for advanced EOC consists of optimal primary debulking surgery (PDS) associated with an adjuvant chemotherapy. Neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) have been proposed in the management of advanced EOC to increase the rate of complete citoreductive surgery and to reduce morbidity and mortality. This systematic review and meta-analysis is conducted to compare the oncologic and postoperative outcomes of NACT and IDS with PDS followed by chemotherapy in patients with ovarian cancer.

EVIDENCE ACQUISITION

We conducted a search on the electronic databases PubMed/Medline, Cochrane and Scopus. All randomized controlled trials, cohort and case-control studies comparing PDS and IDS in ovarian cancer published in English until 28 February 2019 were considered eligible.

EVIDENCE SYNTHESIS

Twenty studies were included in the systematic review. As regards the meta-analysis, only studies that allowed the data we needed to be extracted were included: five were included for the evaluation of overall survival (OS) and PFS and 9 for the evaluation of major postoperative complications and days of hospital stay.

CONCLUSIONS

From the meta-analysis of the current available literature, none of the two investigated procedures has proven to be superior in terms of OS and PFS in the treatment of advanced ovarian cancer. However surgical complexity and postoperative complications are reduced in the IDS group.

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.

Racial Differences in Survival From Epithelial Ovarian Cancer Are Associated With Stage at Diagnosis and Use of Neoadjuvant Therapy: A 10-Year Single-Institution Experience With a Racially Diverse Urban Population

OBJECTIVE

The aim of this study was to evaluate the racial/ethnic disparities in ovarian cancer survival in a diverse population.

METHODS

We performed a retrospective cohort study evaluating all patients with epithelial ovarian cancer who received primary treatment at Montefiore Medical Center from 2005 to 2015. Clinicopathologic and survival data were abstracted from medical records. Two-sided statistical analyses were performed using SAS 9.3.

RESULTS

Three hundred forty-four evaluable patients were identified: 85 (25%) black, 107 (31%) white, 74 (21%) Hispanic, and 78 (23%) other. Black patients were more likely to present with stage IV disease (P = 0.01) and receive neoadjuvant chemotherapy (P < 0.01). By Kaplan-Meier survival analysis, black race was associated with worse recurrence-free survival (P = 0.01) when compared with white race. In multivariate Cox regression model including treatment and stage, race was no longer associated with survival. In a separate multivariate analysis, utilization of neoadjuvant chemotherapy was associated with black race (odds ratio 4.03; 95% confidence interval, 1.56-10.38; P < 0.01) and stage IV disease (odds ratio 3.44; 95% confidence interval, 1.66-7.12; P < 0.01).

CONCLUSIONS

In a racially/ethnically diverse population with ovarian cancer, black women had poorer disease-free survival than whites, although this was statistically accounted for by stage at diagnosis and use of neoadjuvant therapy. Research is needed to determine how differences in access/utilization of care and genetic differences in tumor biology may impact late stage diagnosis and use of neoadjuvant chemotherapy among black ovarian cancer patients.

Senhance robotic platform for gynecologic surgery: a review of literature

The advantages of endoscopic procedures are well demonstrated in various surgical procedures. In this field, the technological improvement has been significant. One of the most relevant was made by the introduction of robotic surgery that, thanks to the instruments articulation and the precision of movement, made possible to perform even the most complex procedures. The terms "Alf-X" OR "Senhance" OR "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. The principal findings considered in the present review were: the study design, the number of patients included in each study, operative time, estimated blood loss (EBL), conversion rate to standard laparoscopy (SLPS) or laparotomy (LPT), post-operative complications, post-operative hospital stay, and the possible advantages and disadvantages reported by the authors of the studies. A total of eight studies were considered eligible for the present review. The average operative time for TH reported was 110-140 min. In two case-control studies, the operative time was significantly prolonged (P < 0.05) for robotic procedures when compared with SLPS. The EBL was ≤ 100 ml in all studies. Whereas no statistically significant differences were shown in the two case-control studies in terms of conversion to LPT, all studies were in accordance with the post-operative hospital stay, reporting an average of 2 days for total hysterectomy and 1 day for adnexal surgery.

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.

Bowel resection rate but not bowel related morbidity is decreased after interval debulking surgery compared to primary surgery in patents with stage IIIC-IV ovarian cancer

OBJECTIVE

To assess the morbidity associate with rectosigmoid resection (RSR) in patients with stage IIIC-IV ovarian cancer (OC) undergone primary debulking surgery (PDS) vs. interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT).

METHODS

From the Oxford Advanced OC database, we retrieved all patients who underwent surgery between January 2009 and July 2016 and included all patients who underwent RSR. We compared the rates of overall related and not-related morbidity and bowel diversion in patients undergone RSR during PDS vs. IDS.

RESULTS

Three hundred and seventy-one patients underwent surgery: 126 in PDS group and 245 in IDS group. Fifty-two patients in the PDS group (41.3%) and 65 patients in IDS group (26.5%) underwent RSR (p<0.001). Overall not related morbidity rate was 37.5% and 28.6%, p=0.625. Bowel specific complications affected 16.3% vs. 11.1% of the patients (p=0.577). IDS group had higher rate of bowel diversion compared with PDS (46.0% vs. 26.5%, p=0.048).

CONCLUSION

NACT was associated to an overall reduced rate of RSR compared to IDS. No differences in overall related and not-related complications in patients requiring RSR were seen between the 2 groups. Patients in the IDS group had a significantly higher rate of bowel diversion.

Cytoreductive surgery followed by HIPEC repetition for secondary ovarian cancer recurrence

Secondary and tertiary cytoreductive surgery was associated with improved overall survival in platinum-sensitive recurrent ovarian cancer (ROC). Hyperthermic intraoperative intra-peritoneal chemotherapy (HIPEC) is considered an attractive method in the treatment of ROC to deliver chemotherapy with enhanced effect directly at the tumor site. However, another deserving aspect is the feasibility and the oncologic role of HIPEC repetition. Twelve patients affected by secondary ovarian cancer recurrence previously submitted to cytoreduction followed by HIPEC were enrolled for the present study to receive tertiary cytoreduction followed by HIPEC repetition. The median operative time, including time for HIPEC procedure, was 360 min (range 240-540). Average EBL was 325 ml (from 100 to 500 ml). The median hospital stay was of 5 days, from 4 to 10. Low-grade post operatory complications occurred in 2 patients (16.6%) and high-grade complication in 1 case (8.3%). Our study report encouraging data about safety of HIPEC repetition in ovarian cancer treatment.

Upfront HIPEC and bevacizumab-containing adjuvant chemotherapy in advanced epithelial ovarian cancer

INTRODUCTION

In advanced epithelial ovarian cancer patients, the standard of care is primary debulking surgery, followed by first-line chemotherapy often with bevacizumab addiction. In this context, some experiences have shown that a comprehensive treatment approach to surgery combined with hyperthermic intraperitoneal chemotherapy (HIPEC) could improve the prognosis.

OBJECTIVE

This is a study aimed to explore the feasibility of primary debulking surgery and HIPEC upfront followed by first-line therapy with bevacizumab.

STUDY DESIGN

Phase II monocentric, open label, non-randomised and single-arm study. Forty patients affected by advanced ovarian cancer submitted to primary debulking surgery with HIPEC were enrolled in the study. After surgery, all patients underwent systemic chemotherapy with bevacizumab addiction.

RESULTS

Complete cytoreduction (RT = 0) was achieved in all cases. Treatment-related early complications were observed in 23 patients and in 15 cases were G1-G2. Major complications were reported in 8 patients. No postoperative death was recorded. Subsequent chemotherapy was administered in all cases. Median time between surgery and first cycle of chemotherapy was 42 days (range 30-76). Concomitant bevacizumab was administered in 34 patients (85%). Maintenance with bevacizumab was feasible in 33 patients (82.5%) and its withdrawal was necessary for 1 patient (2.5%) due to G3 hypertension.

CONCLUSION

Our data suggest that HIPEC can be safely introduced in the upfront therapy of advanced ovarian cancer.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies using new hybrid CO2 system: preliminary experience in referral center

The most frequent peritoneal surface malignancies originate principally by gastric cancer, colorectal cancer and ovarian cancer. Apart from the origin, peritoneal carcinosis (PC) is considered a negative prognostic factor. The hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal malignancies is considered an attractive method to deliver chemotherapy with enhanced effect directly at the tumor site. The use of such loco-regional approach has proved to improve prognosis of peritoneal carcinomatosis from different origins. Recently, new devices are suitable for loco-regional intraperitoneal chemotherapy as Peritoneal Recirculation System (PRS-1.0 Combat) with CO₂ technology. This is a retrospective study with the aim to assess the perioperative outcomes using PRS. Seventeen patients were enrolled affected by colorectal or ovarian cancer. Complete cytoreduction (RT = 0) was achieved for all cases. Median operative time was 420 min (range: 335-665) and median drugs dose used for HIPEC was 137 mg/m2 (115-756). Median EBL was 200 ml (range 50-1000). Median post-operative hospital stay was 9 days (range: 4-24). Treatment-related early complications were recorded in 8 (47.0%) cases and were G1-G2 Major complications occurred in two (11.7%) cases. Considering our aim to test the PRS in different cases and in different pathologies, the results confirmed that the technique is feasible with good perioperative outcomes.

A novel HIPEC technique using hybrid CO2 recirculation system: intra-abdominal diffusion test in a porcine model

The role of loco-regional treatment of peritoneal carcinomatosis using intraperitoneal chemotherapy is still investigated. Actually, new technologies are suitable for these procedures, especially a new hybrid system using CO₂ called Peritoneal Recirculation System (PRS-1.0 Combat). A HIPEC procedure in a porcine model using the PRS system was conducted. The objective of experimentation was to assess the distribution of liquid inside the abdomen, by using methylene blue instead of chemotherapy. Moreover, we positioned six different thermal probes in different abdominal regions inside the abdomen to measure the temperature during procedure. During the procedure, all thermal probes recorded an average temperature of 41.5°. At the end of infusion, the abdomen was emptied and then opened; the tracer distribution was recorded. No technical problems were recorded during the procedure. Good distribution of tracer was recorded. More studies are needed to investigate better this new technology.

Does the Number of Neoadjuvant Chemotherapy Cycles before Interval Debulking Surgery Influence Survival in Advanced Ovarian Cancer?

OBJECTIVE

To evaluate the overall survival (OS) of patients with initially inoperable advanced ovarian cancer, tubal carcinoma, or primary peritoneal carcinoma of stages III or IV undergoing neoadjuvant chemotherapy (NAC) followed by cytoreductive surgery, according to the number of cycles performed.

METHODS

This retrospective study was conducted in three main oncology centres in the east of France, reviewing the charts of all patients who underwent NAC between January 1, 1998 and October 31, 2012. We performed an OS analysis using multivariate Cox regression models adjusted for potential confounders. We also analysed progression-free survival (PFS) as well as chemotherapy- and surgery-related morbidity.

RESULTS

Of the 204 patients included, 75 (36.8%) underwent ≤4 NAC cycles and 129 (63.2%) ≥5 NAC cycles. Characteristic data were similar in the two groups. Five-year OS was 35.0 and 25.8%, respectively. This difference was non-significant [HR = 1.06 (0.70-1.59), p = 0.79]. We also found no differences in PFS or morbidity between the two groups.

CONCLUSIONS

The number of NAC cycles does not seem to play a role in the OS of patients with advanced ovarian cancer. Further evidence and prospective data are needed to assess the value of a high/low number of NAC cycles among these patients.

Porta hepatis peritonectomy and hepato-celiac lymphadenectomy in patients with stage IIIC-IV ovarian cancer: Diagnostic pathway, surgical technique and outcomes

OBJECTIVE

To report the surgical technique of ovarian cancer resection at the porta hepatis (PH) and hepato-celiac lymph nodes (HCL). To assess surgical and survival outcomes. Define the accuracy of an integrated diagnostic pathway.

METHODS

Patients with FIGO stage IIIC-IV ovarian cancer that underwent Visceral-Peritoneal Debulking (VPD). Data of patients with disease at the PH/HCL during VPD were extracted from our database. The CT scan findings were compared with the exploratory laparoscopy. Accuracy of CT scan, intra- and post-operative morbidity, rate of complete resection (CR), disease free and overall survival are reported.

RESULTS

Thirty one patients out of 216 (14.3%) had tumor at the PH and/or HCL. In 8 patients out of 31 (25.8%) it was only found with the aid of the exploratory laparoscopy. CR was achieved in 28 patients out of 31 (90.3%). Pathology confirmed disease in the PH/HCL specimens of all but one patient. Overall morbidity relating to the VPD was 29.2%. No complication was specifically related to the PH/HCL. Median disease free survival was 19months and median overall survival was 42months.

CONCLUSION

PH/HCL surgery was required in 15% of patients with FIGO stage IIIC-IV. The surgery was feasible, safe and significantly contributed to CR. CT scan failed to identify the disease in 31% of the patients. CT and laparoscopy correctly identified all patients.

Interval Laparoscopic En-Bloc Resection of the Pelvis (L-EnBRP) in patients with stage IIIC-IV ovarian cancer: Description of the technique and surgical outcomes

OBJECTIVE

To describe the technique and evaluate the feasibility, efficacy and morbidity of the Laparoscopic En-Bloc Resection of the Pelvis (L-EnBRP) during Visceral-Peritoneal Debulking (VPD) at time of interval surgery.

METHODS

This report is part of a prospective non randomized study (service evaluation protocol) on the feasibility and safety of laparoscopy in patients with stage IIIC-IV ovarian cancer and gross residual disease following neoadjuvant chemotherapy. Primary endpoints of this part of the study were the feasibility (rate of patients in whom the surgery could be completed by laparoscopy), efficacy (rate of patients ended with a complete resection) and morbidity (number of patients that suffered complications specifically associated to the procedure) of L-EnBRP. The results were compared between patients in group 1 (L-EnBRP+L-VPD), group 2 (L-EnBRP+VPD) and group 3 (VPD).

RESULTS

Eighteen patients were in group 1, 8 in group 2 and 32 in group 3. Feasibility of L-EnBRP was 45% (26 patients out of 58), efficacy was 100% of the pelvic disease (94.4% overall disease) and morbidity was 5.5%. Main cause for conversion to laparotomy was high tumor load on diaphragm and/or mesentery. All but one patient had a complete resection (CR) of the disease. Group 1 patients had significantly earlier hospital discharge, lower blood loss and reduced overall morbidity than group 2 and 3.

CONCLUSION

L-EnBRP was feasible in almost half of the patients. In these patients a CR was achieved with a low morbidity rate. The latter was significantly decreased when compared to the patients who had a laparotomy.