The effect of residual mass size on response to chemotherapy after surgical cytoreduction for advanced ovarian cancer: long-term results

Primary tumor consolidative therapy improves the outcomes of patients with advanced EGFR-mutant lung adenocarcinoma treated with first-line osimertinib

Background

Patients with advanced epidermal growth factor receptor (EGFR)-mutant lung adenocarcinoma (LAD) inevitably experience drug resistance following treatment with EGFR-tyrosine kinase inhibitors (TKIs).

Objectives

We aimed to analyze the effect of primary tumor consolidative therapy (PTCT) on patients treated with first-line osimertinib.

Design and methods

This retrospective cohort study was conducted in patients with advanced stage III or stage IV LAD with EGFR-sensitizing mutations (exon 19 deletion or L858R mutation) with disease control after first-line osimertinib. A curative dose of primary tumor radiotherapy or primary tumor resection was classified as PTCT. We compared the progression-free survival (PFS) and overall survival (OS) of patients with and without PTCT.

Results

This study included 106 patients with a median age of 61.0 years, and of those, 42% were male and 73.6% were never-smokers. Exon 19 deletion was observed in 67.9%, 30.2% had a programmed cell death ligand 1 (PD-L1) tumor proportion score <1%, 33.0% had brain metastasis, and 40.6% had oligometastasis. In all, 53 (50%) patients underwent PTCT. Patients who underwent PTCT demonstrated significantly better PFS [30.3 (95% confidence interval (CI), 24.1-36.4) versus 18.2 (95% CI, 16.1-20.2) months; p = 0.005] and OS [not reached versus 36.7 (95% CI, 32.5-40.9) months; p = 0.005] than patients who did not. A multivariate analysis showed that PTCT was an independent factor associated with better PFS [hazard ratio (HR), 0.22; 95% CI, 0.10-0.49; p < 0.001] and OS [HR, 0.10; 95% CI, 0.01-0.82; p = 0.032]. The PFS benefits of PTCT were consistent across subgroups, and the HR tended to be lower in patients aged <65 years, males, smokers, stage IVB disease, L858R, PD-L1 expression ⩾1%, non-oligometastasis, and brain metastasis.

Conclusion

Of the patients with advanced EGFR-mutant LAD, those who underwent PTCT had a significantly better survival outcome than those who did not. The survival benefits were consistent across different subgroups.

A predictive scoring model to select suitable patients for surgery on primary tumor in metastatic esophageal cancer

BACKGROUND

Surgery on primary tumor (SPT) has been a common treatment strategy for many types of cancer.

AIMS

This study aimed to investigate whether SPT could be considered a treatment option for metastatic esophageal cancer and to identify the patient population that would benefit the most from SPT.

METHODS

Data from 18 registration sites in the Surveillance, Epidemiology, and End Results Program database (SEER database) were analyzed to select patients with metastatic esophageal cancer. Multivariate Cox regression analysis was used to identify potential risk factors for pre-treatment survival. Variables with a p-value of less than 0.05 were used to construct a pre-treatment nomogram. A pre-surgery predictive model was then developed using the pre-surgery factors to score patients, called the "pre-surgery score". The optimal cut-off value for the "pre-surgery score" was determined using X-tile analysis, and patients were divided into high-risk and low-risk subsets. It was hypothesized that patients with a low "pre-surgery score" risk would benefit the most from SPT.

RESULTS

A total of 3793 patients were included in the analysis. SPT was found to be an independent risk factor for the survival of metastatic esophageal cancer patients. Subgroup analyses showed that patients with liver or lung metastases derived more benefit from SPT compared to those with bone or brain metastases. A pre-treatment predictive model was constructed to estimate the survival rates at one, two, and three years, which showed good accuracy (C-index: 0.705 for the training set and 0.701 for the validation set). Patients with a "pre-surgery score" below 4.9 were considered to have a low mortality risk and benefitted from SPT (SPT vs. non-surgery: median overall survival (OS): 24 months vs. 4 months, HR = 0.386, 95% CI: 0.303-0.491, p < 0.001).

CONCLUSION

This study demonstrated that SPT could improve the OS of patients with metastatic esophageal cancer. The pre-treatment scoring model developed in this study might be useful in identifying suitable candidates for SPT. The strengths of this study include the large patient sample size and rigorous statistical analyses. However, limitations should be noted due to the retrospective study design, and prospective studies are needed to validate the findings in the future.

Survival benefit of thoracic radiotherapy plus EGFR-TKIs in patients with non-oligometastatic advanced non-small-cell lung cancer: a single-center retrospective study

Objectives:

The study aims to evaluate the efficacy and safety of thoracic radiotherapy in epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI)-treated patients with stage IV non-small-cell lung cancer (NSCLC).

Methods:

Patients with non-oligometastatic NSCLC harboring EGFR mutations were recruited. All patients received the first-generation TKI treatment with or without radiotherapy. The irradiated sites included primary and/or metastatic lesions. Of all the patients who underwent thoracic radiotherapy, some received radiotherapy before EGFR-TKI resistance, others received radiotherapy after progressive disease.

Results:

No statistically significant difference was observed in progression-free survival (PFS) (median 14.7 versus 11.2 months, p = 0.075) or overall survival (OS) (median 29.6 versus 40.6 months, p = 0.116) between patients treated with EGFR-TKIs alone and those with additional radiotherapy to any sites. However, EGFR inhibitors with thoracic radiation significantly improved OS (median 47.0 versus 31.0 months, p < 0.001) but not PFS (median 13.9 versus 11.9 months, p = 0.124). Moreover, longer PFS (median 18.3 versus 8.5 months, p < 0.001) was achieved in the preemptive thoracic radiation cohort than in the delayed thoracic radiation cohort. However, OS was similar between the two cohorts (median 40.6 versus 52.6 months, p = 0.124). The lower incidence rate of grade 1–2 pneumonitis occurred in preemptive radiation cohort (29.8% versus 75.8%, p < 0.001).

Conclusion:

Non-oligometastatic NSCLC patients with EGFR mutations benefited from thoracic radiotherapy while using EGFR inhibitors. Preemptive thoracic radiotherapy could be a competitive first-line therapeutic option due to superior PFS and favorable safety.

Early Locoregional Breast Surgery and Survival in de novo Metastatic Breast Cancer in the Multicenter National ESME Cohort

OBJECTIVE

The aim was to evaluate the impact of local surgery performed during the year after MBC diagnosis on patients' outcomes from a large reallife cohort.

SUMMARY BACKGROUND DATA

Locoregional treatment for patients with MBC at the time of diagnosis remains debated.

METHODS

Women with newly diagnosed, de novo stage IV MBC and who started MBC treatment between January 2008 and December 2014 in one of the 18 French Comprehensive Cancer Centers were included (NCT03275311). The impact of local surgery performed during the first year on overall survival (OS) and progression-free survival (PFS) was evaluated by the Cox proportional hazards model in a 12 month-landmark analysis.

RESULTS

Out of 16,703 patients in the ESME database, 1977 had stage IV MBC at diagnosis, were alive and progression-free at 12 months and eligible for this study. Among them, 530 (26.8%) had received primary breast cancer surgery within 12 months. A greater proportion of patients who received surgery had less than 3 metastatic sites than the no-surgery group (90.8% vs 78.2%, P < 0.0001). Surgery within 12 months was associated with treatment with chemotherapy, HER2-targeted therapy (89.1% vs 69.6%, P < 0.0001) and locoregional radiotherapy (81.7% vs 32.5%, P < 0.0001). Multivariable analyses showed that surgery performed within 12 months was associated with longer OS and PFS (adjusted HR [95%CI] = 0.75 [0.61-0.92] and 0.72 [0.63-0.83], respectively), which were also affected by pattern and number of metastatic sites, histological subtype, and age.

CONCLUSIONS

In the large ESME cohort, surgery within 1 year after de novo MBC diagnosis was associated with a significantly better OS and PFS.

Impact of surgery on survival in breast cancer with bone metastases only: a SEER database retrospective analysis

Background

It was controversial to operate on the primary site of breast cancer (BC) with bone metastasis only. We investigated the impact of surgery on BC patients with bone metastases via a SEER database retrospective analysis.

Methods

A total of 2917 BC cases with bone metastasis, first diagnosed between 2010 and 2015 in the Surveillance, Epidemiology, and Results Database (SEER) of National Cancer Institute were selected. We assessed the effect of different surgical procedures on survival and prognosis.

Results

Compared with the non-surgical group, the primary tumor surgical group showed longer median survival time (χ² = 146.023, P < 0.001), and the breast-conserving subgroup showed the highest median survival time of 70 months (χ² = 157.117, P < 0.001). Compared with the non-surgery group, the median overall survival (OS) of primary surgery group was longer (HR = 0.525, 95%CI = 0.467–0.590, P < 0.001), and the breast-conserving subgroup showed the longest median operative OS (HR = 0.394, 95%CI = 0.325–0.478, P < 0.001).

Conclusion

This study showed that primary surgery could improve the median survival time and OS of BC patients with bone metastasis. Moreover, under the condition of low tumor burden, breast conserving surgery was a better choice.

Primary Tumor Radiotherapy During EGFR-TKI Disease Control Improves Survival of Treatment Naïve Advanced EGFR-Mutant Lung Adenocarcinoma Patients

Background

Whether radiotherapy only for primary lung tumor (RTPLT) after epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitor (TKI) therapy improves survival of treatment naïve advanced EGFR-mutant lung adenocarcinoma (LAD) patients with/without polymetastasis.

Materials and Methods

This was a retrospective, single-center, observational study. Patients with stage IIIB-IV EGFR-mutant LAD with disease control by EGFR-TKI therapy were divided into curative RTPLT, and control, without radiotherapy (WRTPLT) groups.

Results

A total of 138 patients were enrolled; 46 in the RTPLT group and 92 in the WRTPLT group. Amongst them, 37% had oligometastasis, and 26.1% brain metastasis. The RTPLT group had both significantly longer progression-free survival (PFS) (27.5 months [95% CI 18.1–36.9] vs 10.9 months [95% CI 6.3–15.5], P<0.001) and overall survivor (OS) (NR [95% CI NR-NR] vs 38.0 months [95% CI 31.2–44.8], P<0.001), respectively, when compared to the WRTPLT group. In multivariate analysis, the adjusted HR of radiotherapy on PFS was 0.30 (0.19–0.47) and on OS, 0.11 (0.04–0.30). Patients with oligometastasis had significantly longer PFS than those with polymetastasis with an HR of 0.35 (0.14–0.85), P=0.02. Patients with either oligometastasis or polymetastasis had significant longer PFS when undergoing radiotherapy than those without (both P<0.05). An EGFR-TKI to radiotherapy interval <24 weeks seemed more beneficial (P=0.097). Radiation pneumonitis comprised 32 (69.6%), 12 (26.1%), and two (4.3%) cases of common terminology criteria grade I, II, and III, respectively.

Conclusion

Curative RTPLT can prolong survival in patients with LAD following EGFR-TKI disease control, both involving oligometastasis and polymetastasis. RTPLT within 24 weeks after EGFR-TKI initiation appeared to be more beneficial with tolerable radiation pneumonitis.

Role of locoregional surgery in patients with de novo stage IV breast cancer: analysis of real-world data from China

Stage IV breast cancer is metastatic breast cancer (MBC). Because real-world data are lacking in China, our research attempts to explore the effect of locoregional surgery on the prognosis of patients with MBC. A total of 987 patients from 10 hospitals and 2 databases in East China (2004–2018) were included in this study. Overall, 47% of patients underwent locoregional surgery, and 53% did not. Surgeons tended to perform surgery on patients with small tumours (T1/T2), positive hormone receptor (HR) markers, and metastatic sites confined to a single organ and non-visceral sites (bone only/others) (each p < 0.05). Kaplan–Meier survival curves and the log-rank test showed that median survival was longer for patients who had locoregional surgery than for those who did not (45.00 vs. 28.00 months; p < 0.001). Patients who underwent surgery after systemic treatment had better survival than those who underwent surgery immediately (p < 0.001). In most subgroups, overall survival (OS) was significantly longer in the surgery group than in the no-surgery group (each p < 0.05), except for brain metastases and triple negative breast cancer. Therefore, we concluded that locoregional surgery for the primary tumour in MBC patients was associated with a marked reduction in risk of dying except for patients with brain metastases or triple-negative subtype.

Survival value of primary tumour resection for stage IV non-small-cell lung cancer: A population-based study of 6466 patients

INTRODUCTION

For stage IV non-small-cell lung cancer (NSCLC) patients, surgical resection of primary tumour was rarely recommended.

OBJECTIVES

We conducted this population-based study to demonstrate the survival value of primary tumour resection (PTR) for stage IV (NSCLC).

METHODS

The Surveillance, Epidemiology and End Results (SEER) database was searched for selecting stage IV NSCLC patients. The patients were matched according to age, gender, grade, primary tumour site, histopathological type, tumour size and regional lymph nodes metastasis by propensity score matching (PSM) analysis. Kaplan-Meier curves were presented to show the survival differences between resection group and non-resection group. Risk factors which were supposed to influence survival outcome were investigated using a Cox proportional hazard regression model. And a nomogram was performed to present prognostic factors for stage IV NSCLC patients.

RESULTS

6466 patients diagnosed from 2004 to 2015 were included in survival analyses after PSM. The median overall survival (OS) for overall patients with resection was 27 months, much longer than those without resection (8 months). And this trend remained in subgroup analyses, including different histopathological types and distant metastases (All P values < 0.001). Younger age, race other than white and black, female, grade 1/2 (G1/G2), PTR, chemotherapy, no other distant metastases, smaller tumour size and no regional lymph node metastases were favourable prognostic factors for stage IV NSCLC. A predictive nomogram was conducted based on above risk factors.

CONCLUSION

PTR prolonged survival of stage IV NSCLC patients. And PTR should be considered in clinical practice for stage IV NSCLC.

Survival Benefit of Surgical Removal of Primary Tumor in Patients With Stage IV Breast Cancer

BACKGROUND

Several studies have suggested that primary tumor removal improved overall survival for patients with stage IV breast cancer. However, the survival benefit of local treatment remains controversial. The purpose of the present study was to determine whether surgical removal of the primary tumor provides survival benefits to patients with stage IV breast cancer.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of 155 patients with an initial diagnosis of stage IV breast cancer at Seoul National University Bundang Hospital from 2003 to 2014. Kaplan-Meier analysis was used to estimate the median survival. The log-rank test was used to compare differences in patient and tumor characteristics. Multivariate Cox regression analysis for survival was used, controlling for potential confounding variables.

RESULTS

Of 155 patients with stage IV breast cancer, 95 (61%) underwent surgical removal of the primary tumor. The median follow-up period was 59 months (95% confidence interval [CI], 45-73 months). The median survival was longer for the patients with a better response to chemotherapy (70 vs. 47 months; P = .010) and for those who had undergone surgery (118 vs. 28 months; P < .001) than for those who without a better chemotherapy response or surgery. The median survival of the patients who received radiotherapy was better than that of the patients who did not (65 vs. 39 months; P = .004). Patients with luminal A cancer had a median survival of 118 months, the longest compared with those with other subtypes (P = .001). In addition, patients with distant metastasis at a single site had a longer median survival than did those with multiple metastatic sites. The multivariate Cox regression analysis revealed that fewer distant metastases, surgery of the primary tumor, a better response to chemotherapy, and luminal A subtype were significant independent predictors of survival.

CONCLUSION

Our results showed that primary tumor removal was independently associated with improvement in survival. Therefore, surgical management for the primary tumor could be considered more actively in patients with stage IV breast cancer.

Loco-regional cancer drug therapy: present approaches and rapidly reversible hydrophobization (RRH) of therapeutic agents as the future direction

Insufficient drug uptake by solid tumors remains the major problem for systemic chemotherapy. Many studies have demonstrated anticancer drug effects to be dose-dependent, although dose-escalation studies have resulted in limited survival benefit with increased systemic toxicities. One solution to this has been the idea of loco-regional drug treatments, which offer dramatically higher drug concentrations in tumor tissues while minimizing systemic toxicity. Although loco-regional delivery has been most prominent in cancers of the liver, soft tissues and serosal peritoneal malignancies, survival benefits are very far from desirable. This review discusses the evolution of loco-regional treatments, the present approaches and offers rapidly reversible hydrophobization of drugs as the new future direction.

Primary metastatic breast cancer: the impact of locoregional therapy

The impact of treatment for the primary tumor on distant metastases and survival in primary metastatic breast cancer patients is controversial. Previous retrospective studies and meta-analyses suggested a survival benefit for the removal of the primary tumor. Early follow-up data from 2 prospectively randomized trials presented at San Antonio Breast Cancer Symposium 2013 could not confirm this. Only a very small subgroup of patients with solitary bone metastases seemed to profit from surgery, while patients with multiple visceral metastases showed a worse prognosis with initial surgery. There are no studies available with the primary aim to investigate the impact of axillary lymph node surgery or locoregional radiotherapy on the survival of stage IV breast cancer patients. Based on current data, locoregional treatment in primary metastatic breast cancer should not be recommended in patients with asymptomatic primary tumor as a matter of routine. More solid conclusion of the impact of primary tumor treatment in stage IV breast cancer patients on their prognosis will be reached with the completion of the ongoing prospectively randomized trials. Until these studies are completed, locoregional therapy, which can provoke additional morbidity in a metastatic setting with limited live expectancy, is exclusively indicated for palliative reasons.

[Stereotactic body radiation therapy and oligometastases]

In stage IV cancers, locoregional management of primitive tumours as surgery and/or radiotherapy improved both progression-free survival and overall survival. Among metastatic cancer patients, some of them are considered as oligometastatic stage as they present few metastatic sites associated with low tumor aggressiveness. For those patients, metastatic local control, and therefore prolonged time to progression should be reached through local treatments as surgery and/or radiofrequency ablation and/or stereotactic radiotherapy. Here we propose a review of oligometastatic stage and results from extracranial stereotactic radiotherapy in terms of efficacy and tolerance.

Variations in institutional infrastructure, physician specialization and experience, and outcome in ovarian cancer: a systematic review

OBJECTIVE

Ovarian cancer outcome varies among different institutions, regions, and countries. This systematic review summarizes the available data evaluating the impact of different physician and hospital characteristics on outcome in ovarian cancer patients.

METHODS

A MEDLINE database search for pertinent publications was conducted and reference lists of each relevant article were screened. Experts in the field were contacted. Selected studies assessed the relationship between physician and/or hospital specialty or volume and at least one of the outcomes of interest. The primary outcome was survival. Additional parameters included surgical outcome (debulking), completeness of staging, and quality of chemotherapy. The authors independently reviewed each article and applied the inclusion/exclusion criteria. The quality of each study was assessed by focusing on strategies to control for important prognostic factors.

RESULTS

Forty-four articles met inclusion criteria. Discipline and sub-specialization of the primary treating physician were identified as the most important variable associated with superior outcome. Evidence showing a beneficial impact of institutional factors was weaker, but followed the same trend. Hospital volume was hardly related to any outcome parameter.

CONCLUSIONS

The limited evidence available showed considerable heterogeneity and has to be interpreted cautiously. Better utilization of knowledge about institutional factors and well-established board certifications may improve outcome in ovarian cancer. Patients and primary-care physicians should select gynecologic oncologists for primary treatment in countries with established sub-specialty training. Policymakers, insurance companies, and lay organizations should support development of respective programs.

Metastatic disease to the breast: the Washington University experience

Background

Metastases to the breast occur rarely, but may be increasing in incidence as patients live longer with malignant diseases. The aim of this study is to characterize metastatic disease to the breast and to describe the management and prognosis of patients who present with this diagnosis.

Methods

A retrospective review of our institution's pathology and breast cancer databases was performed in order to identify patients with breast malignancies that were not of primary breast origin. Chart review provided additional information about the patients' primary malignancies and course of illness.

Results

Between 1991 and 2006, eighteen patients with metastatic disease to the breast of non-hematologic origin were identified and all had charts available for review. Among the 18 patients with disease metastatic to the breast, tissues of origin included 3 ovarian, 6 melanoma, 3 medullary thyroid, 3 pulmonary neuroendocrine, 1 pulmonary small cell, 1 oral squamous cell, and 1 renal cell. Overall mean survival after diagnosis of metastatic disease to the breast was 22.4 months. Treatment of metastases varied and included combinations of observation, surgery, radiation, and chemotherapy. Five patients (27.8%) required a change in management of their breast disease for local control.

Conclusion

Due to the variable course of patients with metastatic disease, a multi-disciplinary approach is necessary for each patient with disease metastatic to the breast to determine optimal treatment. Based on our review, many patients survive for long periods of time and local treatment of metastases to the breast may be beneficial in these patients to prevent local complications.

Surgical removal of the primary tumor increases overall survival in patients with metastatic breast cancer: analysis of the 1988-2003 SEER data

BACKGROUND

Primary treatments for stage IV breast cancer are chemotherapy and radiation, with surgery usually reserved for tumor-related complications. We sought to determine whether surgical removal of the primary tumor provides a survival advantage for women with metastatic breast cancer.

METHODS

We conducted a retrospective, population-based cohort study by using the 1988-2003 Surveillance, Epidemiology, and End Results (SEER) program data. By use of multivariate Cox regression models, overall survival in women with stage IV disease was compared between women who underwent surgical excision of their breast tumor with women who did not, controlling for potential confounding demographic, tumor- and treatment-related variables, and propensity scores (accounting for variables associated with the likelihood of having surgery).

RESULTS

Of 9734 SEER patients with stage IV breast cancer, 47% underwent breast cancer surgery and 53% did not. Median survival was longer for women who had surgery than for women who did not, both among women who were alive at the end of the study period (36.00 vs. 21.00 months; P < .001) and among women who had died during follow-up (18.00 vs. 7.00 months; P < .001). After controlling for potential confounding variables and propensity scores, patients who underwent surgery were less likely to die during the study period compared with women who did not undergo surgery (adjusted hazard ratio, .63, 95% confidence interval, .60-.66).

CONCLUSIONS

Analysis of the 1988-2003 SEER data indicated that extirpation of the primary breast tumor in patients with stage IV disease was associated with a marked reduction in risk of dying after controlling for variables associated with survival.

Long-term survival in a randomized study of nonplatinum therapy versus platinum in advanced epithelial ovarian cancer

The purpose of this study was to compare long-term survival in first-line chemotherapy with and without platinum in advanced-stage ovarian cancer. From July 1987 to November 1992, 161 untreated patients with FIGO stage III-IV epithelial ovarian cancer were randomized: 81 patients received no platinum and 80 received platinum combination. Residual disease after surgery was <2 cm in 61 patients without platinum, 59 with platinum. Median age was 58 years in nonplatinum arm and 55 years in platinum arm (range: 15-73). Complete and partial responses were 51% and 10% for nonplatinum arm and 51% and 8% for platinum arm, respectively (P= 0.7960). Stable disease was observed in 18% of patients in nonplatinum arm and 15% of patients in platinum arm and progression in 20% of nonplatinum- and 21% of platinum-treated cases. Ten-year disease-free survival was 37% for therapy without platinum and 31% for platinum combination (P= 0.5679); 10-year overall survival was 23% without platinum and 31% with platinum combination (P= 0.2545). Fifteen-year overall survival showed a trend of short duration in favor of platinum (P= 0.0678). Relapses occurred after 60 months in ten patients (seven with and three without platinum). The overall and disease-free survivals at 5, 10, and 15 years show no statistically significant long-term advantage from the addition of cisplatin; however, there is a slight trend in its favor.

Initial chemotherapy followed by surgical cytoreduction for the treatment of stage III/IV epithelial ovarian cancer

OBJECTIVE

The purpose of this study was to evaluate differences in morbidity, progression-free interval, and survival in women with advanced epithelial ovarian cancer treated with initial chemotherapy versus initial surgery.

STUDY DESIGN

All women with epithelial ovarian cancer who were treated surgically at our hospital between January 1, 1995, and January 1, 2003, were eligible; the cases of 200 patients met the criteria and underwent retrospective chart review.

RESULTS

Ninety-eight patients (49%) had initial chemotherapy, and 102 patients (51%) had initial surgery. Patients who received initial chemotherapy were more likely to have stage IV disease (initial chemotherapy, 27%, vs initial surgery, 8%; P = .042) and grade 3 disease (initial chemotherapy, 73%, vs initial surgery, 61%; P = .025). Optimal cytoreduction was achieved more often in patients who received initial chemotherapy (initial chemotherapy, 86%, vs initial surgery, 54%; P < .001). Only optimal cytoreduction (P = .022), and not treatment choice (P = .089), had an impact on median survival.

CONCLUSION

Initial chemotherapy is a reasonable alternative to initial surgery for the treatment of selected patients with advanced epithelial ovarian cancer.

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.

[Secondary debulking surgery and intraperitoneal chemotherapy in advanced or recurrent epithelial ovarian cancer]

OBJECTIVE

The aim of this study was to evaluate the indications and the results of secondary cytoreduction surgery with intraperitoneal (i.p.) paclitaxel chemotherapy in advanced or recurrent epithelial ovarian cancer.

PATIENTS AND METHODS

In a retrospective study, records were reviewed for 13 patients who received i.p. paclitaxel therapy (175 mg/m2) during secondary cytoreductive surgery or surgery for recurrent disease. All these patients were initially treated with optimal debulking surgery (macroscopic persistent residual disease) and systemic chemotherapy.

RESULTS

Nine patients were operated for secondary cytoreductive surgery (group I) and four patients operated for recurrent disease (group II). Postoperative residual disease was absent or microscopic in 69% (n = 9). Median hospital stay was 16 days. Hematologic toxicity grade III-IV was reported by 12 patients (92%). Operative mortality was 7.7% (n = 1). Median follow-up was 22.7 months. The median overall survival was 25.5 months. The median disease-free survival was 8.5 months. The median disease-free survival for group I and II were respectively 11.7 months and 4.2 months (P = 0.3). Progression of disease after completion of treatment was documented in 62% (n = 8): six patients for group I and two patients for group II.

DISCUSSION AND CONCLUSION

Secondary cytoreduction surgery associated with intraperitoneal chemotherapy is feasible after adjuvant systemic chemotherapy for patients with recurrent or suboptimally resected ovarian cancer. Results on loco-regional control for recurrent disease are poor. Intraperitoneal chemotherapy should be discussed during a two-step surgical strategy, as secondary cytoreductive surgery.

The role of interval debulking surgery in ovarian cancer

The mainstay of treatment for advanced ovarian cancer is the multimodality approach of debulking surgery and paclitaxel--platinum chemotherapy. The size of residual lesions after primary surgery remains the most important prognostic factor for survival. Optimal primary debulking surgery can be performed in approximately 40% of patients and up to 80% if it is done by gynecologic oncologists, but sometimes at the cost of considerable morbidity and even mortality. Based on a trial conducted by the European Organization for Research and Treatment of Cancer, optimal as well as suboptimal interval debulking surgery increases overall (P=0.0032) and progression-free survival (P=0.0055). However, not all patients who have undergone suboptimal primary debulking surgery seem to benefit from interval debulking surgery. Preliminary data from the Gynecologic Oncology Group interval debulking study (GOG-152) indicate that, if the gynecologic oncologist makes a maximal effort to resect the tumor, patients who have undergone suboptimal debulking surgery probably gain little benefit from interval debulking surgery.