Interval cytoreduction in ovarian cancer

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Interval debulking surgery (IDS), following induction or neoadjuvant chemotherapy, may have a role in treating advanced epithelial ovarian cancer (stage III to IV) where primary debulking surgery is not an option.

OBJECTIVES

To assess the effectiveness and complications of IDS for women with advanced stage epithelial ovarian cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 6, MEDLINE and EMBASE for the original review in to June 2012. We updated the searches in June 2009, 2012 and 2015 for the review updates.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. We performed meta-analysis of overall and progression-free survival (PFS), using random-effects models.

MAIN RESULTS

Three RCTs randomising 853 women, of whom 781 were evaluated, met the inclusion criteria. Meta-analysis of three trials for overall survival (OS) found no statistically significant difference between IDS and chemotherapy alone (hazard ratio (HR) = 0.80, 95% confidence interval (CI) 0.61 to 1.06, I² = 58%). Subgroup analysis for OS in two trials, where the primary surgery was not performed by gynaecologic oncologists or was less extensive, showed a benefit of IDS (HR = 0.68, 95% CI 0.53 to 0.87, I² = 0%). Meta-analysis of two trials for PFS found no statistically significant difference between IDS and chemotherapy alone (HR = 0.88, 95% CI 0.57 to 1.33, I² = 83%). Rates of toxic reactions to chemotherapy were similar in both arms (risk ratio = 1.19, 95% CI 0.53 to 2.66, I² = 0%), but little information was available for other adverse events or quality or life (QoL).

AUTHORS' CONCLUSIONS

We found no conclusive evidence to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in women whose primary surgery was not performed by gynaecologic oncologists or was less extensive. Data on QoL and adverse events were inconclusive.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Interval debulking surgery (IDS), following induction or neoadjuvant chemotherapy, may have a role in treating advanced epithelial ovarian cancer (stage III to IV) where primary debulking surgery is not an option.

OBJECTIVES

To assess the effectiveness and complications of IDS for women with advanced stage epithelial ovarian cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group's Specialised Register to June 2012, the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 6, MEDLINE to June 2012 and EMBASE to June 2012.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. We performed meta-analysis of overall and progression-free survival (PFS), using random-effects models.

MAIN RESULTS

Three RCTs randomising 853 women, of whom 781 were evaluated, met the inclusion criteria. Meta-analysis of three trials for overall survival (OS) found no statistically significant difference between IDS and chemotherapy alone (hazard ratio (HR) = 0.80, 95% confidence interval (CI) 0.61 to 1.06, I² = 58%). Subgroup analysis for OS in two trials, where the primary surgery was not performed by gynaecologic oncologists or was less extensive, showed a benefit of IDS (HR = 0.68, 95% CI 0.53 to 0.87, I² = 0%). Meta-analysis of two trials for PFS found no statistically significant difference between IDS and chemotherapy alone (HR = 0.88, 95% CI 0.57 to 1.33, I² = 83%). Rates of toxic reactions to chemotherapy were similar in both arms (risk ratio = 1.19, 95% CI 0.53 to 2.66, I² = 0%), but little information was available for other adverse events or quality or life (QoL).

AUTHORS' CONCLUSIONS

We found no conclusive evidence to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in women whose primary surgery was not performed by gynaecologic oncologists or was less extensive. Data on QoL and adverse events were inconclusive.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Interval debulking surgery (IDS), following induction or neoadjuvant chemotherapy, may have a possible role in treating advanced epithelial ovarian cancer (stage III to IV) where primary debulking surgery is not an option.

OBJECTIVES

To assess the effectiveness and complications of IDS for patients with advanced stage epithelial ovarian cancer.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group's Specialised Register to July 2009, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 2, 2009, MEDLINE from January 1966 to June week 4 2009, and EMBASE from January 1966 to week 27 2009.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. Meta-analysis of overall and progression-free survival (PFS) were performed using random-effects models.

MAIN RESULTS

Three RCTs randomising 853 women, of whom 781 were evaluated, met the inclusion criteria. Meta-analysis of three trials for overall survival (OS) found no statistically significant difference between IDS and chemotherapy alone (hazard ratio (HR) = 0.80, 95% confidence interval (CI) 0.61 to 1.06, I(2) = 58%). Subgroup analysis for OS in two trials, where the primary surgery was not performed by gynaecologic oncologists or was less extensive, showed a benefit of IDS: HR = 0.68, 95% CI 0.53 to 0.87, I(2) = 0%). Meta-analysis of two trials for progression-free survival (PFS) found no statistically significant difference between IDS and chemotherapy alone (HR = 0.88, 95% CI 0.57 to 1.33, I(2) = 83%). Rates of toxic reactions to chemotherapy were similar in both arms (risk ratio = 1.19, 95% CI 0.53 to 2.66, I(2) = 0%), but little information was available for other adverse events or quality or life.

AUTHORS' CONCLUSIONS

No conclusive evidence was found to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in patients whose primary surgery was not performed by gynaecologic oncologists or was less extensive. Data on QoL and adverse events were inconclusive.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Primary debulking surgery, a crucial step in the management of epithelial ovarian cancer, is not always an option in patients with advanced stage disease (stage III to IV). In some circumstances, surgery may not yield satisfactory results with residual tumour masses > 1 to 2 cm (so called suboptimal surgery). Induction or neoadjuvant chemotherapy followed by interval debulking surgery (IDS) may have an alternative role in this setting. However, the advantage of IDS compared to conventional methods is still a controversial issue.

OBJECTIVES

To assess the effectiveness and complications of IDS for patients with advanced stage epithelial ovarian cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 2, 2008), MEDLINE (January 1966 to June 2008), EMBASE (January 1966 to June 2008), and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. Meta-analysis of overall and progression free survival (PFS) was performed using fixed effects models.

MAIN RESULTS

Three RCTs, randomising 853 women of whom 781 were evaluated, met the inclusion criteria. Overall survival (OS) showed substantial heterogeneity between trials (I(2) = 58%). Subgroup analysis for overall survival in two trials, wherein the primary surgery was not performed by gynecologic oncologists or was less extensive, showed a benefit of IDS: (relative risk) RR = 0.7 (95% confidence interval (CI): 0.5 to 0.9, I(2) = 0%). Likewise, substantial heterogeneity between two trials for PFS evaluating 702 women was also shown (I(2) =75%). Rates of toxic reactions to chemotherapy were similar in both arms (RR = 1.3, 95%CI: 0.4 to 3.6), but little information is available for other adverse events. Only one trial reported quality of life (QOL), which was generally similar in both treatment arms.

AUTHORS' CONCLUSIONS

No conclusive evidence was found to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in the patients whose primary surgery was not performed by gynecologic oncologists or was less extensive. Data on QOL and adverse events were inconclusive.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Primary debulking surgery, a crucial step in the management of epithelial ovarian cancer, is not always an option in patients with advanced stage disease (stage III to IV). In some circumstances, surgery may not yield satisfactory results with residual tumour masses > 1 to 2 cm (so called suboptimal surgery). Induction or neoadjuvant chemotherapy followed by interval debulking surgery (IDS) may have an alternative role in this setting. However, the advantage of IDS compared to conventional methods is still a controversial issue.

OBJECTIVES

To assess the effectiveness and complications of IDS for patients with advanced stage epithelial ovarian cancer.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), (The Cochrane Library, Issue 2, 2008), MEDLINE (January 1966 to June 2008), EMBASE (January 1966 to June 2008), and reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. Meta-analysis of overall and progression free survival (PFS) was performed using fixed effects models.

MAIN RESULTS

Three RCTs, randomising 853 women of whom 781 were evaluated, met the inclusion criteria. Overall survival (OS) showed substantial heterogeneity between trials (I2 = 58%). Subgroup analysis for overall survival in two trials, wherein the primary surgery was not performed by gynecologic oncologists or was less extensive, showed a benefit of IDS: (relative risk) RR = 0.7 (95% confidence interval (CI): 0.5 to 0.9, I2 = 0%). Likewise, substantial heterogeneity between two trials for PFS evaluating 702 women was also shown (I(2) =75%). Rates of toxic reactions to chemotherapy were similar in both arms (RR = 1.3, 95%CI: 0.4 to 3.6), but little information is available for other adverse events. Only one trial reported quality of life (QOL), which was generally similar in both treatment arms.

AUTHORS' CONCLUSIONS

No conclusive evidence was found to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in the patients whose primary surgery was not performed by gynecologic oncologists or was less extensive. Data on QOL and adverse events were inconclusive.

Interval debulking surgery for advanced epithelial ovarian cancer: a Cochrane systematic review

OBJECTIVES

To assess the effectiveness of interval debulking surgery (IDS) for patients with advanced stage epithelial ovarian cancer (EOC).

METHODS

We searched the Cochrane Central Register of Controlled Trials, Medline, EMBASE, and reference lists for randomized controlled trials (RCTs) of advanced stage EOC. The trials had to report survival of women who had primary surgery and had IDS performed between cycles of chemotherapy comparing to survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy). Two review authors independently assessed trial quality and extracted data. Meta-analysis of overall survival (OS) and progression-free survival (PFS) was performed using fixed effects models.

RESULTS

Three RCTs, involving 853 women of whom 781 were evaluated, met the inclusion criteria. OSs were substantial heterogeneity between trials (I(2)=58%). Subgroup analysis in two trials, wherein the primary surgery was not performed by the gynecologic oncologists, or was less extensive, showed benefit of IDS: hazard ratio=0.7 (95% confidence interval [CI]: 0.5 to 0.9, I(2)=0%). Substantial heterogeneity between two trials for PFS evaluating 702 women was also shown (I(2)=75%). Toxic reactions to chemotherapy were similar in both arms (RR=1.3, 95% CI: 0.4 to 3.6). Only one trial reported quality of life, which was generally similar in both treatment arms.

CONCLUSIONS

Our review could not conclude whether IDS would improve the survival of women with advanced EOC compared with conventional treatment. IDS appeared to yield benefit only in the patients whose primary surgery was not performed by expert surgeons.

Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy

A risk of malignancy index (RMI), based on menopausal status, ultrasound (US) findings, and serum CA125, has previously been described and validated in the primary evaluation of women with adnexal masses and is widely used in selective referral of women from local cancer units to specialized cancer centers. Additional imaging modalities could be useful for further characterization of adnexal masses in this group of women. A prospective cohort study was conducted of 196 women with an adnexal mass referred to a teaching hospital for diagnosis and management. Follow-up data was obtained for 180 women; 119 women had benign and 61 women malignant adnexal masses. The sensitivity and specificity of specialist US, magnetic resonance imaging (MRI), radioimmunoscintigraphy (RS), and the RMI were determined. We identified a subgroup of women with RMI values of 25-1000 where the value of further specialist imaging was evaluated. Sensitivity and specificity for specialist US were 100% and 57%, for MRI 92% and 86%, and for RS 76% and 87%, respectively. Analysis of 123 patients managed sequentially, using RMI cutoff values of > or =25 and <1000 and then US and MRI provided a sensitivity of 94% and a specificity of 90%. Using this RMI cutoff followed by specialist US and MRI, as opposed to the traditional RMI cutoff value of 250, can increase the proportion of patients with cancer appropriately referred in to a cancer center, with no change in the proportion of patients with benign disease being managed in a local unit.

Interval debulking surgery in advanced epithelial ovarian cancer

Cytoreductive surgery and chemotherapy are the mainstay for the treatment of advanced epithelial ovarian cancer. In order to minimize the tumour burden before chemotherapy, cytoreductive surgery is usually performed first. The importance of the amount of residual disease as the main prognostic factor for patients suffering from advanced disease has been almost universally accepted even in the absence of prospective randomized trials addressing the benefit of cytoreductive surgery. In the last decade, the value of debulking surgery after induction chemotherapy - interval debulking surgery, IDS - has been widely debated, especially after the completion of a prospective randomized study from the EORTC addressing the introduction of a surgical procedure with debulking intent preceded and followed by cytoreductive chemotherapy. The rationale of such a strategy in the context of the primary treatment of advanced ovarian cancer lies in a higher cytoreductibility to the 'optimal' status forwarded, and possibly facilitated, by chemotherapy. The results demonstrated a prolongation of both progression-free survival and median survival in favour of patients randomized to IDS (5 and 6 months, respectively). Multivariate analysis revealed IDS to be an independent prognostic factor which reduced the risk of death by 33% at 3 years and by 48% in subsequent re-evaluation after more than 6 years of observation. Despite the above, results have been questioned by many, leading the GOG to perform a similar study which has been concluded very recently. Nevertheless, the main concern regarding the application of IDS in all instances relates to the morbidity of two major surgical procedures integrated within a short period during which cytotoxic chemotherapy is also administered. Neoadjuvant chemotherapy has been recently proposed to avoid a non-useful surgical procedure in patients considered 'optimally unresectable' after diagnosis of advanced ovarian cancer. Whether or not this newer approach will translate into a longer survival with a better quality of life is going to be addressed by a novel EORTC study. Finally, the concept of a 'chemical' cytoreduction preceding and facilitating a subsequent 'surgical' effort has been recently introduced also in the treatment of recurrent disease. The EORTC has recently initiated a prospective randomized study (LOROCSON - Late Onset Recurrent Ovarian Cancer: Surgery or Not) to validate the importance of such an approach to be balanced with medical treatment alone not only in terms of survival but also as far as quality of life is concerned.