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Zhang XM, Zhang XY, Liu YX, Li RN, Li YM, Linghu H. Computed tomographic enterography (CTE) in evaluating bowel involvement in patients with ovarian cancer. Abdom Radiol (NY) 2022; 47:2023-2035. [PMID: 35380247 DOI: 10.1007/s00261-022-03497-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/12/2022] [Accepted: 03/14/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Xiao-Mei Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xin-Yu Zhang
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yue-Xi Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Ruo-Nan Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Yong-Mei Li
- Department of Radiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| | - Hua Linghu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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Park SJ, Mun J, Lee EJ, Park S, Kim SY, Lim W, Song G, Kim JW, Lee S, Kim HS. Clinical Phenotypes of Tumors Invading the Rectosigmoid Colon Affecting the Extent of Debulking Surgery and Survival in Advanced Ovarian Cancer. Front Oncol 2021; 11:673631. [PMID: 33968784 PMCID: PMC8100598 DOI: 10.3389/fonc.2021.673631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/01/2021] [Indexed: 11/18/2022] Open
Abstract
We classified clinical phenotypes based on tumor separability from the rectosigmoid colon and then evaluated the effect of these clinical phenotypes on surgical outcomes and prognosis of advanced ovarian cancer. We collected data of patients with stage IIIB-IVB disease who either underwent visceral segmental serosectomy (VSS) or low anterior resection (LAR) during maximal debulking surgery. All patients were divided into the following, according to the resection types of tumors involving the rectosigmoid colon: the focal (tumor-involved length <18 cm) and separable (FS) group that received VSS, the focal and inseparable (FI) that received LAR, or the diffuse (tumor-involved length ≥18 cm) group (D) that also received LAR. A total of 83 patients were included in FS (n=44, 53%), FI (n=18, 21.7%), and D (n=24, 25.3%) groups. FS and D groups with more extensive tumors were related to wider extent of surgery and more tumor infiltration except for bowels, whereas FI and D groups with more invasive tumors were associated with wider extent of surgery, more tumor infiltration to bowels, longer operation time, more blood loss, more transfusion, longer hospitalization, and higher surgical complexity scores. Moreover, FS and FI groups showed better progression-free survival than D group, whereas FS group demonstrated better overall survival than FI and D groups. Clinical phenotypes based on tumor separability from the rectosigmoid colon may depend on tumor invasiveness and extensiveness in advanced ovarian cancer. Moreover, these clinical phenotypes may affect surgical outcomes and survival.
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Affiliation(s)
- Soo Jin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Jaehee Mun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Eun Ji Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Sunwoo Park
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, South Korea
| | - Sang Youn Kim
- Department of Radiology, Seoul National University College of Medicine, Seoul, South Korea
| | - Whasun Lim
- Department of Food and Nutrition, Kookmin University, Seoul, South Korea
| | - Gwonhwa Song
- Institute of Animal Molecular Biotechnology and Department of Biotechnology, College of Life Sciences and Biotechnology, Korea University, Seoul, South Korea
| | - Jae-Weon Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
| | - Seungmee Lee
- Department of Obstetrics and Gynecology, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, South Korea
| | - Hee Seung Kim
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea
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Abstract
While there is an ongoing debate regarding the timing of the maximal surgical effort in epithelial ovarian cancer, it is well established that patients with suboptimal tumor debulking derive no benefit from the surgical procedure. The amount of residual disease after cytoreductive surgery has been repeatedly identified as a strong predictor of survival, and accordingly, the surgical effort to achieve the goal of complete gross tumor resection has been constantly evolving. Centers that have adopted the concept of radical surgery in patients with advanced ovarian cancer have reported improvements in their patients' survival. In addition to the expected improvements in the pharmacologic treatment of this disease, some of the next challenges in the surgical management of ovarian cancer include the preoperative prediction of suboptimal debulking, improving the drug delivery to the tumor, and increasing access to centers of excellence in ovarian cancer regardless of geographical, financial, or other social barriers. This review will discuss an update on the role of surgery in the treatment of primary epithelial ovarian cancer as it has evolved since the emergence of the concept of surgical cytoreduction.
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Baruah U, Barmon D, Kataki AC, Deka P, Hazarika M, Saikia BJ. Neoadjuvant chemotherapy in advanced epithelial ovarian cancer: A survival study. Indian J Med Paediatr Oncol 2015; 36:38-42. [PMID: 25810573 PMCID: PMC4363849 DOI: 10.4103/0971-5851.151781] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Context: Patients with advanced ovarian cancer have a poor prognosis in spite of the best possible care. Primary debulking surgery has been the standard of care in advanced ovarian cancer; however, it is associated with high mortality and morbidity rates as shown in various studies. Several studies have discussed the benefit of neoadjuvant chemotherapy in patients with advanced ovarian cancer. Aims: This study aims to evaluate the survival statistics of the patients who have been managed with interval debulking surgery (IDS) from January 2007 to December 2009. Materials and Methods: During the period from January 2007 to December 2009, a retrospective analysis of 104 patients who underwent IDS for stage IIIC or IV advanced epithelial ovarian cancer at our institute were selected for the study. IDS was attempted after three to five courses of chemotherapy with paclitaxal (175 mg/m2 ) and carboplatin (5-6 of area under curve). Overall survival (OS) and progression free survival (PFS) were compared with results of primary debulking study from existing literature. OS and PFS rates were estimated by means of the Kaplan-Meier method. Results were statistically analyzed by IBM SPSS Statistics 19. Results: The median OS was 26 months and the median PFS was 18 months. In multivariate analysis it was found that both OS and PFS was affected by the stage, and extent of debulking. Conclusions: Neoadjuvant chemotherapy, followed by surgical cytoreduction is a promising treatment strategy for the management of advanced epithelial ovarian cancers.
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Affiliation(s)
- Upasana Baruah
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Debabrata Barmon
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Amal Chandra Kataki
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Pankaj Deka
- Department of Gynaecologic Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Munlima Hazarika
- Department of Medical Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
| | - Bhargab J Saikia
- Department of Medical Oncology, Dr. B. Borooah Cancer Institute (RCC), Guwahati, Assam, India
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Trillsch F, Ruetzel JD, Herwig U, Doerste U, Woelber L, Grimm D, Choschzick M, Jaenicke F, Mahner S. Surgical management and perioperative morbidity of patients with primary borderline ovarian tumor (BOT). J Ovarian Res 2013; 6:48. [PMID: 23837881 PMCID: PMC3708757 DOI: 10.1186/1757-2215-6-48] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2013] [Accepted: 06/29/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Surgery is the cornerstone for clinical management of patients with borderline ovarian tumors (BOT). As these patients have an excellent overall prognosis, perioperative morbidity is the critical point for decision making when the treatment strategy is developed and the primary surgical approach is defined. METHODS Clinical and surgical parameters of patients undergoing surgery for primary BOT at our institutions between 1993 and 2008 were analyzed with regard to perioperative morbidity depending on the surgical approach (laparotomy vs. laparoscopy). RESULTS A total of 105 patients were analyzed (44 with primary laparoscopy [42%], 61 with primary laparotomy [58%]). Complete surgical staging was achieved in 33 patients at primary surgical approach (31.4%) frequently leading to formal indication of re-staging procedures. Tumor rupture was significantly more frequent during laparoscopy compared to laparotomy (29.5% vs. 13.1%, p = 0.038) but no other intraoperative complications were seen in laparoscopic surgery in contrast to 7 of 61 laparotomies (0% vs. 11.5%, p = 0.020). Postoperative complication rates were similar in both groups (19.7% vs. 18.2%, p = 0.848). CONCLUSIONS Irrespective of the surgical approach, surgical management of BOT has acceptable rates of perioperative complications and morbidity. Choice of initial surgical approach can therefore be made independent of complication-concerns. As the recently published large retrospective AGO ROBOT study observed similar oncologic outcome for both approaches, laparoscopy can be considered for staging of patients with BOT if this appears feasible. An algorithm for the surgical management of BOT patients has been developed.
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Affiliation(s)
- Fabian Trillsch
- Department of Gynecology and Gynecologic Oncology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany.
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Hoffman MS, Zervose E. Colon resection for ovarian cancer: Intraoperative decisions. Gynecol Oncol 2008; 111:S56-65. [DOI: 10.1016/j.ygyno.2008.07.055] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2008] [Accepted: 07/07/2008] [Indexed: 10/21/2022]
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Transverse colectomy in ovarian cancer surgical cytoreduction: operative technique and clinical outcome. Gynecol Oncol 2008; 109:364-9. [PMID: 18396322 DOI: 10.1016/j.ygyno.2008.02.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Revised: 02/09/2008] [Accepted: 02/14/2008] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the operative techniques and associated clinical outcomes of patients undergoing transverse colectomy as a component of cytoreductive surgery for advanced or recurrent ovarian cancer. METHODS Thirty-nine patients underwent transverse colectomy as part of primary (n=33) or secondary (n=6) cytoreductive surgery for ovarian cancer between 1/97 and 4/07. The surgical techniques, associated morbidity, and clinical outcomes are described. RESULTS Among primary surgery patients, 75.6% had Stage IIIC disease, and 24.2% had Stage IV disease. Transverse colon surgery consisted of: partial colectomy in 33 cases and total transverse colectomy in 6 cases. Transverse colectomy with rectosigmoid colectomy was performed in 61.5% of patients, with two separate colonic anastomoses in 48.7%. The majority (89.7%) of transverse colon anastomoses were stapled, most commonly a functional end-to-end colocolostomy. Two patients required end colostomy. The median EBL was 500 cm(3). Residual disease was: no gross in 33.3%, 0.1-1.0 cm in 59.0%, and >1 cm in 7.7% of patients. Post-operative morbidity occurred in 25.6% of patients, with a fistula rate of 5.1% and a mortality rate of 2.6%. The median survival time after primary surgery was 68.3 months. CONCLUSIONS Transverse colectomy can contribute significantly to a maximal ovarian cancer cytoreductive surgical effort and carries acceptable morbidity. Resection of a non-contiguous segment of rectosigmoid colon is frequently necessary, and placement of two separate colonic anastomoses is associated with a low risk of anastomotic breakdown.
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Cai HB, Zhou YF, Chen HZ, Hou HY. The Role of Bowel Surgery with Cytoreduction for Epithelial Ovarian Cancer. Clin Oncol (R Coll Radiol) 2007; 19:757-62. [PMID: 17889517 DOI: 10.1016/j.clon.2007.06.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2006] [Revised: 05/27/2007] [Accepted: 06/22/2007] [Indexed: 11/24/2022]
Abstract
AIMS To assess the efficiency and morbidity associated with bowel resection with the initial cytoreduction procedure for advanced ovarian cancer. MATERIALS AND METHODS A review was carried of 95 patients with ovarian cancer who underwent cytoreductive surgery between 2000 and 2003. The relationship between dichotomised preoperative, intra-operative and postoperative outcome variables were tested using SPSS software. Kaplan-Meier curves were generated to compare survival. Cox proportional hazards regression was used to determine the independent significance of factors after cytoreductive surgery. RESULTS In patients in whom bowel resection was carried out, the largest residual tumour mass was <1cm in 66.67% of patients, compared with 45.28% of patients undergoing surgery without bowel resection (P=0.038). The median survival in the optimally debulked patients was 50.38 months compared with 37.15 months in the patients who had suboptimal cytoreduction (P=0.0021). The median survival in patients undergoing bowel resection was 50.70 months compared with 44.62 months in the patients who had cytoreduction without bowel resection (P=0.2176). Multivariate analysis showed that optimal cytoreduction (P=0.005) was found to be independently prognostic for overall survival. Major adverse events, such as ileus, intestinal fistulae, urinary tract fistulae, were not significantly different between groups. CONCLUSION Bowel resection is a worthwhile endeavour in selected patients with advanced ovarian cancer to increase therapeutic efficiency. The surgical morbidity rate from these procedures is not serious and seems acceptable.
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Affiliation(s)
- H-B Cai
- Department of Gynecological Oncology, Zhong Nan Hospital, Wuhan University, Wuhan 430071, China
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9
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Salani R, Zahurak ML, Santillan A, Giuntoli RL, Bristow RE. Survival impact of multiple bowel resections in patients undergoing primary cytoreductive surgery for advanced ovarian cancer: a case-control study. Gynecol Oncol 2007; 107:495-9. [PMID: 17854870 DOI: 10.1016/j.ygyno.2007.08.003] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2007] [Revised: 07/17/2007] [Accepted: 08/03/2007] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To evaluate clinicopathological factors and survival outcome of patients with advanced epithelial ovarian carcinoma undergoing multiple bowel resections to achieve optimal (< or = 1 cm) cytoreduction. METHODS A case-control study was performed identifying patients undergoing optimal primary cytoreductive surgery with > or = 2 bowel resections between 10/1997 and 2/2006. The two control groups consisted of (1) patients undergoing optimal cytoreduction with < or = 1 bowel resections matched [1:2] for age and stage and (2) patients left with suboptimal disease. Cox proportional hazards model were used to evaluate the effects of demographic and surgico-pathologic factors on survival outcome. RESULTS A total of 34 patients underwent > or = 2 bowel resections. Sixty-eight patients underwent < or = 1 bowel resections. All patients had optimal cytoreduction and 40/102 patients (39.2%) underwent complete cytoreduction. Patients undergoing multiple bowel resections experienced a higher EBL (700 v 500 mL, p=0.01) and longer LOS (10 v 7 days, p=0.01) compared to patients with < or = 1 bowel resections. Multivariate analysis revealed the amount of residual disease to be a statistically significant and radiation therapy to the right pelvic sidewall and cul-de-sac independent predictor of overall survival. The median overall survival time for patients undergoing > or = 2 bowel resections was 28.3 months, which was comparable to patients undergoing < or = 1 bowel resections, (37.8 months, p=0.09) but statistically significantly superior to patients left with suboptimal residual disease (12 months, p=0.02). CONCLUSIONS Although primary surgery that includes > or = 2 bowel resections is associated with longer LOS and a higher EBL, such extensive procedures are warranted if they will contribute to an overall optimal residual disease state.
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Affiliation(s)
- Ritu Salani
- The Kelly Gynecologic Oncology Service, Department of Gynecology and Obstetrics, The Sidney Kimmel Comprehensive Cancer Center, The Johns Hopkins Medical Institutions, Baltimore, MD 21224, USA.
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Abstract
PURPOSE OF REVIEW This review examines the current role of intestinal surgery in advanced ovarian cancer. Institutions differ considerably in surgical procedures and therapeutic outcomes for this disease. Moreover, therapeutic outcomes are influenced by the inclusion criteria for surgical procedures and the degree of surgical completion. We discuss the role of intestinal surgery and suggest surgical indications for intestinal surgery in advanced ovarian cancer. RECENT FINDINGS Prognosis in advanced ovarian cancer is better when there is a smaller postoperative tumor mass. However, it is necessary to investigate the effects of intestinal surgery on residual tumor mass and its prognostic benefits. Here, recent reports were reviewed to ascertain the usefulness and safety of intestinal surgery for advanced ovarian cancer and examine surgical indications and institutional requirements. SUMMARY By performing aggressive intestinal surgery such as combined bowel resection, optimal cytoreductive surgery can be performed in 70-98% of cases. The morbidity associated with intestinal surgery is acceptably low. Prognostic benefits for intestinal surgery are clear in patients with operable ovarian cancer with no residual disease. Women with suspected ovarian cancer should therefore be referred to centers with experienced tumor surgeons.
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Affiliation(s)
- Osamu Takahashi
- Department of Obstetrics and Gynecology, Akita City Hospital, Kawamoto, Akita, Japan.
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11
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Takahashi O, Sato N, Miura Y, Ogawa M, Fujimoto T, Tanaka H, Sato H, Tanaka T. Surgical indications for combined partial rectosigmoidectomy in ovarian cancer. J Obstet Gynaecol Res 2005; 31:556-61. [PMID: 16343259 DOI: 10.1111/j.1447-0756.2005.00336.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIM To evaluate surgical indications for combined partial rectosigmoidectomy in ovarian cancer with direct invasion of the rectum and sigmoid colon or dissemination into the pouch of Douglas. METHODS Subjects comprised 25 patients with ovarian cancer who underwent primary surgery and rectosigmoidectomy between 1990 and 2002 at our hospital. Federation of Obstetrics and Gynecology staging of tumors was II (n = 6), III (n = 17) or IV (n = 2). The histologic type was serous adenocarcinoma (n = 18), clear cell adenocarcinoma (n = 4), and others (n = 3). Bowel resection was performed during primary surgery in 18 patients, and after neoadjuvant chemotherapy (NAC) in seven patients. Cumulative survival rate was compared between NAC and non-NAC groups. Patients were divided into three groups based on extent of surgical resection to compare survival rates: no residual tumor (n = 19); maximum residual tumor diameter <1 cm (n = 5); and maximum residual tumor diameter > or =1 cm (n = 1). RESULTS Cumulative 5-year survival was 41.3% for all patients. Cumulative 5-year survival in the 18 patients who underwent bowel resection during primary surgery was 62.2%, compared to 13.9% in the seven patients who underwent bowel resection after NAC. Cumulative 5-year survival based on extent of surgical resection was: no residual tumor, 60.8%; residual <1 cm, 0%; and residual > or =1 cm, 0%. Cumulative 5-year survival for patients with complete tumor resection (no residual tumor), excluding clear cell adenocarcinoma, was 79.5%. CONCLUSION In ovarian cancer with direct invasion of the rectum or sigmoid colon or dissemination into the pouch of Douglas, complete tumor resection with rectosigmoidectomy during primary surgery is associated with good clinical outcomes.
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Affiliation(s)
- Osamu Takahashi
- Department of Obstetrics and Gynecology, Akita University School of Medicine, Akita, Japan.
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Yildirim Y, Sanci M. The feasibility and morbidity of distal pancreatectomy in extensive cytoreductive surgery for advanced epithelial ovarian cancer. Arch Gynecol Obstet 2004; 272:31-4. [PMID: 15480722 DOI: 10.1007/s00404-004-0657-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2004] [Accepted: 06/08/2004] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Pancreatic metastasis of ovarian cancer is extremely rare and its therapeutic approach is not well documented. The objective of this study is to evaluate the feasibility and morbidity of pancreatic resection as a component of extensive cytoreductive surgery in epithelial ovarian cancer (EOC) patients with pancreas metastasis. METHODS Between December 2000 and February 2003, 98 EOC patients were treated with primary cytoreduction. Six (6.12%) of these patients had pancreatic tail metastasis and were operated on using the distal pancreatectomy. RESULTS Preoperatively, only 1 (16.7%) of the 6 patients had signs of metastasis to the pancreas on computed tomography (CT). Optimal cytoreduction (absent or < or =1 cm macroscopic residual tumor size) was achieved in all patients. In the early postoperative period, there were 4 patients (66.7%) with complications and no perioperative mortality. In 1 patient (16.7%), glucose intolerance as a late complication of pancreatic resection was detected. All patients received six cycles of platinum-based adjuvant chemotherapy following a cytoreductive operation. Mean follow-up was 27 months (range 9-36), and 3 (50%) patients are still alive at the end of the study period. The two-year survival rate was 66.7%. CONCLUSION In conclusion, if optimal cytoreduction is foreseen in advanced epithelial ovarian cancer with pancreatic tail metastasis, distal pancreatectomy should be kept in mind. This procedure has acceptable morbidity and seems to be an attribute for survival.
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Affiliation(s)
- Yusuf Yildirim
- Department of Gynecologic Oncology, SSK (Social Security Agency) Aegean Obstetrics and Gynecology Teaching Hospital, Izmir, Turkey.
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13
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Joulie F, Morice P, Rey A, Thoury A, Camatte S, Pautier P, Lhommé C, Haie-Meder C, Duvillard P, Castaigne D. Les métastases ganglionnaires du cancer épithélial de l'ovaire sont-elles chimio-sensibles ? Étude comparative de la lymphadénectomie première ou après chimiothérapie. ACTA ACUST UNITED AC 2004; 32:502-7. [PMID: 15217565 DOI: 10.1016/j.gyobfe.2004.04.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2004] [Accepted: 04/06/2004] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim of this study is to compare the rates of nodal involvement in epithelial ovarian cancer (EOC) in patients who underwent initial lymphadenectomy (before chemotherapy/group 1) and patients who underwent lymphadenectomy after chemotherapy (during interval debulking surgery/group 2 or second-look surgery/group 3). PATIENTS AND METHODS The rates of nodal involvement in 205 patients with EOC who underwent complete pelvic and paraaortic lympadenectomy were compared. One hundred and five patients underwent this surgical procedure at the end of chemotherapy (group 3) or during chemotherapy (group 2) for 28 patients (with three courses of a platinum-based regimen containing paclitaxel) and were compared to 100 patients who underwent initial lymphadenectomy (group 1). RESULTS In patients with stage I and II disease the rate of nodal involvement in group 1 and 3 were similar (respectively 19% vs. 21% and 50% vs. 33% in stage I or II disease-NS). In patients with stage III disease, the rates of nodal involvement in patients treated with initial surgery, interval debulking surgery (with paclitaxel-based regimen) and second-look surgery were respectively: 53%, 58% and 48% (NS). Adding to the platinum-based regimen does not seem to improve node sterilization rates. DISCUSSION AND CONCLUSIONS The rates of nodal involvement seem to be similar in patients treated before or after chemotherapy but the comparison of groups is difficult because the presence of several bias (particularly in early stage disease). Such results suggest that nodal metastases are not totally sterilized by chemotherapy. However, further studies are needed to evaluate the therapeutic value of lymphadenectomy in patients with nodal involvement.
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Affiliation(s)
- F Joulie
- Département de chirurgie oncologique gynécologique, institut Gustave-Roussy, 39, rue Camille-Desmoulins, 94805 Villejuif, France
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14
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Morice P, Dubernard G, Rey A, Atallah D, Pautier P, Pomel C, Lhommé C, Duvillard P, Castaigne D. Results of interval debulking surgery compared with primary debulking surgery in advanced stage ovarian cancer. J Am Coll Surg 2004; 197:955-63. [PMID: 14644284 DOI: 10.1016/j.jamcollsurg.2003.06.004] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Results of IDS (after three to four courses of induction chemotherapy) were compared with PDS followed by chemotherapy in patients treated for advanced stage ovarian cancer (stage IIIC or IV). STUDY DESIGN A retrospective study was done on a group of 57 patients who underwent IDS (because of an unresectable tumor) compared with a group of 28 patients treated with PDS (for resectable disease) followed by chemotherapy. All patients were treated between 1996 and 2001 by the same team of surgeons and received the same regimen of chemotherapy (platinum based plus paclitaxel). RESULTS Optimal cytoreductive surgery (residual disease < or = 2 cm) was achieved in IDS and PDS groups in 84% (48 of 57) and 100% (28 of 28) of patients, respectively. Complete resection was observed in 51% (29 of 57) of patients in the IDS group and 54% (15 of 28) of patients in the PDS group. The rates of bowel resection, large peritoneal resection, and postoperative morbidity were significantly reduced in the IDS group. After adjusting for the size of residual disease (< or /= 2 cm and absence of residual tumor), overall and event-free survival were not different in the two groups. CONCLUSIONS Survival rates were similar in patients with advanced stage ovarian cancer who underwent IDS or PDS. The rates of surgical resection and morbidity were reduced after IDS. IDS can be safely used in unresectable advanced stage ovarian cancer.
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Affiliation(s)
- Philippe Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France
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15
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Morice P, Brehier-Ollive D, Rey A, Atallah D, Lhommé C, Pautier P, Pomel C, Camatte S, Duvillard P, Castaigne D. Results of interval debulking surgery in advanced stage ovarian cancer: an exposed-non-exposed study. Ann Oncol 2003; 14:74-7. [PMID: 12488296 DOI: 10.1093/annonc/mdg003] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND To study the results of interval debulking surgery (IDS) in patients treated for 'unresectable' advanced stage ovarian cancer compared with primary debulking surgery (PDS) followed by chemotherapy. PATIENTS AND METHODS An exposed-non-exposed study including a group of 34 patients who underwent an IDS and were matched to an historic control group of 34 patients treated with PDS. RESULTS Optimal cytoreductive surgery was achieved in 94% (32 out of 34) of patients in both groups. The rates of post-operative morbidity, blood transfusion and median length of hospitalisation were significantly reduced in the study (IDS) group, but survival did not differ in both groups. CONCLUSIONS IDS in patients with advanced stage ovarian cancer offers the same chance of survival as PDS, but it is better tolerated.
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MESH Headings
- Adenocarcinoma, Clear Cell/drug therapy
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/surgery
- Adenocarcinoma, Mucinous/drug therapy
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Adult
- Aged
- Antineoplastic Agents/therapeutic use
- Carcinoma, Endometrioid/drug therapy
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/surgery
- Case-Control Studies
- Combined Modality Therapy
- Cystadenocarcinoma, Serous/drug therapy
- Cystadenocarcinoma, Serous/pathology
- Cystadenocarcinoma, Serous/surgery
- Female
- Hospitalization
- Humans
- Middle Aged
- Ovarian Neoplasms/drug therapy
- Ovarian Neoplasms/pathology
- Ovarian Neoplasms/surgery
- Ovariectomy/methods
- Postoperative Complications
- Survival Rate
- Time Factors
- Treatment Outcome
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Affiliation(s)
- P Morice
- Department of Surgery, Institut Gustave Roussy, Villejuif, France.
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Miller J, Proietto A. The place of bowel resection in initial debulking surgery for advanced ovarian cancer. Aust N Z J Obstet Gynaecol 2002; 42:535-7. [PMID: 12495103 DOI: 10.1111/j.0004-8666.2002.00535.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the efficacy and morbidity associated with bowel resection at the initial debulking procedure for patients with advanced ovarian cancer. DESIGN Retrospective medical record and computerised database review. SETTING John Hunter Hospital, Newcastle, New South Wales. SAMPLE All women with FIGO stage III or IV epithelial ovarian cancer and with adequate case note documentation who underwent bowel resection as part of their primary debulking surgery at the John Hunter Hospital from 1991 to July 2000. MAIN OUTCOME MEASURES Cumulative overall and disease free survival, optimal (residual disease < 1 cm) versus suboptimal cytoreduction and short (< 6 weeks) and long-term postoperative morbidity. RESULTS For the optimally debulked patients the two and five-year overall and disease free survival rates were 49%, 30%, 19% and 8.9% respectively. The two-year overall survival rate for the suboptimally debulked patients was 20%. The major short-term morbidity rate was 17.6%. Long-term morbidity occurred in 10 of 51 patients; however, not all morbidity was surgery related. CONCLUSIONS Cytoreductive surgery, including bowel resection, appears indicated in the treatment of patients with advanced ovarian cancer. The surgical morbidity rate from these procedures appears acceptable.
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Affiliation(s)
- John Miller
- Queensland Centre for Gynaecological Cancer, Royal Women's Hospital, Brisbane, Queensland, Australia
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Kimmig R, Wimberger P, Hillemanns P, Kapsner T, Caspari C, Hepp H. Multivariate analysis of the prognostic significance of DNA-ploidy and S-phase fraction in ovarian cancer determined by flow cytometry following detection of cytokeratin-labeled tumor cells. Gynecol Oncol 2002; 84:21-31. [PMID: 11748971 DOI: 10.1006/gyno.2001.6440] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The outcome of patients with advanced ovarian cancer is poor despite aggressive therapy including surgery and multiagent chemotherapy. Valid prognostic factors are necessary to estimate the course of the disease and to define biologically similar subgroups for analysis of therapeutic efficacy. METHODS This study is the first published prospective study concerning the prognostic significance of DNA-ploidy and S-phase fraction in ovarian cancer following enrichment of tumor cells by cytokeratin labeling. Epithelial cells were labeled by FITC-conjugated cytokeratin antibody (CK 5, 6, 8, and 17) prior to flow cytometric cell cycle analysis in 129 fresh specimens of primary ovarian cancer. RESULTS Recurrence-free survival of patients with DNA-diploid primary ovarian cancer was significantly better compared to that of patients with DNA-aneuploid tumors in univariate analysis (47% vs 18%, P = 0.01). The tumor-dependent overall survival of patients with DNA-diploid tumors was 57% compared to 30% with DNA-aneuploid tumors (P = 0.04). In FIGO stage III ovarian cancer DNA-ploidy, optimized by cytokeratin gating for tumor cells, achieved independent prognostic significance. No significance was found for S-phase fraction. However, despite convincing methodological advantages in the detection of DNA-aneuploid subpopulations the clinical significance of cytokeratin gating of epithelial cells was only marginal. CONCLUSION DNA-ploidy has been shown to be as powerful or even more so in comparison to postoperative residual tumor in multivariate analysis for predicting clinical outcome in advanced ovarian cancer. Thus, determination of DNA-ploidy should be introduced to currently recruiting phase III studies for therapy of ovarian cancer for better definition of prognostic subgroups.
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Affiliation(s)
- Rainer Kimmig
- Department of Obstetrics and Gynecology, Ludwig-Maximilians-University, Munich, D-81377, Germany.
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Gillette-Cloven N, Burger RA, Monk BJ, McMeekin DS, Vasilev S, DiSaia PJ, Kohler MF. Bowel resection at the time of primary cytoreduction for epithelial ovarian cancer. J Am Coll Surg 2001; 193:626-32. [PMID: 11768679 DOI: 10.1016/s1072-7515(01)01090-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The purpose of this study was to determine the morbidity and survival associated with bowel resection at the time of primary cytoreductive surgery for ovarian cancer. STUDY DESIGN We reviewed all patients undergoing bowel resection by gynecologic oncology faculty at the time of primary cytoreduction for advanced epithelial ovarian cancer diagnosed between 1983 and 1995. RESULTS There were 105 patients meeting the above criteria. The median age was 65 years (range 34 to 85 years). There were 76 stage III and 25 stage IV cancers. The primary indication for bowel resection was tumor debulking in 92% of the patients. Seventy patients had segmental resection of the colon only, and 22 patients underwent resections that included the large and small bowels. Mean operating time was 260 minutes and mean estimated blood loss was 1,447 mL. Thirty-three (31%) patients were optimally cytoreduced to less than 1 cm residual disease. Ten patients experienced major complications directly related to bowel resection, including bowel fistula (4 patients), early postoperative bowel obstruction (5 patients), and stomal hernia (1 patient). Other morbidity included ileus for more than 10 days (18 patients), cardiac complications (17 patients), pneumonia (8 patients), sepsis (5 patients), and thromboembolism (4 patients). Six patients died and five patients required reexploration within 30 days of operation. Patients with preoperative bowel obstruction and suboptimal residual disease were more likely to have postoperative morbidity. Median survival in the optimally debulked patients was 35 months compared with 18 months in patients suboptimally cytoreduced (p = 0.006). Multivariate analysis demonstrated that optimal debulking (p = 0.009) and platinum chemotherapy (p = 0.00006) were independently associated with improved survival. Age, International Federation of Gynecologia Oncologists stage, American Society of Anesthesiologists class, and paclitaxel chemotherapy did not influence survival. CONCLUSIONS In patients undergoing bowel resection at the time of primary cytoreduction for ovarian cancer, optimal cytoreduction to less than 1 cm residual disease results in improved survival. Morbidity is common but is comparable to other published series of ovarian cancer patients undergoing primary cytoreductive surgery without bowel resection. Additionally, patients with preoperative bowel obstruction and suboptimal residual disease are more likely to have serious morbidity.
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Abstract
Ovarian cancer spreads early in the disease into the abdomen. An en bloc resection of the tumor, according to surgical principle, is not possible in patients with high-stage ovarian cancer. At surgery, large pelvic tumor lesions are found together with multiple tumor lesions involving the omentum, bowel, and mesentery together with a diffuse peritoneal carcinomatosis and diaphragmatic involvement. A multimodality approach with cytoreductive surgery and taxol platinum-based chemotherapy is therefore the mainstay of treatment of advanced ovarian cancer. The size of residual disease after surgery is one of the most important prognostic factors for survival. Patients with an optimal tumor cytoreduction (residual lesions smaller than 1 cm) have a significant longer survival (almost two times the median survival) than patients with larger residual lesions. This holds true even for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease. Patients in whom all macroscopic tumor is resected do have the longest survival. The 2-year survival of patients with a radical resection of all macroscopic tumors is 80%, in contrast to less than 22% for the patients with lesions larger than 2 cm. An optimal primary cytoreductive surgery can generally be performed in 30% to 50% of patients. Only in more experienced gynecologic oncology centers is the percentage as high as 85%, but sometimes at the cost of an increased morbidity and even mortality. The worse prognosis of the patients with a suboptimal primary cytoreductive surgery can be improved by an interval cytoreductive surgery after platinum-containing induction chemotherapy. The median survival and progression-free survivals are significantly lengthened by cytoreductive surgery. After more than 5-years follow-up there is still a significant survival benefit: the 5-year survival of the surgery patients was 24% versus 13% for the no-surgery patients (P = 0.0032). All patients, including those with unfavorable prognostic factors (stage IV disease, peritonitis carcinomatosis, or ascites at primary surgery), and even patients with stable disease after induction chemotherapy, seem to benefit from interval cytoreductive surgery. The increase in progression-free survival and overall survival does outweigh the morbidity associated with interval debulking surgery, which is not different from those associated with primary surgery.
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Affiliation(s)
- M E van der Burg
- Department of Medical Oncology, University Hospital Rotterdam Dijkzigt, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
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Abstract
Surgery is the cornerstone of management of epithelial ovarian cancer and has broad applications throughout the clinical course of disease, from initial diagnosis to palliative care. Comprehensive surgical staging is essential for precise prognostic determination and treatment planning for patients with apparent early-stage ovarian cancer. Although randomized trials are lacking, the survival advantage associated with optimal primary cytoreduction has been consistent and reproducible. With increasing radicality of cytoreductive surgical techniques and sophistication of postoperative care, it appears that an "optimal" surgical procedure is that which leaves the patient with no visible residual disease. The survival benefits of cytoreductive surgery are also applicable to women with stage IV ovarian cancer, although the rate of success is somewhat attenuated compared with patients with stage III disease. Recent data also indicate that with appropriate surgical selection criteria, secondary cytoreduction is associated with a significant prolongation of survival for patients with recurrent ovarian cancer. Unfortunately, several recent publications illustrate how the decentralization of health care may have significant ramifications on the ability of women with known or suspected ovarian cancer to avail themselves of the surgical standard of care.
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Affiliation(s)
- R E Bristow
- Department of Gynecology and Obstetrics, The Johns Hopkins Hospital and Medical Institutions, Baltimore, Maryland 21287-1248, USA.
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