Can pre-operative computed tomography predict resectability of ovarian carcinoma at primary laparotomy?

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumors, including imaging techniques, biomarkers and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on preoperative diagnosis of ovarian tumours

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the preoperative diagnosis of ovarian tumours, including imaging techniques, biomarkers and prediction models.

ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the preoperative diagnosis of ovarian tumours and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised.

Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements.

This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the preoperative diagnosis of ovarian tumours and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

ESGO/ISUOG/IOTA/ESGE Consensus Statement on pre-operative diagnosis of ovarian tumors

The European Society of Gynaecological Oncology (ESGO), the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG), the International Ovarian Tumour Analysis (IOTA) group, and the European Society for Gynaecological Endoscopy (ESGE) jointly developed clinically relevant and evidence-based statements on the pre-operative diagnosis of ovarian tumors, including imaging techniques, biomarkers, and prediction models. ESGO/ISUOG/IOTA/ESGE nominated a multidisciplinary international group, including expert practising clinicians and researchers who have demonstrated leadership and expertise in the pre-operative diagnosis of ovarian tumors and management of patients with ovarian cancer (19 experts across Europe). A patient representative was also included in the group. To ensure that the statements were evidence-based, the current literature was reviewed and critically appraised. Preliminary statements were drafted based on the review of the relevant literature. During a conference call, the whole group discussed each preliminary statement and a first round of voting was carried out. Statements were removed when a consensus among group members was not obtained. The voters had the opportunity to provide comments/suggestions with their votes. The statements were then revised accordingly. Another round of voting was carried out according to the same rules to allow the whole group to evaluate the revised version of the statements. The group achieved consensus on 18 statements. This Consensus Statement presents these ESGO/ISUOG/IOTA/ESGE statements on the pre-operative diagnosis of ovarian tumors and the assessment of carcinomatosis, together with a summary of the evidence supporting each statement.

CT-Based Fagotti Scoring System for Non-Invasive Prediction of Cytoreduction Surgery Outcome in Patients with Advanced Ovarian Cancer

Objective

To construct a CT-based Fagotti scoring system by analyzing the correlations between laparoscopic findings and CT features in patients with advanced ovarian cancer.

Materials and Methods

This retrospective cohort study included patients diagnosed with stage III/IV ovarian cancer who underwent diagnostic laparoscopy and debulking surgery between January 2010 and June 2018. Two radiologists independently reviewed preoperative CT scans and assessed ten CT features known as predictors of suboptimal cytoreduction. Correlation analysis between ten CT features and seven laparoscopic parameters based on the Fagotti scoring system was performed using Spearman's correlation. Variable selection and model construction were performed by logistic regression with the least absolute shrinkage and selection operator method using a predictive index value (PIV) ≥ 8 as an indicator of suboptimal cytoreduction. The final CT-based scoring system was internally validated using 5-fold cross-validation.

Results

A total of 157 patients (median age, 56 years; range, 27–79 years) were evaluated. Among 120 (76.4%) patients with a PIV ≥ 8, 105 patients received neoadjuvant chemotherapy followed by interval debulking surgery, and the optimal cytoreduction rate was 90.5% (95 of 105). Among 37 (23.6%) patients with PIV < 8, 29 patients underwent primary debulking surgery, and the optimal cytoreduction rate was 93.1% (27 of 29). CT features showing significant correlations with PIV ≥ 8 were mesenteric involvement, gastro-transverse mesocolon-splenic space involvement, diaphragmatic involvement, and para-aortic lymphadenopathy. The area under the receiver operating curve of the final model for prediction of PIV ≥ 8 was 0.72 (95% confidence interval: 0.62–0.82).

Conclusion

Central tumor burden and upper abdominal spread features on preoperative CT were identified as distinct predictive factors for high PIV on diagnostic laparoscopy. The CT-based PIV prediction model might be useful for patient stratification before cytoreduction surgery for advanced ovarian cancer.

Individualized Prediction of Colorectal Cancer Metastasis Using a Radiogenomics Approach

Objectives: To evaluate whether incorporating the radiomics, genomics, and clinical features allows prediction of metastasis in colorectal cancer (CRC) and to develop a preoperative nomogram for predicting metastasis.

Methods: We retrospectively analyzed radiomics features of computed tomography (CT) images in 134 patients (62 in the primary cohort, 28 in the validation cohort, and 44 in the independent-test cohort) clinicopathologically diagnosed with CRC at Dazhou Central Hospital from February 2018 to October 2019. Tumor tissues were collected from all patients for RNA sequencing, and clinical data were obtained from medical records. A total of 854 radiomics features were extracted from enhanced venous-phase CT of CRC. Least absolute shrinkage and selection operator regression analysis was utilized for data dimension reduction, feature screen, and radiomics signature development. Multivariable logistic regression analysis was performed to build a multiscale predicting model incorporating the radiomics, genomics, and clinical features. The receiver operating characteristic curve, calibration curve, and decision curve were conducted to evaluate the performance of the nomogram.

Results: The radiomics signature based on 16 selected radiomics features showed good performance in metastasis assessment in both primary [area under the curve (AUC) = 0.945, 95% confidence interval (CI) 0.892–0.998] and validation cohorts (AUC = 0.754, 95% CI 0.570–0.938). The multiscale nomogram model contained radiomics features signatures, four-gene expression related to cell cycle pathway, and CA 19-9 level. The multiscale model showed good discrimination performance in the primary cohort (AUC = 0.981, 95% CI 0.953–1.000), the validation cohort (AUC = 0.822, 95% CI 0.635–1.000), and the independent-test cohort (AUC = 0.752, 95% CI 0.608–0.896) and good calibration. Decision curve analysis confirmed the clinical application value of the multiscale model.

Conclusion: This study presented a multiscale model that incorporated the radiological eigenvalues, genomics features, and CA 19-9, which could be conveniently utilized to facilitate the individualized preoperatively assessing metastasis in CRC patients.

The Significance of Preoperative Computed Tomography for Predicting Optimal Cytoreduction in Advanced Ovarian Cancer

Introduction Optimal cytoreduction is the most important prognostic factor in advanced ovarian cancer. Although staging and assessment of operability are made by exploratory surgery, preoperative computed tomography (CT) of the abdomen is regarded as standard. The aim of this study was to examine various CT parameters with regard to prediction of optimal cytoreduction. Patients and Methods The retrospective study included 131 patients with ovarian cancer newly diagnosed between 2010 and 2014. Of these, n = 36 with FIGO stage I to IIB were excluded from the study. A preoperative abdominal CT was available for n = 75 of the 95 patients with FIGO stage IIC to IV. The CT scans underwent blinded review. The 11 evaluated CT parameters were examined by means of χ ² test and logistic regression analysis with regard to the endpoints of macroscopic residual tumour and residual tumour > 1 cm. Survival analyses used the Kaplan-Meier method and log rank test. Results Of 75 patients, 28 (37.3%) had complete tumour resection and 26 (34.7%) had residual tumour ≤ 1 cm. Residual tumours > 1 cm were found in 21 (28%) patients, five of which were not resectable. Overall survival with residual tumour > 1 cm differed significantly from the group with no macroscopic residual tumour (p = 0.003) and with residual tumour ≤ 1 cm (p = 0.04). The CT parameters tumour foci in the diaphragm, mesocolon, greater omentum and peritoneum as well as ascites correlated with macroscopic residual tumour. In the multivariate logistic regression analysis only the CT parameter intraparenchymal liver metastasis was statistically significant with regard to prediction of suboptimal tumour resection (> 1 cm) (OR 8.04; 95% CI 1.57 - 42.4; p = 0.0134). The sensitivity, specificity, PPV and NPV were 37.5, 89.7, 66.7 and 72.2%. Conclusion Although risk parameters for suboptimal tumour reduction can be identified by CT of the abdomen, surgical exploration with histological confirmation of the diagnosis is essential because of the poor diagnostic accuracy.

The accuracy of multi-detector computed tomography and laparoscopy in the prediction of peritoneal carcinomatosis index score in primary ovarian cancer

RATIONALE AND OBJECTIVES

The purpose of this study was to compare the accuracy of MDCT and laparoscopy in the prediction of peritoneal carcinomatosis index score. Reproducibility of MDCT interpretation was also assessed.

METHODS

This prospective study included 85 ovarian cancer patients underwent MDCT and diagnostic laparoscopy before cytoreductive surgery. We calculated the accuracy of diagnostic modalities in the calculation of the peritoneal cancer index score (PCI). Radiologist interobserver agreement was calculated using kappa statistics.

RESULTS

Nine hundred-thirty (84.2%) of the 1105 regions had peritoneal deposits at exploratory laparotomy. Computed tomography (CT) and laparoscopy sensitivity were 94.9%, 98.3%, specificity 86.7%, 80.4%, PPV 97.9 %, 96.8%, NPV 72.2%, 88.8 %, and accuracy 93.8 %, 95.7%, respectively. However, computed tomography (CT) diagnostic performance is less accurate than laparoscopy in pelvic and small intestinal regions; no statistically significant differences were evident regarding total PCI score compared to surgery (p> 0.05). CT and laparoscopy correctly depicted peritoneal carcinomatosis in 88.2%, 90.6% of patients, respectively. Optimal cytoreduction was achieved in 68 (80%) patients.

CONCLUSION

Both CT and laparoscopy seems to be effective tools for assessment of peritoneal carcinomatosis using the PCI score. Dedicated MDCT protocol with routine use of a standardized PCI form may provide better comprehensive multi-regional analysis that may help surgeons referring patients to the best treatment option. Laparoscopy is a valuable tool in cases with a high risk of suboptimal cytoreduction related to disease extent.

[Diagnostic value of imaging (ultrasonography, doppler, CT, MR, PET-CT) for the diagnosis of a suspicious ovarian mass and staging of ovarian, tubal or primary peritoneal cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

Transvaginal ultrasound is the first-line examination allowing characterizing 80 to 90% of adnexal masses (LP1). If performed by an expert, a subjective analysis is optimal. If performed by a non-expert, combining the use of Simple Rules with subjective analysis can achieve the diagnostic performance of an expert (LP1). Whichever the chosen model (subjective analysis by an expert or combination of the Simple Rules with a subjective analysis by a non-expert), a second-line examination will have to be proposed in the complex or indeterminate cases (about 20% of the masses) (grade A). The best-performing second-line test for characterization is pelvic MRI (LP1). If read by an expert, a pathological hypothesis can or should be suggested (grade D). In case of non-expert reading, the use of the ADNEXMR score allows a reliable assessment of the positive predictive value of malignancy to guide the patient towards the best management (gradeC). For preoperative assessment and evaluation of resectability of ovarian, fallopian tube or primary peritoneal cancer, it is recommended to perform a chest abdomen and pelvis CT with contrast agent injection (LP2, grade B). In the event of a contraindication to the injection of iodinated contrast agent (severe renal insufficiency, GFR <30mL/min), an abdomen and pelvis MRI completed with a non-injected chest CT may be proposed (LP3, grade C). By analogy, the same examinations are recommended to evaluate the disease after neo-adjuvant chemotherapy (LP3, Recommendation grade C). Further studies will be required to determine whether PET-CT provides better lymph node assessment before retroperitoneal and pelvic lymphadenectomy. PET-CT may be used to eliminate lymph node involvement in the absence of suspicious lymph nodes on morphological examination (LP3, grade C). The report should specify the localizations leading to a risk of incomplete cytoreductive surgery and lesions outside the field explored during surgery.

A pre-operative predictive score to evaluate the feasibility of complete cytoreductive surgery in patients with epithelial ovarian cancer

Objective

Postoperative residual tumor is the major prognostic factor in ovarian cancer. The feasibility of complete cytoreductive surgery is assessed by laparoscopy. Our goal was to develop a predictive score prior to laparoscopy to evaluate the feasibility of complete cytoreductive surgery in patients with epithelial ovarian cancer.

Methods

We developed a score to predict incomplete cytoreductive surgery by performing multiple logistic regressions after bootstrap procedures on data from a retrospective cohort of 247 patients with advanced ovarian cancer. This score was validated on a different population of 45 patients with ovarian cancer.

Results

Four criteria were independently associated with incomplete cytoreduction, confirmed by surgery: BMI ≥ 30 kg/m² (adjusted odds ratio [aOR], 3.07; 95% confidence interval [95% CI], 1.0–9.6), CA125 > 100 IU/L (aOR, 3.99; 95% CI, 1.6–10.1), diaphragmatic and/or omental carcinomatosis by CT-Scan (aOR, 5.82; 95% CI, 2.6–13.1), and positive parenchymal metastases by PET/CT (aOR, 3.59; 95% CI, 1.0–12.8). The 100-point score was based on these criteria. The area-under-the-curve of the score was 0.79 (95% CI, 0.73–0.86). In the validation group, no patient ranked in the high-risk group of incomplete cytoreductive surgery had a complete upfront cytoreductive surgery (95% CI 0–16). Three of 29 patients for whom primary complete cytoreduction was not possible were classified in the group at low risk of incomplete cytoreductive surgery (12%; 95% CI 4–27).

Conclusion

This pre-operative score may be useful for distinguishing which patients may have complete cytoreductive surgery from those who will receive neoadjuvant chemotherapy, while avoiding unnecessary laparoscopy.

Preoperative prediction of suboptimal resection in advanced ovarian cancer based on clinical and CT parameters

Background Cytoreduction is important as a survival predictor in advanced ovarian cancer. Purpose To determine the prediction of suboptimal resection (SOR) in advanced ovarian cancer based on clinical and computed tomography (CT) parameters. Material and Methods Between 2007 and 2015, 327 consecutive patients with FIGO stage III-IV ovarian cancer and preoperative CT were included. During 2007-2012, patients were assigned to a derivation dataset ( n = 220) and the others were assigned to a validation dataset ( n = 107). Clinical parameters were reviewed and two radiologists assessed the presence or absence of tabulated parameters on CT images. Logistic regression analyses based on area under the receiver-operating characteristic curve (AUROC) were performed to identify variables predicting SOR, and generated simple score using Cox proportional hazards model. Results There was no statistical difference in patients' characteristics in both datasets, except for residual disease ( P = 0.001). Optimal resection improved from 45.0% (99/220) in the derivation dataset to 64.4% (69/107) in the validation dataset. Logistic regression identified that Eastern Cooperative Oncology Group-performance status (ECOG-PS 2), involvements of peritoneum, diaphragm, bowel mesentery and suprarenal lymph nodes, and pleural effusion were independent variables of SOR. Overall AUROC for score predicting SOR was 0.761 with sensitivity, specificity, and positive and negative predictive values of 70.6%, 73.2%, 68.7%, and 91.9%, respectively. In the derivation dataset, AUROC was 0.792, with sensitivity of 71.4% and specificity of 74.3%, and AUROC of 0.758 with sensitivity of 69.2% and specificity of 72.8% in the validation dataset. Conclusion CT may be a useful preoperative predictor of SOR in advanced ovarian cancer.

Non-surgical management of ovarian cancer: Prevalence and implications

PURPOSE

To identify prevalence, correlates and survival implications of non-surgically managed epithelial ovarian cancer (EOC).

METHODS

The National Cancer Database (NCDB) was queried for EOC cases between 2003 and 2011. Type of treatment, survival data, reasons for non-surgical treatment, clinicopathologic and process-based factors were collected. Logistic regression identified independent predictors of surgical treatment; Cox proportional hazards regression modeled association between time to death and receipt of surgery.

RESULTS

172,687 of 210,667 patients (82%) received surgical treatment for EOC. 95% of patients treated non-surgically had stage III, stage IV or unknown stage disease. The reason for non-surgical treatment was unclear in 80% of cases. Black race and uninsurance were significantly associated with non-surgical treatment. Median survival time was 57.4months (95% CI: 56.8-57.9) for surgery with or without systemic treatment compared to 11.9months (95% CI: 11.6-12.2) for systemic treatment alone and 1.4months (95% CI: 1.3-1.4) for no treatment. Relative to surgical treatment, the adjusted hazard ratio for death associated with systemic treatment alone was 1.9 (p<0.001); hazard ratio for untreated patients was 4.7 (p<0.001). Among 29,921 patients older than 75 with Stage III/IV disease, 21.5% received only systemic treatment; 22.8% were entirely untreated.

CONCLUSION

18% of EOC patients in the NCDB did not receive surgical treatment. These patients experienced significantly worsened survival. Prospective investigation is needed to determine how often apparent deviation from best-practices guidelines is clinically appropriate. Non-surgically treated patients may be at risk for poor access to gynecologic oncology care and deserve further study.

Prediction of incomplete primary debulking surgery in patients with advanced ovarian cancer: An external validation study of three models using computed tomography

OBJECTIVE

To test the ability of three prospectively developed computed tomography (CT) models to predict incomplete primary debulking surgery in patients with advanced (International Federation of Gynecology and Obstetrics stages III-IV) ovarian cancer.

METHODS

Three prediction models to predict incomplete surgery (any tumor residual >1cm in diameter) previously published by Ferrandina (models A and B) and by Gerestein were applied to a validation cohort consisting of 151 patients with advanced epithelial ovarian cancer. All patients were treated with primary debulking surgery in the Eastern part of the Netherlands between 2000 and 2009 and data were retrospectively collected. Three individual readers evaluated the radiographic parameters and gave a subjective assessment. Using the predicted probabilities from the models, the area under the curve (AUC) was calculated which represents the discriminative ability of the model.

RESULTS

The AUC of the Ferrandina models was 0.56, 0.59 and 0.59 in model A, and 0.55, 0.60 and 0.59 in model B for readers 1, 2 and 3, respectively. The AUC of Gerestein's model was 0.69, 0.61 and 0.69 for readers 1, 2 and 3, respectively. AUC values of 0.69 and 0.63 for reader 1 and 3 were found for subjective assessment.

CONCLUSIONS

Models to predict incomplete surgery in advanced ovarian cancer have limited predictive ability and their reproducibility is questionable. Subjective assessment seems as successful as applying predictive models. Present prediction models are not reliable enough to be used in clinical decision-making and should be interpreted with caution.

Surgical outcome prediction in patients with advanced ovarian cancer using computed tomography scans and intraoperative findings

OBJECTIVE

This study aimed to identify features on preoperative computed tomography (CT) scans that are predictive of suboptimal primary cytoreduction and to evaluate the correlation between CT findings and intraoperative findings in advanced ovarian cancer.

MATERIALS AND METHODS

We retrospectively reviewed preoperative CT scans and operative findings from patients with stage III/IV epithelial ovarian cancer who underwent primary cytoreduction between 2003 and 2006. Fourteen criteria were assessed. Clinical data were extracted from medical records. Residual tumors measuring ≥1 cm were considered suboptimal.

RESULTS

We retrospectively identified 118 patients who met the study inclusion criteria. The rate of optimal cytoreduction (≤1 cm residual disease) was 40%. On preoperative CT scans, omental extension to the stomach or spleen and inguinal or pelvic lymph nodes >2 cm were predictors of suboptimal cytoreduction on univariate (p = 0.016 and p = 0.028, respectively) and multivariate analysis (p = 0.042 and p = 0.029, respectively). Involvement of both omental extension and inguinal or pelvic lymph nodes had a positive predictive value (PPV) of 100%, a specificity of 100%, and an accuracy of 45.8% in predicting suboptimal cytoreduction. We correlated the preoperative CT findings with the intraoperative findings. There were significant correlations between CT and intraoperative findings of omental extension (p = 0.007), inguinal or pelvic lymph nodes >2 cm (p < 0.001), and large bowel mesentery implants >2 cm (p = 0.001).

CONCLUSION

The combination of omental extension to the stomach or spleen and involvement of inguinal or pelvic lymph nodes in preoperative CT scans is considered predictive of suboptimal cytoreduction. These patients may be more appropriately treated with neoadjuvant chemotherapy followed by surgical cytoreduction.

Radiological predictors of cytoreductive outcomes in patients with advanced ovarian cancer

OBJECTIVE

To assess site of disease on preoperative computed tomography (CT) to predict surgical debulking in patients with ovarian cancer.

DESIGN

Two-phase retrospective cohort study.

SETTING

West London Gynaecological Cancer Centre, UK.

POPULATION

Women with stage 3 or 4, ovarian, fallopian or primary peritoneal cancer undergoing cytoreductive surgery.

METHODS

Preoperative CT images were reviewed by experienced radiologists to assess the presence or absence of disease at predetermined sites. Multivariable stepwise logistic regression models determined sites of disease which were significantly associated with surgical outcomes in the test (n = 111) and validation (n = 70) sets.

MAIN OUTCOME MEASURES

Sensitivity and specificity of CT in predicting surgical outcome.

RESULTS

Stepwise logistic regression identified that the presence of lung metastasis, pleural effusion, deposits on the large-bowel mesentery and small-bowel mesentery, and infrarenal para-aortic nodes were associated with debulking status. Logistic regression determined a surgical predictive score which was able to significantly predict suboptimal debulking (n = 94, P = 0.0001) with an area under the curve (AUC) of 0.749 (95% confidence interval [95% CI]: 0.652, 0.846) and a sensitivity of 69.2%, specificity of 71.4%, positive predictive value of 75.0% and negative predictive value of 65.2%. These results remained significant in a recent validation set. There was a significant difference in residual disease volume in the test and validation sets (P < 0.001) in keeping with improved optimal debulking rates.

CONCLUSIONS

The presence of disease at some sites on preoperative CT scan is significantly associated with suboptimal debulking and may be an indication for a change in surgical planning.

A framework for a personalized surgical approach to ovarian cancer

The standard approach for the treatment of advanced-stage ovarian cancer is upfront cytoreductive surgery followed by a combination of platinum-based and taxane-based chemotherapy. The extent of residual disease following upfront cytoreductive surgery correlates with objective response to adjuvant chemotherapy, rate of pathological complete response at second-look assessment operations, and progression-free survival and overall survival. Contemporary data and meta-analyses indicate a correlation between volume of residual disease and patient outcome, with those patients undergoing complete gross resection having the best outcomes. Thus, attention has focused on surgical efforts to remove as much disease as possible with the metric of 'optimal' cytoreduction being R0 disease. Because patients with R0 resection seem to have the best overall outcomes, preoperative or intraoperative assessment to avoid unnecessary primary debulking surgery has become common. The use of serum CA-125 levels, physical examination and CT imaging have lacked accuracy in determining if disease can be optimally debulked. Therefore, an algorithm that identifies patients in whom complete gross resection at primary surgery is likely to be achieved would be expected to improve patient survival. We discuss contemporary definitions of 'optimal' residual disease, and opportunities to personalize surgical therapy and improve the quality of surgical care.

Neoadjuvant chemotherapy and cytoreductive surgery in epithelial ovarian cancer

Ovarian cancer is one of the leading causes of death among gynecological cancers. This is because the majority of patients present with advanced stage disease. Primary debulking surgery (PDS) followed by adjuvant chemotherapy is still a mainstay of treatment. An optimal surgery, which is currently defined by leaving no gross residual tumor, is the goal of PDS. The extent of disease as well as the operative setting, including the surgeon’s skill, influences the likelihood of successful debulking. With extensive disease and a poor chance of optimal surgery or high morbidity anticipated, neoadjuvant chemotherapy (NACT) prior to primary surgery is an option. Secondary surgery after induction chemotherapy is termed interval debulking surgery (IDS). Delayed PDS or IDS is offered to patients who show some clinical response and are without progressive disease. NACT or IDS has become more established in clinical practice and there are numerous publications regarding its advantages and disadvantages. However, data on survival are limited and inconsistent. Only one large randomized trial could demonstrate that NACT was not inferior to PDS while the few randomized trials on IDS had inconsistent results. Without a definite benefit of NACT prior to surgery over PDS, one must carefully weigh the chances of safe and successful PDS against the morbidity and risks of suboptimal surgery. Appropriate selection of a patient to undergo PDS followed by chemotherapy or, preferably, to have NACT prior to surgery is very important. Some clinical characteristics from physical examination, serum tumor markers and/or findings from imaging studies may be predictive of resectability. However, no specific features have been consistently identified in the literature. This article will address the clinical data on prediction of surgical outcomes, the role of NACT, and the role of IDS.

Diagnostic accuracy of hand-assisted laparoscopy in predicting resectability of peritoneal carcinomatosis from gynecological malignancies

OBJECTIVES

Residual disease after excision surgery is the main prognostic factor in advanced ovarian cancer. Open surgery can delay neoadjuvant chemotherapy initiation. Therefore, a minimally invasive method for evaluating resectability would be of great interest. Aim of our study is to evaluate a new technique for assessing the extent of peritoneal carcinomatosis, combining manual palpation and standard laparoscopy.

METHODS

Prospective single-center study from October 2008 to January 2010. Patients with peritoneal carcinomatosis from gynecological malignancies were investigated by standard laparoscopy followed by laparoscopy plus manual palpation using Lapdisc(®) (Ethicon Inc.), at 43 abdominopelvic sites. When both techniques indicated resectability, standard cytoreduction surgery was performed via a midline laparotomy. The Fagotti, modified Fagotti, and Sugarbaker scores were computed. The diagnostic performance of each evaluation criterion was assessed by computing sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver-operating characteristic curves (ROC-AUCs).

RESULTS

Of the 29 included patients, 18 (62.1%) were considered to have resectable disease. Fourteen (14/18, 77.8%) had macroscopically complete cytoreduction. With Lapdisc(®), sensitivity was 100%, specificity 73.3%, PPV 77.8%, NPV 100%, and ROC-AUC 0.87. Corresponding values were as follows: laparoscopy, 100%, 40%, 60.9%, 100%, and 0.70; Fagotti and modified Fagotti scores, 100%, 46.7%, 63.6%, 100%, and 0.73; Sugarbaker score, 64.3%, 93.3%, 90%, 73.7%, and 0.79. The ROC-AUCs showed significantly better performance of Lapdisc(®) than of standard laparoscopy (P = 0.008).

CONCLUSION

Hand-assisted laparoscopy may perform better than laparoscopy alone for predicting the resectability of peritoneal carcinomatosis by increasing the number of sites evaluated.

Accuracy of 64-multidetector computed tomography in diagnosis of adnexal tumors

BACKGROUND

Adnexal cancers are in fifth place among the tumors with the highest mortality in the female population. The aim of the present study was to evaluate the accuracy of Multi-detector computed tomography (MDCT) on a 64-multislice CT scanner in the detection and differentiation of adnexal masses stages.

METHODS

During the present prospective study, 95 women with a primary diagnosis of ovarian mass in base of clinical examination and ultrasonographic findings underwent preoperative evaluation by a 64-slice MDCT with a section thickness of 0.6 mm, 50% overlap and reconstructed images. Afterward, results of MDCT were compared with surgical and histopathological findings, and the sensitivity, specificity, positive and negative predictive value and accuracy were determined.

RESULTS

The mean age of patients was 48.63 ± 13.93 years. MDCT diagnosed 25 (26.3%) masses to be benign and 70 (73.7%) to be malignant (sensitivity, specificity, positive and negative predictive value and accuracy were 92.8%, 88.0%, 95.5%, 81.4% and 91.5% respectively). The sensitivity and specificity of MDCT in determining local extension was 72.2% and 93.4% respectively. And the sensitivity and specificity of MDCT in determining peritoneal seeding and liver extension was 81.8% and 93% respectively. Estimated stage was significantly agreed with the surgical (Cohen's Kappa (κ) = 0.891) and histopathological findings (κ = 0.858).

CONCLUSION

MDCT is a highly sensitive and specific diagnostic method in evaluation of adnexal masses and successfully stage the tumor in consistent with surgery and histopathology.

Role of CT scan-based and clinical evaluation in the preoperative prediction of optimal cytoreduction in advanced ovarian cancer: a prospective trial

BACKGROUND

In advanced ovarian cancer, maximal efforts have to be attemptedto achieve optimal cytoreduction, as this represents the keystone in the therapeutic management. This large, prospective study aims at investigating the role of computed tomography (CT) scan in predicting the feasibility of optimal cytoreduction in ovarian cancer.

METHODS

A total of 195 consecutive patients with clinical/radiographic suspicion of advanced ovarian/peritoneal cancer were enrolled at the Gynecologic Oncology Unit, Catholic University of Rome and Campobasso, Italy. Preoperative CT scans were performed with a high-speed scanner (CT Hi Speed Nx/i Pro; 2-slice; GE Medical System). All patients underwent standard laparotomy, and maximal surgical effort was attempted. The following CT parameters were used: peritoneal thickening, peritoneal implants >2 cm, bowel mesentery involvement, omental cake, pelvic sidewall involvement and/or hydroureter, suprarenal aortic lymph nodes >1 cm, infrarenal aortic lymph nodes >2 cm, superficial liver metastases >2 cm and/or intraparenchimal liver metastases any size, large volume ascites (>500 ml). Clinical data included were age, Ca125 serum levels, and ECOG-PS. Radiographic and clinical features exhibiting a specificity >75%, a positive and negative predictive value >50%, an accuracy >60% in predicting surgical outcome were assigned a point value of 2. With this scoring system, a predictive index (PI) was calculated for each patient.

RESULTS

The PI scores ranged from 0 to 6, and from 0 to 8, in Model 1 (including only radiographic parameters) and in Model 2 (including radiographic and clinical data). The AUC was 0.78+0.035 in Model 1, and 0.81+0.031 in Model 2. Therefore, the addition of ECOG-PS data led to the improvement of the diagnostic performances (z=2.41, P-value <0.05).

CONCLUSIONS

Computed scan still represents a valid tool to predict ovarian cancer optimal cytoreduction; the predictive ability of a CT scan-based model is improved by integrating ECOG-PS data.

Management of women with newly diagnosed ovarian cancer

Ovarian cancer is the leading cause of death from gynecologic cancers in the United States. Initial management is reviewed here and is best provided by a multidisciplinary team, including a gynecologic oncologist and a medical oncologist. Typically these patients are first treated with aggressive surgical debulking, followed by chemotherapy. Exceptions to this strategy, including those for patients adequately treated with surgery alone and those better served by neoadjuvant chemotherapy (NAC), are discussed. The history and rationale of current chemotherapy regimens, both intravenous (IV) and intraperitoneal (IP), are reviewed. Given the chemo-sensitive nature of this disease, as well as the fact that it remains largely incurable in advanced stages, efforts continue to be made to improve initial therapy. This disease represents an excellent target for new drug development, and some of the newer agents in trials for ovarian cancer are discussed.

Preoperative serum CA125 levels do not predict suboptimal cytoreductive surgery in epithelial ovarian cancer

The objective is to assess the ability of preoperative serum CA125 levels to identify patients at high risk of suboptimal cytoreductive surgery for epithelial ovarian cancer (EOC). One hundred and thirty-two women diagnosed with EOC between 1998 and 2004, who had serum CA125 levels measured preoperatively and received primary cytoreductive surgery, were retrospectively evaluated. The value of CA125 and patient and disease characteristics to predict suboptimal cytoreduction were determined, and a prognostic scoring system, based on statistically significant variables, was created. Optimal cytoreduction was achieved in 42.7% of the women with FIGO stage III/IV EOC. The optimal cutoff point of preoperative CA125 to predict surgical outcome in this group was 330 U/mL (sensitivity 80.0%; specificity 41.5%). The area under the receiver-operating characteristic curve (AUC) for preoperative CA125 predicting suboptimal surgery in FIGO stage III/IV was 0.576 (P = 0.617). Preoperative radiologic amount of ascites and weight loss (ie, >or=10% in the last 6 months before diagnosis) were independent prognostic factors for suboptimal cytoreduction, showing an AUC of 0.76 (P < 0.001) in women with FIGO stage III/IV. A prognostic scoring system showed that the chance of suboptimal surgery was 84.6% in FIGO stage III/IV when both these factors are present preoperatively. The role of CA125 levels predicting suboptimal cytoreduction seems questionable. Instead, women with considerable weight loss and a gross amount of ascites have a higher risk of suboptimal cytoreduction. These patients may be candidates for neoadjuvant chemotherapy.

Ovarian cancer

Imaging has become an essential part of the clinical management of patients with ovarian cancer, contributing to tumor detection, characterization, staging, treatment planning, and follow-up. Imaging findings incorporated into the clinical impression assist in creating a treatment plan specific for an individual patient. Advances in cross-sectional imaging and nuclear medicine (PET) have yielded new insights into the evaluation of tumor prognostic factors. A multimodality approach can satisfy the complex imaging needs of a patient with ovarian cancer; however, the success of such an approach always depends on available resources and on the skills of the physicians involved.

Delaying the primary surgical effort for advanced ovarian cancer: a systematic review of neoadjuvant chemotherapy and interval cytoreduction

OBJECTIVE

To summarize the existing data on interval cytoreductive surgery and neoadjuvant chemotherapy as alternative treatment strategies for patients with advanced-stage ovarian cancer.

METHODS

All investigational studies with evaluable survival data on interval cytoreductive surgery and neoadjuvant chemotherapy for ovarian cancer reported in the English language literature between 1989 and 2006 were systematically reviewed.

RESULTS

Three randomized trials and six non-randomized studies of interval cytoreduction following suboptimal initial surgery were identified. Twenty-six studies, including a total of 1336 patients, reporting on neoadjuvant chemotherapy administered in lieu of primary cytoreductive surgery were analyzed according to the survival outcome achieved, the degree of surgical effort or success, and the particular selection criteria employed to justify deferring an attempt at primary cytoreductive surgery.

CONCLUSIONS

Interval surgery following a concerted but suboptimal attempt at up-front cytoreduction does not appear to have an appreciable impact on survival outcome. Maximal primary cytoreductive surgery remains the standard of care for the majority of women with suspected advanced ovarian cancer. Neoadjuvant chemotherapy represents a viable alternative management strategy for the limited number of patients felt to be optimally unresectable by an experienced ovarian cancer surgical team; however, currently available data suggest that the survival outcome achievable with initial chemotherapy is inferior to successful up-front cytoreductive surgery. Additional research is needed to devise universal selection criteria for neoadjuvant chemotherapy, determine the most efficacious treatment program, and characterize the appropriate proportion of patients in which an attempt at primary surgery should be abandoned in favor of initial chemotherapy.

The utility of presurgical CA125 to predict optimal tumor cytoreduction of epithelial ovarian cancer

The objective of this study was to evaluate the ability of a preoperative serum CA125 to predict whether optimal debulking (OD) could be achieved for patients with stage III and IV epithelial ovarian cancer (EOC). The records of consecutive patients who underwent primary surgery for EOC at Indiana University Hospital between January 1997 and January 2003 were reviewed. Eligibility criteria included FIGO stage III/IV disease, surgery by gynecologic oncology faculty, preoperative CA125, and an operative note clearly defining volume of residual disease. The Medcalc software statistical package was used to generate a receiver-operating characteristic (ROC) curve. Two hundred and eighty-nine cases of stage III/IV EOC were identified, of which 164 met the eligibility criteria. Serum CA125 </=400 was associated with OD >/=75% of the time. Conversely, OD was achieved in </=40% of patients with CA125 >/=4500. The area under the ROC curve for CA125 was .670. The OD rate for those with and without ascites was 49% and 79%, respectively (P < 0.001). In a multivariate analysis using CA125, age, and ascites, the area under the curve was 0.686. We conclude that preoperative serum CA125 did not reliably predict OD in patients with stage III-IV EOC.

A laparoscopy-based score to predict surgical outcome in patients with advanced ovarian carcinoma: a pilot study

BACKGROUND

Our objective was to set up a more objective quantitative laparoscopy-based model in predicting the chances of optimal cytoreductive surgery in advanced ovarian cancer patients.

METHODS

Sixty-four advanced ovarian cancer patients were submitted to both laparoscopy and standard longitudinal laparotomy sequentially, to define the chances of optimal debulking surgery (residual disease < or = 1 cm). Three patients could not be evaluated by laparoscopy because of the presence of multiple and tenacious adherences. Sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy were calculated for each laparoscopic parameter. On the basis of the statistical probability of each factor to predict surgical outcome, seven laparoscopic features were selected for inclusion in the final model. Each parameter was assigned a numerical score based on the strength of statistical association, and a total predictive index value was tabulated for each patient. Receiver operating characteristic curve analysis was used to assess the ability of the model to predict surgical outcome.

RESULTS

After debulking surgery, 41 (67.2%) of 61 patients were left with optimal residual disease. The presence of omental cake, peritoneal carcinosis, diaphragmatic carcinosis, mesenteric retraction, bowel and/or stomach infiltration, and liver metastases satisfied the basic inclusion criteria and were assigned a final predictive index value of 2. In the final model, a predictive index score > or = 8 identified patients undergoing suboptimal surgery with a specificity of 100%. The positive predictive value was 100%, and the negative predictive value was 70%.

CONCLUSIONS

The reliability of laparoscopy in assessing the chance of optimal cytoreduction can be improved by using a simple scoring system.

Major hepatectomy and right hemicolectomy at the time of primary cytoreductive surgery for advanced ovarian cancer: report of a case

Major liver involvement at the time of diagnosis is a rare event in patients with ovarian cancer, and the issue of major hepatectomy at the time of primary cytoreductive surgery is controversial. A 61-year-old woman was admitted to our hospital with nonspecific abdominal pain of 2-month duration and weight loss of 5 kg during the last semester. A computed tomography scan demonstrated bilateral ovarian masses, extending to the right iliac fossa, pressing the cecum-ascending colon. In the liver parenchyma, three cystic lesions were found of about 6-cm maximum diameter each, along with pelvic lymphadenopathy. There was no ascites. The diagnosis of advanced ovarian cancer was clinically suspected; the patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, right hemicolectomy, omentectomy, left lobectomy, deroofing, and draining of the cystic formation of the right liver lobe along with systematic pelvic and para-aortic lymphadenectomy. Systemic chemotherapy (six cycles of paclitaxel/carboplatin) was subsequently administered, and after 15 months of follow-up period, the patient is still in first remission and alive. Ovarian cancer with concomitant extensive right colon infiltration and hematogenous liver metastases can be successfully managed with aggressive surgical resection and postoperative chemotherapy in carefully selected patients.

Ultrasound and color power Doppler in the detection of metastatic omentum: a prospective study

OBJECTIVES

To analyze prospectively the ability of ultrasound to detect metastatic omentum in patients with suspicious pelvic masses and to describe the sonographic features of metastatic omental disease.

METHODS

One hundred and eighty-four patients were evaluated preoperatively by ultrasound examination and of these 173 were used in the analysis. We defined as an ultrasound-positive examination one which visualized intra-abdominal aperistaltic solid tissue, located above the bowel loops and below the anterior peritoneal surface. Preoperative sonographic findings were compared with pathological results.

RESULTS

Sonographic detection of metastatic omentum was achieved in 104 of 173 patients (60.1%), appearing as either solid aperistaltic tissue (80.8% of cases), or as solid discrete nodules (19.2%). When considering the echostructure of the surrounding bowel loops, this tissue appeared hypoechoic in 46 (44.2%) cases and isoechoic or slightly hyperechoic in the other 58 (55.8%) cases. In the overall series, the negative and positive predictive values (NPV and PPV) and the accuracy of ultrasound examination were 92.7%, 91.3% and 91.9%, respectively. When considering only the group of ovarian tumors, the NPV, PPV and accuracy were 91.9%, 94.6%, and 93.8%, respectively.

CONCLUSION

Ultrasound examination is highly accurate in detecting metastatic omental involvement in cases with suspicious pelvic masses.

Preoperative computed tomography and selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

AIM

A survival benefit has been observed for colorectal cancer patients with peritoneal carcinomatosis treated by cytoreductive surgery with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). However, this treatment modality is associated with a considerable morbidity and mortality and in a significant number of patients survival is not improved. We studied whether poor survivors could be identified on preoperative computed tomography (CT), in order to avoid unnecessary surgery.

PATIENTS AND METHODS

Films of abdominopelvic CT scans from 25 such patients treated by cytoreductive surgery and HIPEC were retrospectively analysed by two radiologists separately. A simplified peritoneal cancer index (SPCI) was used to determine the extent of peritoneal involvement. Correlation between the on preoperative CT based SPCI-scores as well as number of involved abdominopelvic areas (N) and survival was examined with the log-rank test. The relation between each affected region and survival was evaluated with Cox regression analysis.

RESULTS

The preoperative SPCI- and N-scores of one of the radiologists had no statistically significant prognostic value, while for the second radiologist SPCI > or = 7 and N > or = 4 were associated with particularly poor outcome. Additionally, the presence of ileocaecal region involvement and, depending on the radiologist, the occurrence of tumour deposits in the left subdiaphragmatic area on CT appeared to be unfavourable prognostic signs.

CONCLUSIONS

The prognostic value of preoperative conventional CT appeared to be radiologist dependent and may, therefore, be of limited value in selecting colorectal cancer patients with peritoneal carcinomatosis who will not benefit from extensive cytoreductive surgery followed by HIPEC.

Transvaginal sonographic features of peritoneal carcinomatosis

OBJECTIVES

Peritoneal carcinomatosis involves the dissemination of intra-abdominal tumor tissue often associated with gynecological malignancies. The objective of this study was to describe the transvaginal sonographic appearance of this condition.

METHODS

The data of 60 patients with surgically and histologically proven peritoneal carcinomatosis were analyzed. Transvaginal sonograms performed within 7 days of admission to the operating theater were re-evaluated in order to identify the sonographic features associated with peritoneal carcinomatosis.

RESULTS

Carcinomatosis was revealed in 53/60 cases (88%) by the presence of hypoechoic nodules attached to the peritoneum and visible on transvaginal sonography (TVS). The pouch of Douglas was the site most frequently involved. Power Doppler sonography showed the presence of blood vessels in 48 (91%) of these metastases. Ascites was found in 50 (83%) women. An adnexal mass suggestive of being the primary tumor was present in only 41 women (68%).

CONCLUSIONS

Peritoneal carcinomatosis has typical features on TVS and, in the vast majority of cases, its genital origin can be correctly hypothesized. Power Doppler sonography strengthens the diagnosis by showing vascularity of the peritoneal implants. In a patient with a known pelvic malignancy or whenever peritoneal carcinomatosis is suspected, TVS can give useful information in order to better assess the presence and extension of metastatic nodules within the abdominal cavity.

Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer

OBJECTIVE

To determine the relative accuracy of CT or MR imaging in the detection of inoperable tumor sites prior to cytoreductive surgery in a large series of patients with newly diagnosed primary epithelial ovarian cancer.

METHODS

One hundred thirty-seven women with newly diagnosed primary epithelial ovarian cancer underwent CT (n = 91) or MR imaging (n = 46) prior to cytoreductive surgery. The following imaging criteria were used to identify inoperable tumor sites: (1) peritoneal implants greater than 2 cm in maximum diameter in the porta hepatis, intersegmental fissure, gall bladder fossa, subphrenic space, gastrohepatic ligament, gastrosplenic ligament, lesser sac, or root of the small bowel mesentery; (2) retroperitoneal adenopathy greater than 2 cm in maximum diameter above the renal hila; (3) hepatic metastases or abdominal wall invasion. Imaging results were compared with operability at surgery.

RESULTS

Cytoreductive surgery was suboptimal in 21 of the 137 (15%) patients. Sixteen of these patients had inoperable tumor on preoperative imaging, while one additional patient had apparently inoperable tumor on imaging but was optimally debulked at surgery. The sensitivity, specificity, positive predictive value, and negative predictive value of preoperative imaging for the prediction of suboptimal debulking were 76% (16/21), 99% (115/116), 94% (16/17), and 96% (115/120), respectively. CT and MR imaging were equally effective (P = 1.0) in the detection of inoperable tumor.

CONCLUSION

Preoperative CT and MR imaging are equally accurate in the detection of inoperable tumor and the prediction of suboptimal debulking in newly diagnosed epithelial ovarian cancer. This suggests imaging may help select patients who might be more appropriately managed by neoadjuvant chemotherapy.

Chirurgie initiale ou d'intervalle dans les cancers de l'ovaire de stade avancé ? État de la question en 2004 et critères de sélection des patientes

The management of advanced stage ovarian cancer has been deeply modified over the last few years. In patients with massive peritoneal spread, the use of neoadjuvant chemotherapy, followed by interval surgery, reduces the morbidity of radical surgery with an improvement of the quality of life. Nevertheless, results of ongoing randomized studies should be waited before stating about the results on survival of such management compared to initial debulking surgery. Waiting such results, the standard treatment of advanced stage ovarian cancer in 2005 remains initial surgery, performed in order to obtain ideally a total resection of all macroscopic diseases, and followed by adjuvant chemotherapy. However, in patients with massive spread, interval debulking surgery is becoming an interesting option, and will perhaps become a standard management. But criteria to select patients between initial and interval debulking surgery should be clearly defined. Those different points will be studied in this paper.