Secondary cytoreduction for ovarian cancer following cisplatin therapy

Prognosis Following Surgery for Recurrent Ovarian Cancer and Diagnostic Criteria Predictive of Cytoreduction Success: A Systematic Review and Meta-Analysis

For women achieving clinical remission after the completion of initial treatment for epithelial ovarian cancer, 80% with advanced-stage disease will develop recurrence. However, the standard treatment of women with recurrent platinum-sensitive diseases remains poorly defined. Secondary (SCS), tertiary (TCS) or quaternary (QCS) cytoreduction surgery for recurrence has been suggested to be associated with increased overall survival (OS). We searched five databases for studies reporting death rate, OS, cytoreduction rates, post-operative morbidity/mortality and diagnostic models predicting complete cytoreduction in a platinum-sensitive disease recurrence setting. Death rates calculated from raw data were pooled based on a random-effects model. Meta-regression/linear regression was performed to explore the role of complete or optimal cytoreduction as a moderator. Pooled death rates were 45%, 51%, 66% for SCS, TCS and QCS, respectively. Median OS for optimal cytoreduction ranged from 16-91, 24-99 and 39-135 months for SCS, TCS and QCS, respectively. Every 10% increase in complete cytoreduction rates at SCS corresponds to a 7% increase in median OS. Complete cytoreduction rates ranged from 9-100%, 35-90% and 33-100% for SCS, TCS and QCS, respectively. Major post-operative thirty-day morbidity was reported to range from 0-47%, 13-33% and 15-29% for SCS, TCS and QCS, respectively. Thirty-day post-operative mortality was 0-6%, 0-3% and 0-2% for SCS, TCS and QCS, respectively. There were two externally validated diagnostic models predicting complete cytoreduction at SCS, but none for TCS and QCS. In conclusion, our data confirm that maximal effort higher order cytoreductive surgery resulting in complete cytoreduction can improve survival.

Secondary Cytoreductive Surgery in Platinum-Sensitive Recurrent Ovarian Cancer: A Meta-Analysis

PURPOSE

The survival impact of secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer was studied.

METHODS

We identified published studies from 1983 to 2021 following our inclusion criteria from MEDLINE, EMBASE, and Cochrane library. To integrate the effect size of single-arm studies, meta-analysis was performed using death rate as a primary outcome. The effect of complete cytoreduction and optimal cytoreduction on survival was evaluated using meta-regression. The pooled death rate was presented with a 95% CI. The publication bias was evaluated with the funnel plot and Egger's test, and sensitivity analysis was performed. To overcome missing death rates, the linear regression model was performed on log-transformed median overall survival (OS) time using study size as a weight.

RESULTS

Thirty-six studies with 2,805 patients reporting death rates were used for this meta-analysis of the 80 eligible studies. There was strong heterogeneity, with the P value of the Cochrane Q test of < 0.0001 and Higgins's I² statistics of 86%; thus, we considered a random effect model. The pooled death rate was 44.2% (95% CI, 39.0 to 49.5), and both the complete and optimal cytoreductions were associated with better survival outcomes as significant moderators in the meta-regression model (P < .001 and P = .005, respectively). Although 14 studies were located outside the funnel plot, Egger's test indicated no publication bias (P = .327). A sensitivity analysis excluding 14 studies showed similar results. In the linear regression model on the basis of 57 studies, the median OS time increased by 8.97% and 7.04% when the complete and optimal cytoreduction proportion increased by 10%, respectively, after adjusting other variables.

CONCLUSION

Secondary cytoreductive surgery, resulting in maximal tumor resection, significantly prolongs OS in platinum-sensitive recurrent ovarian cancer.

Positive DESKTOP and Tian Scores Systems Are Adequate to Predict Optimal (R0) Secondary Debulking Surgery in Ovarian Cancer, But a Negative Score Does Not Preclude Secondary Surgery

OBJECTIVE

The aim of this study was to assess the safety and feasibility of macroscopically complete (R0) secondary debulking surgery (SDS) in a single-center cohort of patients with recurrent ovarian cancer. The performances of existing prediction models (DESKTOP score, Tian model) for R0 SDS were evaluated in this cohort.

METHODS

Patient, disease, and treatment characteristics of 102 patients undergoing SDS for recurrent ovarian cancer at the University Hospitals Leuven between 1997 and 2014 were collected.

RESULTS

R0 SDS was achieved in 73% of patients and associated with improved progression-free survival (P = 0.0002) and overall survival (P = 0.0003) compared with non-R0 resection. Variables associated with R0 SDS were site of relapse (P = 0.046) and absence of ascites (P = 0.045). The DESKTOP score and Tian model showed positive predictive values for R0 SDS of 80% and 73%, respectively. However, a false-negative rate for R0 resection of 61% and 70% was observed in our study. Progression-free survival and overall survival did not significantly differ between DESKTOP score-positive and -negative patients with R0 SDS.

CONCLUSIONS

We confirmed a high positive predictive value in the selection of candidates for R0 SDS with the DESKTOP score and the Tian model. However, because 61% and 70% of the patients with a negative score were debulked to R0, we suggest that other selection criteria based on anatomic and metabolic imaging such as whole-body diffusion-weighted magnetic resonance imaging should be evaluated when selecting patients for SDS.

The Prognostic Value of 18F-FDG PET/CT in Monitoring Chemotherapy in Ovarian Cancer Both at Initial Diagnosis and at Recurrent Disease

Published experiences related to the prognostic relevance of negative or positive FDG PET/CT in patients treated for ovarian cancer for progression-free survival and overall survival are typically heterogeneous retrospective analyses. Several points have been well defined, these are as follows: (a) there is a correlation between FDG tumor uptake and prognosis; (b) ovarian cancer patients treated by neoadjuvant or adjuvant chemotherapy can be divided into responders with reduction in tumor FDG uptake during and after treatment and nonresponders where tumor FDG uptake remains stable or increases after treatment;

When should Surgery be used for Recurrent Ovarian Carcinoma?

Cytoreductive surgery is an important column in the treatment of primary ovarian cancer. Surgical outcome is one of the most important prognostic factors and one of the few prognostic variables that can be influenced by therapists. Retrospective studies suggested that only complete cytoreduction was associated with a benefit. Therefore, definition of predictors of complete resection is of the utmost importance to avoid surgical burden in patients with both limited benefit of the procedure and limited overall life expectancy. Two prospective multicentre randomised surgical trials in platinum-sensitive recurrent ovarian cancer (DESKTOP III [NCT #01166737] and GOG 213 [NSC #704865]) comparing secondary cytoreductive surgery followed by platinum-based chemotherapy versus chemotherapy alone have been conducted. The results of the DESKTOP III were recently presented at the American Society of Clinical Oncology meeting in Chicago. It showed a benefit of secondary cytoreductive surgery exclusively in patients with complete resection with a progression-free survival of 5.6 months (P < 0.001). This overview aims to support this task and concentrates on the currently available data regarding surgery in recurrent ovarian cancer.

Cytoreductive Surgery Followed by Intraperitoneal Hyperthermic Perfusion in the Treatment of Recurrent Epithelial Ovarian Cancer: A Phase II Clinical Study

Aims and Background

The optimal salvage therapy for recurrent ovarian carcinoma has not been clearly established. Response to second-line chemotherapy is low, with a short median survival (8.8-15 months). We investigated the effect of an aggressive approach consisting of surgery followed by intraperitoneal drug delivery and local hyperthermia.

Patients and Methods

In a phase II clinical study, 27 patients with advanced/recurrent ovarian carcinoma were treated with cytoreductive surgery and intraperitoneal hyperthermic perfusion. Median patient age was 53 years (range, 30-67) and mean follow-up was 17.4 months (range, 0.3-36.0). Patients had been surgically staged and heavily pretreated with cisplatin-based, taxol-based or taxol/platinum-containing regimens. Nineteen (70%) patients were cytoreduced to minimal residual disease <2.5 mm. The intraperitoneal hyperthermic perfusion was performed with the closed abdomen technique, using a preheated polysaline perfusate containing cisplatin (25 mg/m2/L) + mitomycin C (3.3 mg/m2/L) through a heart-lung pump (mean flow of 700 mL/min) for 60 min in the hyperthermic phase (42.5 °C).

Results

Two-year overall survival was 55%. Median times to overall progression and local progression were 16 months and 21.8 months, respectively. Variables that affected the overall survival or time to progression were as follows: residual disease (P = 0.00025), patient age (P = 0.04), and lag time between diagnosis and cytoreductive surgery + intraperitoneal hyperthermic perfusion (P = 0.04). Treatment-related morbidity, mortality and acute toxicity (grade II-III) rates were 11%, 4% and 11%, respectively. Eight (89%) of 9 patients had ascites resolution.

Conclusion

Our results suggest that cytoreductive surgery + intraperitoneal hyperthermic perfusion is a well-tolerated, feasible and promising alternative in the management of selected patients with recurrent ovarian cancer, but further randomized controlled studies are needed in order to confirm our findings.

Preoperative predictors that impact the survival and outcome of patients undergoing secondary cytoreduction for ovarian cancer

This study aimed to examine the factors affecting feasibility of optimal and complete secondary cytoreductive surgery (SCRS) and to characterise the prognostic factors that correlate with improved survival in patients who underwent SCRS. This is a retrospective single-institutional cohort study of patients who underwent SCRS for recurrent epithelial ovarian cancer (EOC). One hundred and forty-eight patients met inclusion criteria. Platinum sensitivity was associated with complete cytoreduction at SCRS. Factors associated with suboptimal cytoreduction (SOC) were age >55 years, serous histology, largest tumour implant size >4 cm, and SOC at primary surgery. Overall survival analysis showed significantly longer survival with complete cytoreduction compared to optimal and SOC. Surgical outcome of SCRS was an independent predictor of survival regardless of the outcome of primary cytoreduction. Location of the largest implant, DFI and timing of chemotherapy also impact on survival.

Fludeoxyglucose F 18 PET/CT Assessment of Ovarian Cancer

Ovarian cancer is one of the most common gynecologic cancers and one of the leading causes of cancer death in women. It is often asymptomatic in early stages, and thus most patients are diagnosed when it is of advanced stage. For these reasons, the role of biomarkers and tomographic imaging is crucial. Fludeoxyglucose F 18 PET/CT is a useful imaging modality in different clinical settings of the disease, overcoming some limits of conventional imaging and influencing prognosis and therapeutic approaches. PET/MR imaging is an emerging modality, and its potential role remains to be explored.

Surgical management of recurrent ovarian cancer

Most patients with advanced-stage epithelial ovarian cancer will experience a relapse of disease despite a complete response after surgical cytoreduction and platinum-based chemotherapy. Treatment of recurrent ovarian cancer mainly comprises various combinations of systemic chemotherapy with or without targeted agents. The role of cytoreductive surgery for recurrent ovarian cancer is not well established. Although the literature on survival benefit of cytoreductive surgery for recurrent disease has expanded steadily over the past decade, most studies were retrospective, single-institution series with small numbers of patients. Given the balance between survival benefit and surgery-related morbidity during maximum cytoreductive surgical effort, it is essential to establish the optimal selection criteria for identifying appropriate candidates who will benefit from surgery without worsening quality of life. Three phase III randomized trials for this issue are currently underway. Herein, we present contemporary evidence supporting the positive role of cytoreductive surgery and offer selection criteria for optimal candidates for surgery in the treatment of recurrent ovarian cancer.

Percutaneous cryoablation of ovarian cancer metastasis to the liver: initial experience in 13 patients

OBJECTIVE

To evaluate the feasibility, safety, and effectiveness of percutaneous cryoablation for the treatment of liver metastases from ovarian cancer.

METHODS/MATERIALS

A retrospective review was performed on 13 patients with liver metastases from ovarian cancer who underwent percutaneous cryoablation with computed tomography (CT) guidance. The tumor response was assessed by enhanced computed tomography performed before treatment, 1 month after, and every 3 months after treatment. The Functional Assessment of Cancer Therapy-General quality of life (QOL) was used to assess the patients' QOL before, 1 week, 1 month, and 3 months after cryoablation.

RESULTS

A total of 27 procedures of cryoablation were performed on these patients, and 5 patients underwent repeat procedures. Complete ablation was achieved for all lesions. Months are counted from the time of cryoablation, and the median duration of follow-up was 15 months (4-22 months). At the 1-month follow-up, the primary technique effectiveness was 100%. At the 3-month follow-up, local tumor progression was observed in 2 (7.14%) of 28 lesions. The 1-year survival from the time of cryoablation was 92.3%. Two patients died after 9 and 14 months, respectively. The QOL symptoms and functioning scales were preserved in patients alive at 3 months after cryoablation. No major complications such as cryoshock, hepatic bleeding, liver abscess, biliary fistula, and renal insufficiency were encountered.

CONCLUSIONS

Our initial experience showed that cryoablation is a safe and effective ablative therapy, providing a high rate of local tumor control in ovarian cancer liver metastases.

Survival Impact of Secondary Cytoreductive Surgery for Recurrent Ovarian Cancer in an Asian Population

OBJECTIVE

The aim of this study was to evaluate the role of secondary cytoreductive surgery in Asian patients with recurrent ovarian cancer and to assess prognostic variables on overall post-recurrence survival time.

METHODS

We conducted a retrospective review of patients with recurrent ovarian cancer who underwent secondary cytoreduction at the Gynaecological Cancer Center at the KK Women's and Children's Hospital, Singapore, between 1999 and 2009. Eligible patients included those who had been firstly treated by primary cytoreductive surgery and followed by adjuvant chemotherapy and had a period of clinical remission of at least six months and subsequently underwent secondary cytoreductive surgery for recurrence. Univariate analysis was performed to evaluate various variables influencing the overall survival.

RESULTS

Twenty-five patients met our eligibility criteria. The median age was 52 years (range=31-78 years). The median time from completion of primary treatment to recurrence was 25.1 months (range=6.4-83.4). Secondary cytoreduction was optimal in 20 of 25 patients (80%). The median follow-up duration was 38.9 months (range=17.8-72.4) and median overall survival time was 33.1 months (95% confidence interval, 15.3-undefined.). Ten (40.0%) patients required bowel resection, but no end colostomy was performed. One (4.0%) patient had wedge resection of the liver, one (4.0%) had a distal pancreatectomy, one (4.0%) had a unilateral nephrectomy, and one (4.0%) had adrenalectomy. There were no operative deaths. The overall survival of patients who responded to secondary cytoreductive surgery and adjuvant chemotherapy was significantly longer than those patients who did not respond to the treatment. Of those patients who responded to the surgical management, patients with clear cell carcinoma fared well compared to those with the endometrioid, mucinous adenocarcinoma, and papillary serous type (p<0.001). Complete secondary cytoreductive surgery appeared to have some relationship to overall survival but was not statistically significant.

CONCLUSION

In carefully selected patients with recurrent ovarian cancer, optimal cytoreductive surgery is possible and in a subgroup of patients who respond to surgery and chemotherapy survival is significantly longer.

Surgery for relapsed ovarian cancer: when should it be offered?

Whilst cytoreductive surgery is the mainstay treatment for primary ovarian cancer, its role in relapse is still unclear. Surgery in platinum-sensitive recurrent ovarian cancer might be beneficial if it results in complete resection of the disease. Clinical scores could help to identify suitable patients. Level I evidence is still missing; however, two randomized trials (DESKTOP III and GOG 213) are ongoing.

The role of secondary surgery in recurrent ovarian cancer

Despite optimal treatment (complete cytoreduction and adjuvant chemotherapy), 5-year survival for advanced ovarian cancer is approximately 30% and most patients succumb to their disease. Cytoreductive surgery is accepted as a major treatment of primary ovarian cancer but its role in recurrent disease is controversial and remains a field of discussion mainly owing to missing data from prospective randomized trials. A critical review of literature evidence on secondary surgery in recurrent ovarian cancer will be described.

The role of secondary cytoreductive surgery in patients with recurrent epithelial ovarian, tubal, and peritoneal cancers: a comparative effectiveness analysis

Background. All published reports concerning secondary cytoreductive surgery for relapsed ovarian cancer have essentially been observational studies. However, the validity of observational studies is usually threatened from confounding by indication. We sought to address this issue by using comparative effectiveness methods to adjust for confounding. Methods. Using a prospectively collected administrative health care database in a single institution, we identified 1,124 patients diagnosed with recurrent epithelial, tubal, and peritoneal cancers between 1990 and 2009. Effectiveness of secondary cytoreductive surgery using the conventional Cox proportional hazard model, propensity score, and instrumental variable were compared. Sensitivity analyses for residual confounding were explored using an array approach. Results. Secondary cytoreductive surgery prolonged overall survival with a hazard ratio (95% confidence interval) of 0.76 (range 0.66-0.87), using the Cox proportional hazard model. Propensity score methods produced comparable results: 0.75 (range 0.64-0.86) by nearest matching, 0.73 (0.65-0.82) by quintile stratification, 0.71 (0.65-0.77) by weighting, and 0.72 (0.63-0.83) by covariate adjustment. The instrumental variable method also produced a comparable estimate: 0.75 (range 0.65-0.86). Sensitivity analyses revealed that the true treatment effects may approach the null hypothesis if the association between unmeasured confounders and disease outcome is high. Conclusions. This comparative effectiveness study provides supportive evidence for previous reports that secondary cytoreductive surgery may increase overall survival for patients with recurrent epithelial, tubal, and peritoneal cancers.

Predictors of survival in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery based on the pooled analysis of an international collaborative cohort

BACKGROUND

This study aims to identify prognostic factors and to develop a risk model predicting survival in patients undergoing secondary cytoreductive surgery (SCR) for recurrent epithelial ovarian cancer.

METHODS

Individual data of 1100 patients with recurrent ovarian cancer of a progression-free interval at least 6 months who underwent SCR were pooled analysed. A simplified scoring system for each independent prognostic factor was developed according to its coefficient. Internal validation was performed to assess the discrimination of the model.

RESULTS

Complete SCR was strongly associated with the improvement of survival, with a median survival of 57.7 months, when compared with 27.0 months in those with residual disease of 0.1-1 cm and 15.6 months in those with residual disease of >1 cm, respectively (P<0.0001). Progression-free interval (≤23.1 months vs >23.1 months, hazard ratio (HR): 1.72; score: 2), ascites at recurrence (present vs absent, HR: 1.27; score: 1), extent of recurrence (multiple vs localised disease, HR: 1.38; score: 1) as well as residual disease after SCR (R1 vs R0, HR: 1.90, score: 2; R2 vs R0, HR: 3.0, score: 4) entered into the risk model.

CONCLUSION

This prognostic model may provide evidence to predict survival benefit from secondary cytoreduction in patients with recurrent ovarian cancer.

Potential survival benefit of secondary cytoreductive surgery for recurrent epithelial ovarian, tubal, and peritoneal cancers

OBJECTIVE

Although treatment for recurrent epithelial ovarian, tubal, and peritoneal cancers is usually not curative and intends to be palliative, a certain significance of secondary cytoreductive surgery (SCS) for recurrent tumor has been reported; still, there are limitations in this strategy including difficulty in predicting successful complete resection and selecting good candidates. The purpose of this study was to explore the potential survival benefit of SCS in patients with recurrent epithelial ovarian, tubal, and peritoneal cancers.

METHODS

Among all patients who underwent primary therapy for epithelial ovarian, tubal, and peritoneal cancers between 1994 and 2006 at our institute, medical records of patients who were submitted to SCS for recurrence following complete remission after primary therapy were retrospectively investigated. Kaplan-Meier method and log-rank test were used for survival analysis, and Cox proportional hazard regression model was used for quantifying the relations between survival and covariates.

RESULTS

Thirty-four patients met the inclusion criteria. Complete resection of all visible tumors at SCS was achieved in 24 of patients (75%). Median postrecurrence survival was 60 months. On univariate analysis, solitary recurrence, disease-free interval, CA125 value at recurrence, and complete resection were significant prognostic factors on postrecurrence survival; whereas on multivariate analysis, CA125 value at recurrence and complete resection were independent prognostic factors. In addition, a comparison according to the initial method that detected recurrence revealed that patients whose recurrence was detected with CA125 elevations had significantly worse postrecurrence survival than those detected with routine examinations including image scans (P = 0.021).

CONCLUSIONS

In the present study, the impact of SCS on the significant survival benefit was identified for patients with low CA125 value at recurrence as well as with complete resection. Although further analyses are needed, patients whose recurrence was diagnosed by routine examinations without CA125 elevation might be better candidates for SCS.

New emerging drugs targeting the genomic integrity and replication machinery in ovarian cancer

INTRODUCTION

Ovarian cancer is a difficult to treat cancer entity with a high relapse rate. After initial surgery and chemotherapy, only a few options for therapeutic treatment remain in case of cancer recurrence. New treatment options with improved efficacies to circumvent acquired or pre-existing drug resistance are needed.

MATERIALS

This survey focuses on new prospective drugs for ovarian cancer treatment that either cause direct damage to the nuclear DNA or inhibit chromosome segregation by acting as mitotic spindle inhibitors.

RESULTS

Among a plethora of currently tested and proposed new drugs for ovarian cancer treatment, only a few appear to meet the criteria of sufficient and reliable efficacy with tolerable toxicity. These include the naturally occurring DNA-alkylating alkaloid trabectedin, the nitrogen mustard prodrug canfosfamide, and the synthetic kinase inhibitor ON-01910. The latter inhibits mitotic spindle formation without a direct tubulin interaction, avoiding adverse neurotoxic reactions common to the taxanes. Further, epothilones and oxaliplatin, already approved drugs for other cancer entities, show promising activity against ovarian cancer; they are even of interest as a first-line treatment option.

DISCUSSION

Although the current focus and interest of modern cancer drug design tends to be more specific and targeted therapies, including therapeutic antibodies and specific small molecules to inhibit growth-, apoptosis-, and angiogenesis-regulating signalling cascades, the main target for ovarian cancer treatment appears to remain its basic, though uncontrolled working proliferation machinery. This includes the current gold standard for ovarian cancer chemotherapy, carboplatin, and taxanes, as well as the few remaining alternatives, such as topotecan, doxorubicin, and gemcitabine, which all rely on their ability to bind to or to modify the DNA or the chromosome-separating spindle apparatus. Thus, the genomic integrity and replication machinery of ovarian cancer cells prove to represent an established, and obviously still effective target to be tackled for ovarian cancer treatment.

Robotic-assisted resection of liver and diaphragm recurrent ovarian carcinoma: description of technique

GOALS

To describe port placement and operative technique for resection of right hepatic and full-thickness diaphragm metastatic ovarian carcinoma in a patient with recurrent disease using the da Vinci® Surgical System.

CASE

A 60-year-old female with recurrent platinum sensitive ovarian cancer presented with disease confined to the liver by PET-CT scan. The lesion measured 3.4 cm on the dome of the right hepatic lobe. After two attempts at intra-hepatic arterial chemo-embolization the lesion remained stable. She subsequently agreed to robotic-assisted resection of the right lobe liver mass after refusing laparotomy for 9 months.

PROCEDURE

Pnuemoperitoneum was established in the left upper quadrant by directly inserting a 5-mm laparoscope. There were no midline adhesions. The 12-mm camera port was placed in the midclavicular line on the right 10 cm off the costal margin with the right and left operative arms 10 cm from the camera near the costal margin, and the third arm in the right flank. The robot was docked from the right shoulder. Resection was accomplished with a monopolar spatula in the right, fenestrated bipolar grasper in the left, and double fenestrated grasper in the third operative arm. Adhesions between diaphragm and liver were separated, the liver lesion was excised, the diaphragm lesion was resected full thickness, and diaphragm was closed with running prolene. Surgicel® was placed on the liver for hemostasis. Console time was 82 min and the patient discharged on day-5 after drainage of a cytology negative pleural effusion day-4.

CONCLUSIONS

Robotic resection of liver and full-thickness diaphragm lesions is possible. The port placement used in this patient was efficient and without operative arm collisions. Patients with isolated upper-abdominal recurrence are candidates for robotic secondary cytoreduction.

Maximal cytoreductive effort in epithelial ovarian cancer surgery

The surgical management of advanced epithelial ovarian cancer involves cytoreduction, or removal of grossly-evident tumor. Residual disease after surgical cytoreduction of ovarian cancer has been shown to be strongly associated with survival. The goal of surgery is "optimal" surgical cytoreduction, which is generally defined as residual disease of 1 cm or less. However, the designation of "optimal" surgical cytoreduction has evolved to include maximal surgical effort and no gross residual disease. In order to achieve this, more aggressive surgical procedures such as rectosigmoidectomy, diaphragm peritonectomy, partial liver resection, and video-assisted thoracic surgery are reported and increasingly utilized in the surgical management of advanced ovarian cancer. The role of maximal surgical effort also extends to the recurrent setting where the goal of surgery should be complete cytoreduction. Patient selection is important in identifying appropriate candidates for surgical cytoreduction in the recurrent setting. The purpose of this article is to review the role of maximum surgical effort in primary and recurrent ovarian cancer.

Secondary cytoreductive surgery in the management of platinum-sensitive recurrent epithelial ovarian cancer

BACKGROUND AND OBJECTIVES

To assess the surgical and survival outcomes after secondary cytoreductive surgery (SCRS) in patients with platinum-sensitive recurrent epithelial ovarian cancer (EOC) and to identify patients who would most benefit from SCRS.

METHODS

Inclusion criteria consisted of (1) recurrent EOC; (2) disease-free interval (DFI) >or=6 months after primary therapy; and (3) SCRS with therapeutic intent followed by adjuvant chemotherapy.

RESULTS

Sixty-seven patients met the inclusion criteria in the interval 1992-2008. Median DFI was 20 months (range: 6-109 months). Median time in surgery was 240 min (range: 60-680 min), and median estimated blood loss was 100 ml (range: 50-3,000 ml). There was no significant perioperative complication requiring reoperation. Complete resection of all visible tumor tissue was achieved in 37 patients (55.2%), with residual tumors (RT) <or=1 cm remaining in four patients (6%). After a mean follow-up of 41 months (range: 6-145 months), the 2- and 5-year disease-free survival (DFS) rates were 32% and 10%, respectively, and the 2- and 5-year overall survival (OS) rates were 58% and 26%, respectively. In multivariable analysis, DFI >24 months and RT <or=1 cm were significant predictors of DFS and OS.

CONCLUSIONS

SCRS is safe and effective, with a low rate of complications. Patients who benefited most from this surgery were those with a DFI >24 months and patients who achieved optimal cytoreduction.

Tertiary cytoreduction in patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer: an updated series

OBJECTIVE

Surgical cytoreduction is an integral therapeutic modality for patients with epithelial ovarian (EOC), fallopian tube (FTC), or primary peritoneal (PPC) cancer in the primary setting. The role of surgical cytoreduction in the recurrent setting is not clearly defined and remains controversial. The objective of this study was to assess this potential survival benefit in a large cohort of patients with a long follow-up period.

METHODS

We performed a retrospective chart review of all patients with recurrent EOC, FTC, or PPC who underwent tertiary cytoreduction at our institution from 2/98 to 2/08. Disease-specific survival (DSS) was calculated from the time of tertiary cytoreduction to death or last follow-up. Univariate and multivariate analyses were used to analyze outcomes and to identify potential prognostic factors.

RESULTS

A total of 77 patients were identified, of which 38 (49%) have died of disease. The median time from secondary to tertiary cytoreduction was 25.7 months (range, 4.1-99.4 months). The median follow-up after tertiary cytoreduction was 28.9 months (range, 0.7-123.7 months), with a median DSS for the entire cohort of 47.7 months (95% CI, 25.5-69.9 months). On univariate analysis, residual disease after tertiary cytoreduction and TFI were found to be significant prognostic factors. On multivariate analysis, only residual disease after tertiary cytoreduction retained prognostic significance (P<0.001).

CONCLUSION

Tertiary surgical cytoreduction may offer a survival benefit in a highly select group of patients with recurrent EOC, FTC, or PPC. This benefit appears to be greatest in patients in whom a complete gross resection can be achieved.

Surveillance of patients after initial treatment of ovarian cancer

The surveillance of ovarian cancer patients after initial treatment is a challenging question in clinical practice. Serum CA 125 assay, physical examination, and imaging examinations have been employed with different time schedules for the follow-up of asymptomatic patients. Rising serum CA 125 levels may precede the clinical detection of relapse in 56-94% of cases with a median lead time of 3-5 months. An ongoing randomised phase III European trial is comparing the benefits of early administration of chemotherapy based on serum CA 125 assay alone versus delaying treatment until clinical or radiological detection of recurrent disease. Physical examination, with or without ultrasound, is very useful for the surveillance of these patients, since approximately 25-50% of relapses involve the pelvis. Additional radiological imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI), are usually performed in asymptomatic patients with rising CA 125 levels as well as in patients with suspicious symptoms or signs. Integrated positron emission tomography (PET) and CT scanners (PET/CT) can identify recurrent disease in tissues that appear normal at CT imaging as well as metastatic lesions intimately associated with the bowel wall that are difficult to detect with CT or MRI, so that in most series PET/CT has a higher diagnostic reliability than that of conventional imaging techniques. Moreover, PET/CT can disclose unusual supra-diaphragmatic spreading of the disease and may be very helpful for treatment planning, especially for the selection of patients suitable for secondary surgical cytoreduction. A prospective, randomised trial of therapeutic interventions based on stratification by PET/CT disease status could elucidate the real impact of this diagnostic procedure in the management of patients with recurrent ovarian cancer.

Prognostic factors of secondary cytoreductive surgery for patients with recurrent epithelial ovarian cancer

OBJECTIVE

The objective of this study was to identify the prognostic factors of secondary cytoreductive surgery on survival in patients with recurrent epithelial ovarian cancer.

METHODS

The medical records of all patients who underwent secondary cytoreductive surgery between May 2001 and October 2007 at the National Cancer Center, Korea were reviewed. Univariate and multivariate analyses were executed to evaluate the potential variables for overall survival.

RESULTS

In total, 54 patients met the inclusion criteria. Optimal cytoreduction to <0.5 cm residual disease was achieved in 87% of patients who had received secondary cytoreductive surgery. Univariate analysis revealed that site of recurrence (median survival, 53 months for the largest tumors in the pelvis vs. 24 months for the largest tumors except for the pelvis; p=0.007), progression free survival (PFS) (median survival, 43 months for PFS>/=12 months vs. 24 months for PFS<12 months; p=0.036), and number of recurrence sites (median survival, 49 months for single recurred tumor vs 29 months for multiple recurred tumors; p=0.036) were significantly associated with overall survival. On multivariate analysis, prognostic factors that correlated with improved survival were site of recurrence (p=0.013), and PFS (p=0.043).

CONCLUSION

In the author's analysis, a significant survival benefit was identified for the recurred largest tumors within the pelvis and PFS>/=12 months. Secondary cytoreductive surgery should be offered in selected patients and large prospective studies are needed to define the selection criteria for secondary cytoreductive surgery.

Extreme drug resistance assay results do not influence survival in women with epithelial ovarian cancer

OBJECTIVES

Extreme drug resistance (EDR) assays have been used to identify chemotherapy regimens that are least likely to be of clinical benefit in the treatment of epithelial ovarian cancer (EOC). We sought to examine the impact of EDR assay-guided therapy on the outcome of patients with EOC in the primary and recurrent settings.

METHODS

We conducted a retrospective review of demographic, pathologic, EDR assay and clinical outcome data from 377 patients with EOC who had an assay sent at the time of their primary or subsequent cytoreductive surgeries. Multivariate analyses were performed using Cox proportional hazards method to identify and estimate the impact of independent prognostic factors on time to progression (TTP), overall survival (OS) and survival after recurrence (RS).

RESULTS

Increasing age was associated with a worse OS and RS (HR=1.34; 95% CI, 1.14-1.58 and HR=1.14; 95% CI, 1.00-1.31, respectively for each decade increase in age). Surgical outcome in the setting of primary or secondary cytoreduction remained an important predictor of survival. Compared with patients with microscopic residual disease, patients who were left with 0.1 to 1.0 cm and >1.0 cm residual disease had an increased risk of recurrence (HR=1.94; 95% CI, 1.33 to 2.84 and HR=3.61; 95% CI; 2.07 to 6.39, respectively) and death (HR=1.59; 95% CI, 1.03 to 2.45; and HR=2.14; 95% CI, 1.09 to 4.20, respectively). For patients who recurred, those who did not undergo secondary cytoreductive surgery and patients who were left with >1.0 cm residual had an increased risk of death compared to patients with microscopic residual (HR=2.13; 95% CI, 1.28 to 3.54; and HR=2.84; 95% CI, 1.71 to 4.71, respectively). EDR assay results analyzed for single agents or combinations of chemotherapies failed to independently predict patient outcomes no matter if the assay was performed at the time of the primary surgery or recurrence.

CONCLUSION

EDR assay results do not independently predict or alter the outcomes of patients with EOC who are treated with the current standards of primary cytoreductive surgery followed by platinum and taxane combination chemotherapy.

Surgical management of recurrent ovarian cancer

Surgery is the cornerstone of treatment for patients with advanced ovarian cancer. The majority of patients with advanced ovarian cancer who experience a clinical remission after initial surgery will develop a recurrence. The optimal management for patients with recurrent ovarian cancer remains to be defined. Chemotherapy is frequently used with varying response rates. Repeat surgical cytoreduction appears to offer a survival benefit for select patients with recurrent ovarian cancer and should be considered. Surgery also plays a role in the palliation of certain patients. Continued investigations, especially randomized trials, are needed to further define the optimal treatment modalities for these patients.

The role of secondary cytoreductive surgery for recurrent mucinous epithelial ovarian cancer (mEOC)

BACKGROUND

Mucinous epithelial ovarian cancer (mEOC) may exhibit a distinct biological behavior in epithelial ovarian cancer (EOC). The role of secondary cytoreductive surgery was evaluated in patients with recurrent mEOC, and the prognosis was assessed.

METHODS

Twenty-one patients with stages IIc to IV mEOC who experienced disease recurrence and received secondary cytoreductive surgery at Fudan University Cancer Hospital between Jan. 1997 and Dec. 2005 were retrospectively reviewed. Survival curves were generated using the Kaplan-Meier method and the significant comparison of survival rate was estimated by the log-rank test.

RESULTS

The median progression-free interval (PFI) was 14 months (range, 5-46 months) after the first cytoreduction. Seven patients (33%) who received secondary cytoreductive surgery were optimally cytoreduced with residual disease less than or equal 1cm, and the other 14 patients (67%) underwent suboptimal surgical cytoreduction. The overall median survival time was 27 months (range, 8-64 months). The median survival time after recurrence was 10 months (range, 3-32 months). There was no significant statistical difference in median survival between patients with optimal and suboptimal secondary surgical cytoreduction, with an estimated survival of 10 months and 9.8 months, respectively (P>0.05).

CONCLUSION

Optimal primary cytoreductive surgery for advanced mEOC was very important. Once it recurs, the prognosis is very poor. Patients with recurrent mEOC should be carefully assessed before performing secondary cytoreductive surgery, as this may have limited impact on the overall survival rates.

The impact of PET-CT in suspected recurrent ovarian cancer: A prospective multi-centre study as part of the Australian PET Data Collection Project

OBJECTIVE

To assess the impact of FDG PET-CT on the management of patients with suspected recurrent ovarian cancer and to determine the incremental information provided by PET-CT.

METHODS

This was a prospective, multi-centre, cohort study. Ninety women (mean age 59.9 years; age range 35-85 years) with a previous history of treated epithelial ovarian carcinoma and suspected recurrence based on elevated CA-125, anatomical imaging or clinical symptoms were studied with FDG PET-CT across two States. Referring doctors were asked to specify a management plan pre-PET, if management was altered after PET-CT and, the impact (rated - none, low, medium, high) of PET-CT on patient management. The pre-PET management plan could include radiotherapy, chemotherapy, surgery, and 'other' including observation. Patients were followed at 6 and 12 months and clinical status, evidence of recurrence and progression were recorded.

RESULTS

Patients were referred by 34 individual specialists. At least 168 additional sites of disease in 61 patients (68%), not identified by conventional imaging were identified by PET-CT. In 77% the additional lesions were located below the diaphragm and most were nodal or peritoneal. PET-CT affected management in 60% (49% high, 11% medium impact). Patients where more disease was detected with PET-CT were more likely to progress in the following 12 months.

CONCLUSIONS

For women with previously treated ovarian carcinoma with recurrent disease, PET-CT can: a) alter management in close to 60% of patients, b) detect more sites of disease than abdominal and pelvic CT, c) is superior in the detection of nodal, peritoneal and subcapsular liver disease and d) offers the opportunity for technology replacement in this setting.

Cytoreductive surgery for recurrent ovarian cancer: a meta-analysis

OBJECTIVE

To determine the relative effect of multiple prognostic variables on overall post-recurrence survival time among cohorts of patients with recurrent ovarian cancer undergoing cytoreductive surgery.

METHODS

Forty cohorts of patients with recurrent ovarian cancer (2019 patients) meeting study inclusion criteria were identified from the MEDLINE database (1983-2007). Simple and multiple linear regression analyses, with weighted correlation calculations, were used to assess the effect on median post-recurrence survival time of the following variables: year of publication, age, disease-free interval, localized disease, tumor grade and histology, the proportion of patients undergoing complete cytoreductive surgery, requirement for bowel resection, and the sequence of cytoreductive surgery and salvage chemotherapy.

RESULTS

The mean weighted median disease-free interval prior to cytoreductive surgery was 20.2 months, and the mean weighted median overall post-recurrence survival time was 30.3 months. The weighted mean proportion of patients in each cohort undergoing complete cytoreductive surgery was 52.2%. Median survival improved with increasing year of publication (p=0.009); however, the only statistically significant clinical variable independently associated with post-recurrence survival time was the proportion of patients undergoing complete cytoreductive surgery (p=0.019). After controlling for all other factors, each 10% increase in the proportion of patients undergoing complete cytoreductive surgery was associated with a 3.0 month increase in median cohort survival time.

CONCLUSIONS

Among patients undergoing operative intervention for recurrent ovarian cancer, the proportion of patients undergoing complete cytoreductive surgery is independently associated with overall post-recurrence survival time. For this select group of patients, the surgical objective should be resection of all macroscopic disease.

Recurrent epithelial ovarian cancer: pharmacotherapy and novel therapeutics

Epithelial ovarian cancer will strike between 1 - 2% of women in developed countries and, unfortunately, it largely remains a lethal disease due to late-stage at diagnosis and the eventual development of chemotherapy resistance. Ovarian cancer is initially treated with surgical resection and chemotherapy (primarily platinum/taxane combinations) and remission can be attained for the majority of patients. Despite this, most women will recur and require multiple further therapies. The purpose of this paper is to review the existing treatment options, including surgery, traditional chemotherapy as well as upcoming novel and targeted therapies that may one day improve outcomes in this disease.

Bulky lymph node resection in patients with recurrent epithelial ovarian cancer: impact of surgery

The aim of this study was to evaluate the role of systematic lymphadenectomy, feasibility, complications rate, and outcome in epithelial ovarian cancer (EOC) patients with recurrent bulky lymph node disease. A prospective observational study of EOC patients with pelvic/aortic lymph node relapse was conducted between January 1995 and June 2005. After a clinical and laparoscopic staging, secondary cytoreduction, including systematic lymphadenectomy, were performed. The eligibility criteria were as follows: disease-free interval ≥6 months, radiographic finding suggestive of bulky lymph node recurrence, and patients' consent to be treated with chemotherapy. Forty-eight EOC patients with lymph node relapse were recruited. Twenty-nine patients were amenable to cytoreductive surgery. Postoperatively, all patients received adjuvant treatment. The median numbers of resected aortic and pelvic nodes were 15 (2–32) and 17 (8–47), respectively. The median numbers of resected aortic and pelvic positive lymph nodes were 4 (1–18) and 3 (1–17), respectively. The mean size of bulky nodes was 3.3 cm. Four patients (14%) experienced one severe complication. No treatment-related deaths were observed. After a median follow-up of 26 months, among cytoreduced patients, 18 women were alive with no evidence of disease, nine were alive with disease. Among the 11 patients not amenable to surgery, five women were alive with persistent disease, six patients died of disease, at a median follow-up of 18 months. Estimated 5-year overall survival and disease-free interval for operated women were 87% and 31%, respectively. In conclusion, patients with bulky lymph node relapse can benefit from systematic lymphadenectomy in terms of survival. The procedure is feasible with an acceptable morbidity rate

Cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma

OBJECTIVE

This study aims to identify favorable preoperative characteristics and examine the impact of secondary cytoreductive surgery on survival for patients with recurrent epithelial ovarian carcinoma.

METHODS

Patients who underwent cytoreductive surgery for recurrent epithelial ovarian cancer were identified in our surgical database for the period 1988-2004. Patient charts were reviewed and data collected regarding patient demographics, surgical management, preoperative evaluation, perioperative complications, and oncologic outcome.

RESULTS

Eighty-five patients met eligibility criteria. Preoperative factors that correlated with improved survival were disease-free interval of greater than 12 months (p<0.01) and residual disease after primary surgery of <2 cm (p<0.02). Other preoperative factors evaluated but not found significant included radiographic findings, physical findings, previous histology, stage, grade, previous chemotherapy, prior recurrence, and serum CA-125 level. Optimal resection to <1 cm residual disease was achieved in 86% of patients who had secondary cytoreduction. Small bowel and colon resection for cytoreduction occurred in 7% and 51% of patients, respectively. Operative complications occurred in 14% and postoperative complications occurred in 21% of patients. The median survival of patients who were optimally cytoreduced to <1 cm was 30 months compared to 17 months for patients with residual disease>or=1 cm (p<0.05). Operative factors that were evaluated and did not significantly effect survival were location of recurrence, presence of ascites, and extent of recurrence. Recurrent or progressive disease occurred in 75% of patients during follow-up.

CONCLUSION

When selecting patients for secondary cytoreduction, the most significant preoperative factors are disease-free interval and success of a prior cytoreductive effort. Once secondary cytoreductive surgery is attempted, the most important factor for improved survival is optimal cytoreduction. Of equal importance is counseling regarding the significant risk for bowel surgery, colostomy, and complications.

Role of surgery in ovarian carcinoma

Surgery plays a critical role in the optimal management of all stages of ovarian carcinoma. In apparent early-stage ovarian cancer, a comprehensive surgical evaluation allows stratification of patients into low- and high-risk categories. Low-risk patients may be candidates for fertility-sparing surgery and can safely avoid chemotherapy and be observed. Treatment of patients with high-risk early- or advanced-stage ovarian cancer usually requires a combined modality approach. Although it is well known that epithelial ovarian cancer is moderately chemosensitive, what distinguishes it most from other metastatic solid tumors is that surgical cytoreduction of tumor volume is highly correlated with prolongation of patient survival. Procedures such as radical pelvic surgery, bowel resection, and aggressive upper abdominal surgery are commonly required to achieve optimal cytoreduction. Women who develop recurrent disease may be eligible for a secondary cytoreductive surgery or may require a surgical intervention to palliate disease-related symptoms. For women at high risk of ovarian cancer, prophylactic bilateral salpingo-oophorectomy significantly reduces the incidence of this disease. The purpose of this article is to provide a comprehensive review of the surgical management of ovarian carcinoma. The roles of primary, interval, and secondary cytoreductive surgeries; second-look procedures; and palliative surgery are reviewed. The indications for fertility-sparing and minimally invasive surgery as well as the current guidelines for prophylactic surgery in high-risk mutation carriers are also discussed.

Current management strategies for ovarian cancer

Epithelial ovarian cancer originates in the layer of cells that covers the surface of the ovaries. The disease spreads readily throughout the peritoneal cavity and to the lymphatics, often before causing symptoms. Of the cancers unique to women, ovarian cancer has the highest mortality rate. Most women are diagnosed as having advanced stage disease, and efforts to develop new screening approaches for ovarian cancer are a high priority. Optimal treatment of ovarian cancer begins with optimal cytoreductive surgery followed by combination chemotherapy. Ovarian cancer, even in advanced stages, is sensitive to a variety of chemotherapeutics. Although improved chemotherapy has increased 5-year survival rates, overall survival gains have been limited because of our inability to eradicate all disease. Technologic advances that allow us to examine the molecular machinery that drives ovarian cancer cells have helped to identify numerous therapeutic targets within these cells. In this review, we provide an overview of ovarian cancer with particular emphasis on recent advances in operative management and systemic therapies.

Cytoreductive surgery for recurrent ovarian cancer

PURPOSE OF REVIEW

The issue facing clinicians managing ovarian cancer has evolved over the past three decades from treatment for cure and subsequently palliation, to prolongation of survival for most patients. The purpose of this paper is to review the data, rationale, and issues surrounding cytoreductive surgery in recurrent ovarian cancer and its potential role in this new paradigm shift.

RECENT FINDINGS

Abundant retrospective series report prolongation of survival with secondary cytoreductive surgery in recurrent ovarian cancer. Selection bias, publication bias, and subsequent therapies, however, are confounding factors for survival. As management of ovarian cancer has recently evolved to a treatment of a 'chronic disease', surgery (which has a definite role in primary therapy) should be considered.

SUMMARY

No prospective randomized studies have been performed to date, and therefore adoption of this method of management has been limited. The absence of good data leaves clinicians without clear direction on how to best manage patients. Patients with favorable characteristics such as a long disease-free interval, good performance status, a single or few small intra-abdominal recurrences may benefit from secondary cytoreduction. A prospective randomized study is needed.

Secondary cytoreductive surgery for localized, recurrent epithelial ovarian cancer: analysis of prognostic factors and survival outcome

BACKGROUND

The objective of this study was to evaluate the role of secondary cytoreductive surgery in the outcome of patients who had recurrent epithelial ovarian carcinoma that was limited to <or=5 recurrence sites within the abdomen or pelvis on preoperative imaging studies and attempt to define selection criteria associated with improved survival, with specific attention to the number of lesions suspicious for recurrent disease.

METHODS

: Patients who underwent secondary surgical cytoreduction for recurrent epithelial ovarian cancer between September 1997 and March 2005 were identified retrospectively from tumor registry databases. Study inclusion criteria required a complete clinical response to primary therapy, >or=12 months between initial diagnosis and recurrence, and <or=5 recurrence sites on preoperative imaging studies. Univariate and multivariate logistic regression analyses were used to evaluate the effect of clinicopathologic variables on overall postrecurrence survival.

RESULTS

Fifty-five patients met the study inclusion criteria. The median patient age at recurrence was 57.7 years, and the median diagnosis-to-recurrence interval was 32 months (range, 12-164 months). Complete cytoreduction was achieved in 41 patients (74.5%). On multivariate analysis, the statistically significant and independent predictors of overall survival were a diagnosis-to-recurrence interval >or=18 months (median survival, 49 months vs 3 months; P < .01), the number of radiographic recurrence sites (median survival, 50 months for patients with 1 or 2 sites vs 12 months for patients with 3 to 5 sites; P < .03), and residual disease (median survival, 50 months for patients with no macroscopic residual disease vs 7.2 months for patients with macroscopic residual disease; P < .01). Age, tumor grade, histology, CA-125 level, ascites, and tumor size were not associated significantly with survival.

CONCLUSIONS

: The current data supported the definition of localized recurrent ovarian cancer as patients with 1 or 2 radiographic recurrence sites. In this select population, a diagnosis-to-recurrence interval >or=18 months and complete secondary surgical cytoreduction, which was achievable in the majority of patients, were associated with a median postrecurrence survival of approximately 50 months.

Renal artery thrombosis following secondary cytoreduction in a patient with ovarian cancer

BACKGROUND

In order to successfully perform aggressive cytoreductive surgery for patients with recurrent epithelial ovarian cancer, resection of retroperitoneal disease in close proximity to major vessels is often required.

CASE

We describe a case of a 44-year-old female patient with a history of Stage IV carcinoma of the ovary, who underwent a successful secondary debulking procedure. To remove the left para-aortic tumor implant she required complete mobilization of the left kidney, with skeletonization of the left renal artery and vein. Postoperatively, the patient developed left renal artery thrombosis necessitating a unilateral nephrectomy.

CONCLUSION

This is, to our knowledge, the first reported case of renal artery thrombosis following a debulking procedure. Gynecologic oncologists should be aware of this possibility and be familiar with the diagnosis and management of this condition.

Tertiary cytoreductive surgery in recurrent ovarian cancer: Selection criteria and survival outcome

OBJECTIVES

Studies of tertiary cytoreductive surgery (TCS) in recurrent epithelial ovarian cancer are limited, and appropriate patient selection remains a clinical challenge. We sought to evaluate the impact of TCS on survival and to determine predictors of optimal tertiary resection.

METHODS

Between January 1997 and July 2004, 47 women with recurrent epithelial ovarian cancer underwent TCS at two institutions. All patients received initial platinum and taxane-based chemotherapy following primary cytoreductive surgery. Clinico-pathologic factors and survival were retrospectively abstracted from medical records. Optimal TCS was defined as microscopic residual disease.

RESULTS

Thirty of 47 (64%) patients underwent optimal TCS. Size of tumor implants<5 cm on preoperative imaging was the only significant predictor of achieving optimal TCS. Overall survival after TCS was statistically longer in patients with microscopic versus macroscopic residual disease (24 versus 16 months, p=0.03). After controlling for age, time to progression and optimal TCS, only the presence of diffuse disease at tertiary exploration remained a significant poor predictor of survival. However, in a cohort of patients with limited disease implants, multivariate analysis indicated that optimal TCS retained prognostic significance as a positive predictor of survival. Twelve patients (26%) experienced severe postoperative complications, including six with pulmonary embolism, four with fistulae and two with postoperative myocardial infarctions.

CONCLUSIONS

Size of disease implants on preoperative imaging may guide the selection of candidates for TCS. In those patients with limited disease implants at laparotomy, optimal TCS is associated with improved survival.