A predictive score for optimal cytoreduction at interval debulking surgery in epithelial ovarian cancer: a two- centers experience

Change of Fagotti score is associated with outcome after neoadjuvant chemotherapy for ovarian cancer

OBJECTIVE

To investigate whether a change in the Fagotti score (ΔFagotti) following neoadjuvant chemotherapy is predictive of resection to no residual disease (R0) and survival in women diagnosed with ovarian cancer.

METHODS

Women treated with neoadjuvant chemotherapy for newly diagnosed ovarian cancer between January 2012 and June 2021 at the Bern University Hospital were included in this retrospective cohort study. Fagotti scores before and after neoadjuvant chemotherapy treatment were assessed for a potential association with resection status at interval debulking surgery defined as no residual disease (R0), macroscopic residual disease with a diameter of 0.1-1 cm (R1) or >1 cm (R2), and survival.

RESULTS

During the study period, 130 patients received neoadjuvant chemotherapy, mainly in response to advanced ovarian cancer International Federation of Gynecology and Obstetrics (FIGO) stages IIIC (68.5%) or IV (20.8%). 91 patients (70%) experienced a relapse and 81 (62%) died due to their disease. Median overall survival was 40 months (95% CI 30.6 to 49.4). Fagotti scores dropped from a mean of 7.8 (95% CI 7.14 to 8.42) at diagnosis to 3.9 (95% CI 3.34 to 4.46, p<0.001) after neoadjuvant therapy. This decrease was associated with resection status during interval debulking surgery (mean ΔFagotti -4.9 in R0, -2.2 in R1, -0.6 in R2, p<0.001). Women whose Fagotti score declined more than 2 points after neoadjuvant chemotherapy (n=51/88, 58%) survived significantly longer (median overall survival of 42 vs 32 months, p=0.048).

CONCLUSION

Fagotti scores and ΔFagotti scores are associated with complete cytoreduction at interval debulking surgery and longer overall survival in women treated with neoadjuvant chemotherapy for ovarian cancer. These markers are valuable for individualized patient treatment planning and should always be performed after neoadjuvant therapy.

Critical Analysis of Advanced High-Grade Serous Epithelial Ovarian Cancer in Women: An Experience of 100 Cases from a Regional Cancer Center in Northeast India

Debabrata BarmonOvarian cancer is the sixth most common cancer in women worldwide. Patients with ovarian carcinoma mostly present at an advanced stage with serous type of epithelial ovarian cancers, which is the most lethal of all pelvic malignancies. This study aims to critically analyze high-grade serous epithelial ovarian carcinomas in women from the Northeastern region of India and compare our data with Western literature to modify treatment strategies and improve survival outcomes. This hospital-based retrospective analysis involved data from the records of 100 women with high-grade epithelial ovarian cancer treated primarily with neoadjuvant chemotherapy followed by interval debulking surgery in the department of gynecologic oncology at a tertiary level regional cancer institute from January 2018 to December 2019. The demographic, clinical and pathological profile, and survival outcome were evaluated using descriptive statistics. The overall survival of the study population was calculated using Kaplan-Meier curves using SPSS software (version 24). The majority of women belonged to 41 to 55 years age group. At first presentation to the hospital, 89 and11% patients were in stage III and stage IV of disease, respectively. Clinically, 95% of women had ascites, and 18% had metastasis to lymph nodes. Distant metastasis to lungs and liver was present in 10 and 3% of cases, respectively. A substantial percentage (98%) of women had raised serum Ca125 > 1000 at baseline, ranging from 1,745 to 10,987 IU/mL. Almost two-thirds of the cases had partial-to-complete response to neoadjuvant chemotherapy (78%). In most of the women (72%), there was no residual disease at interval debulking surgery (R0), though 28% women had R1& R2 resection. The median overall survival time was 36 months. High-grade serous ovarian cancer is commonly seen in older age group, but its occurrence in younger population has also been observed. Early diagnosis is crucial in decreasing morbidity and mortality among these patients. Therefore, efforts should be made to identify risk factors for malignancy. Assessing each parameter of statistical information reflecting its own profile may be important for calculating the risk for the development of ovarian cancer, which can help in implementing preventive measures in the future.

Prediction of Surgical Outcome in Advanced Ovarian Cancer by Imaging and Laparoscopy: A Narrative Review

Maximal-effort upfront or interval debulking surgery is the recommended approach for advanced-stage ovarian cancer. The role of diagnostic imaging is to provide a systematic and structured report on tumour dissemination with emphasis on key sites for resectability. Imaging methods, such as pelvic and abdominal ultrasound, contrast-enhanced computed tomography, whole-body diffusion-weighted magnetic resonance imaging and positron emission tomography, yield high diagnostic performance for diagnosing bulky disease, but they are less accurate for depicting small-volume carcinomatosis, which may lead to unnecessary explorative laparotomies. Diagnostic laparoscopy, on the other hand, may directly visualize intraperitoneal involvement but has limitations in detecting tumours beyond the gastrosplenic ligament, in the lesser sac, mesenteric root or in the retroperitoneum. Laparoscopy has its place in combination with imaging in cases where ima-ging results regarding resectability are unclear. Different imaging models predicting tumour resectability have been developed as an adjunctional objective tool. Incorporating results from tumour quantitative analyses (e.g., radiomics), preoperative biopsies and biomarkers into predictive models may allow for more precise selection of patients eligible for extensive surgery. This review will discuss the ability of imaging and laparoscopy to predict non-resectable disease in patients with advanced ovarian cancer.

Predicting incomplete cytoreduction in patients with advanced ovarian cancer

Purpose

The most important prognostic factor for survival in ovarian cancer patients is complete cytoreduction. The preoperative prediction of suboptimal cytoreduction, considered as any residual disease at the end of surgery, could prevent futile surgery and morbidity. Here, we aimed to identify markers in the preoperative abdominal CT scans of an unselected cohort of patients with ovarian cancer that are predictive of incomplete cytoreduction.

Methods

This is a single-institution retrospective analysis of 105 epithelial ovarian cancer (EOC) patients treated with surgical cytoreduction between 2010 and 2020. Twenty-two variables on preoperative abdominal CT scans were compared to the intraoperative macroscopic findings by Fisher's exact test. Parameters with a significant correlation between intraoperative findings and imaging were analyzed by multivariate binary logistic regression analysis regarding the surgical outcome of complete versus incomplete cytoreduction.

Results

Complete cytoreduction (CC), indicated by the absence of macroscopic residual disease, was achieved in 79 (75.2%) of 105 patients and 46 (63.9%) of 72 International Federation of Gynecology and Obstetrics (FIGO) stage III and IV patients. Twenty patients (19%) were incompletely cytoreduced due to miliary carcinomatosis of the small bowel, and six patients (5.7%) had various locations of residual disease. Thirteen variables showed a significant correlation between imaging and surgical findings. Large-volume ascites, absence of numerically increased small lymph nodes at the mesenteric root, and carcinomatosis of the transverse colon in FIGO stage III and IV patients decreased the rate of CC to 26.7% in the multivariate analysis.

Conclusion

Large-volume ascites, the absence of numerically increased small lymph nodes at the mesenteric root, and carcinomatosis of the transverse colon are markers in preoperative CT scans predicting a low chance for complete cytoreduction in unselected ovarian cancer patients in a real-world setting.

Preoperative Cancer Antigen 125 Level as Predictor for Complete Cytoreduction in Ovarian Cancer: A Prospective Cohort Study and Systematic Review

Background: The tumor marker ‘cancer antigen 125’ (CA-125) plays a role in the management of women with advanced stage ovarian cancer. This study aims to describe the predictive value of pre-treatment CA-125 level and the reduction after neoadjuvant chemotherapy (NACT) on surgical outcome. Methods: A systematic review and a prospective clinical study were performed. Multiple databases were searched from database inception to April 2022. The clinical study is part of a randomized controlled trial named “PlaComOv-study”. A regression analysis was performed to demonstrate correlations between preoperative CA-125 levels, CA-125 reduction after NACT, and surgical outcome. Results: Fourteen relevant articles were analyzed of which eleven reported that lower preoperative CA-125 levels were associated with a higher probability of complete cytoreduction. In the clinical study, 326 patients with FIGO stage IIIB-IV ovarian cancer who underwent CRS were enrolled from 2018 to 2020. Patients who underwent interval CRS with preoperative CA-125 levels ≤35 kU/L had higher odds of achieving complete CRS than patients with CA-125 level >35 kU/L (85% vs. 67%, OR 2.79, 95%CI 1.44−5.41, p = 0.002). In multivariable analysis with presence of ascites and peritoneal carcinomatosis, normalized preoperative CA-125 did not appear as a significant predictor for complete CRS. Conclusions: In literature, preoperative CA-125 levels ≤35 kU/L were associated with a significant higher percentage of complete CRS in univariable analysis. According to our cohort study, preoperative CA-125 level ≤35 kU/L cannot independently predict surgical outcome either for primary or interval CRS.

Concordance of laparoscopic and laparotomic peritoneal cancer index using a two-step surgical protocol to select patients for cytoreductive surgery in advanced ovarian cancer

PURPOSE

The aim of our study was to assess concordance of staging laparoscopy and cytoreductive surgery (CRS) peritoneal cancer index (PCI) when applying a two-step surgical protocol. We also aimed to evaluate the accuracy of diagnostic laparoscopy to triage patients for complete cytoreduction, and to define optimal time between staging laparoscopy and CRS.

METHODS

We designed a retrospective review of prospectively collected data from patients with advanced ovarian cancer who underwent a diagnostic laparoscopy followed by a CRS a few weeks later (two-step surgical protocol), from January 2010 to April 2019. Only patients selected for complete cytoreduction, and with available PCI score from both surgeries were included. PCI concordance was assessed using intraclass correlation coefficient (ICC).

RESULTS

During the study period 543 patients underwent a laparoscopic staging for ovarian carcinomatosis. Among them, 43 patients fulfilled inclusion criteria. ICC between laparoscopic and laparotomic PCI was 0.54. After applying the linear regression equation: laparoscopic PCI + 0.2 x [days between surgeries] + 2, ICC increased to 0.79. Completeness cytoreduction score and laparoscopic PCI were significantly associated (OR 1.27, 95% CI 1.03-1.57, p = 0.03). AUC of laparoscopic PCI to predict complete cytoreduction was 0.90.

CONCLUSION

Concordance between laparoscopic PCI assessment and PCI score at the end of CRS is fair within a two-step surgical management. Laparoscopic assessment underestimates final PCI score by two points, and this difference increases with the delay between both surgeries. Diagnostic laparoscopy can adequately select patients for CRS, and optimal time to perform it is no more than 10 days after laparoscopy.

HIPEC after neoadjuvant chemotherapy and interval debulking is associated with development of platinum-refractory or -resistant disease

OBJECTIVE

To describe our single-institution oncologic outcomes of patients who received neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) with or without hyperthermic intraperitoneal chemotherapy (HIPEC).

METHODS

We compared clinicopathologic information and outcomes for all patients with advanced stage, high-grade serous ovarian cancer who received NACT and IDS with (N = 20) or without (N = 48) HIPEC at our institution from 2010 to 2019 RESULTS: Mean age (62 years with HIPEC and 60 years without HIPEC) and proportion of stage 4 disease (40% for both) did not differ between cohorts. HIPEC patients had higher rates of complete cytoreduction (95% vs 50%), longer mean duration of surgery (530 vs. 216 min), more grade 3 or 4 postoperative complications (65% vs. 4%), and longer mean length of hospital stay (8 vs. 5 days). HIPEC patients had significantly higher risk for platinum-refractory progression or platinum-resistance recurrence (50% vs 23%; RR = 2.18; 95% CI 1.11, 4.30, p = 0.024). Median progression free survival (11.5 vs. 12 months) and all-cause mortality (19.1 vs. 30.5 months) in the HIPEC and non-HIPEC cohorts, respectively, did not differ CONCLUSIONS: HIPEC was associated with increased risk for platinum refractory or resistant disease. Higher surgical complexity may contribute to higher complication rates without improving oncologic outcomes in our patients. Further investigations and long-term follow-up are needed to assess the utility of HIPEC in primary treatment of advanced stage ovarian cancer.

Prognostic relevance of high pretreatment CA125 levels in primary serous ovarian cancer

The objective of the present study was to analyze the prognostic relevance of pretreatment serum CA125 ≥500 U/ml and its role as a non-invasive factor for estimating optimal cytoreduction (≤1 cm) in primary serous ovarian cancer. Clinicopathological parameters and CA125 levels prior to primary cytoreductive surgery were retrospectively evaluated in all 261 consecutive patients with primary epithelial ovarian cancer from a single centre. Inclusion criteria were existing preoperative CA125 level, serous ovarian cancer and performed full primary treatment (surgery/platinum-based chemotherapy). A total of 136 patients met the criteria. Among them, 74 patients had CA125 ≥500 U/ml. The other 62 patients that met the aforementioned criteria and had CA125 <500 U/ml were defined as controls. The present study tested cut-off CA125 values to detect subgroups affecting prognosis. The goal was to evaluate patients with optimal cytoreduction (R≤1 cm). Univariate analyses were performed with PASW to identify clinicopathological parameters associated with the pretreatment CA125 level. For survival analyses, a cut-off-value of CA125 ≥500 U/ml was used to identify the association between preoperative CA125 levels, resection status and prognosis. To test significant differences between examined groups, Student's t-test and the Mann-Whitney test were used. P<0.05 was considered to indicate a statistically significant difference. Significantly worse prognosis in terms of overall survival (P=0.023) and progression-free survival (P=0.011) was detected in the CA125 ≥500 U/ml group of optimally cytoreduced patients compared with in the CA125 <500 U/ml group. The complete cytoreduction rate was higher in CA125 <500 U/ml (33.9%) vs. CA125 ≥500 U/ml (21.6%). A CA125 level >1,404 U/ml had a higher rate of suboptimal cytoreduction (32.4%) compared with lower CA125 levels. A pretreatment CA125 level ≥500 U/ml had significantly worse prognostic impact after optimal cytoreduction compared with CA125 <500 U/ml. The higher the CA125 level the higher the suboptimal cytoreduction rate. Patients with CA125 ≥500 U/ml may be candidates for an initial laparoscopic approach to specify resectability and to determine how to proceed. Overall, CA125 levels appear to be helpful in predicting suboptimal cytoreductive surgery for patients with primary ovarian cancer, but should be interpreted together with clinical and radiologic findings. This may improve defining the optimal treatment strategy in these patients.

Nadir CA-125 serum levels during neoadjuvant chemotherapy and no residual tumor at interval debulking surgery predict prognosis in advanced stage ovarian cancer

BACKGROUND

Recent phase III randomized trials have suggested that neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) is a treatment option for patients with advanced epithelial ovarian cancer. This study aimed to use CA-125 and computed tomography (CT) scanning to generate a simple and clinically applicable model of predicting complete cytoreduction by interval debulking surgery (IDS) and the overall survival in patients who receive taxane/platinum-based chemotherapy as neoadjuvant chemotherapy (NACT).

METHODS

Patients with stage IIIc or IV epithelial ovarian cancer who underwent taxane/platinum-based NACT followed by IDS in Gunma Prefectural Cancer Center, Takasaki General Medical Center, and Gunma University from April 2009 to March 2015 were included. Patients underwent a CT scan to confirm confirm tumors unresectable by standard surgery before NACT. CA-125 levels were measured pre-NACT, after each cycle of NACT, and before IDS. CT was also performed before IDS to evaluate tumor metastasis. Data were collected retrospectively and analyzed to determine the predictive factors of complete resection and overall survival.

RESULTS

Among 63 patients who received NACT-IDS, 43 and 20 patients had stages IIIc and IV epithelial ovarian cancer at diagnosis, respectively. CT predictors of residual tumors after IDS such as extra-ovarian implants (P = 0.009) and omental cakes (P = 0.038) were not present. Univariate analysis revealed that the independent factors for overall survival were no residual tumor by IDS (P = 0.0016) and CA125 ≤ 20 U/ml before IDS (P = 0.0011).

CONCLUSIONS

Although this study had a small sample size, NACT-IDS used to completely remove macroscopic disease which significantly improved the prognosis of patients with preoperative CA-125 ≤ 20 U/ml. Results from this study provide useful information for future studies on the management of patients with advanced epithelial ovarian cancer.

Scoring systems for the evaluation of adnexal masses nature: current knowledge and clinical applications

Adnexal masses are a common finding in women, with 20% of them developing at least one pelvic mass during their lifetime. There are more than 30 different subtypes of adnexal tumours, with multiple different subcategories, and the correct characterisation of the pelvic masses is of paramount importance to guide the correct management. On that basis, different algorithms and scoring systems have been developed to guide the clinical assessment. The first scoring system implemented into the clinical practice was the Risk of Malignancy Index, which combines ultrasound evaluation, menopausal status, and serum CA-125 levels. Today, current guidelines regarding female patients with adnexal masses include the application of International Ovarian Tumours Analysis simple rules, logistic regression model 1 (LR1) and LR2, OVERA, cancer ovarii non-invasive assessment of treating strategy, and assessment of Different Neoplasias in the adnexa. In this scenario, the choice of the scoring system for the discrimination between benign and malignant ovarian tumours can be complex when approaching patients with adnexal masses. This review aims to summarise the available evidence regarding the different scoring systems to provide a complete overview of the topic.

Radiological assessment of Peritoneal Cancer Index on preoperative CT in ovarian cancer is related to surgical outcome and survival

PURPOSE

To evaluate whether Peritoneal Cancer Index (PCI) assessed on preoperative CT (CT-PCI) can be used as non-invasive preoperative tool to predict surgical outcome, disease-free survival (DFS) and overall survival (OS).

MATERIALS AND METHODS

This is a retrospective, observational cohort study performed in a single institution. We considered all patients with diagnosis of ovarian cancer and preoperative CT, who had undergone upfront cytoreductive surgery between 2008 and 2010 and had post-operative clinical follow-up to December 2015. Two radiologists reviewed CT scans and assessed CT-PCI using Sugarbaker's diagram. We assessed the discriminatory capacity of the CT-PCI score on the surgical outcome by ROC curve analysis. DFS and OS were assessed by Kaplan-Meier nonparametric curves and by multivariable Cox-regression analysis.

RESULTS

A total of 297 patients were included in the present analysis. CT-PCI was positively correlated with post-operative residual disease [odds ratio (OR) 1.04, 95% CI 1.01-1.07, p = 0.003]. ROC curve analysis returned AUC = 0.64 for the prediction of total macroscopic tumour clearance. In multivariable analysis, patients with no peritoneal disease seen on CT had a significantly longer DFS [Hazard ratio (HR) 2.28, p = 0.007]. Radiological serosal small bowel involvement was an independent predictor for shorter OS (HR 3.01, p = 0.002).

CONCLUSION

Radiological PCI assessed on preoperative CT is associated with the probability of residual disease after cytoreductive surgery; however, it has low performance as a triage test to reliably identify patients who are likely to have complete cytoreductive surgery. CT-PCI is positively correlated with both DFS and OS and may be used as an independent prognostic factor, for example in patients with high FIGO stages.

The role of changes in systemic inflammatory response markers during neoadjuvant chemotherapy in predicting suboptimal surgery in ovarian cancer

AIM

The aim of this study was to investigate the possibility of using the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio, and platelet count and their dynamic changes during chemotherapy to predict suboptimal interval debulking surgery (IDS) in stage IIIC-IVA serous ovarian cancer (OC).

METHOD

Patients who underwent IDS after neoadjuvant chemotherapy (NAC) for stage IIIC-IVA serous OC at 3 centers between January 2008 and March 2018 were analyzed retrospectively. All women with complete blood counts both at diagnosis (T0) and after the completion of NAC but prior to IDS (T1) were included. An average of 3 weeks passed between IDS and the last cycle of NAC.

RESULTS

A total of 214 patients were found suitable for the study. Suboptimal surgery was performed in 25.2% of the patients and optimal surgery was performed in 74.8%. The rate of change in NLR was calculated as [(NLR T0 - NLR T1)/NLR T0] × 100. A higher rate of change in NLR was found in the optimal surgery group. Recovery of thrombocytosis (When platelet count before NAC was >400,000/mm³, recovery of thrombocytosis was defined as ≤400,000/mm³ after NAC.) was found to have 85.7% sensitivity and 64.8% specificity in predicting suboptimal surgery (P < 0.001). According to both multivariate and univariate regression analysis, a large change in NLR (>17%) and recovery of thrombocytosis significantly predicted suboptimal surgery.

CONCLUSION

To identify the likelihood of suboptimal surgery in advanced stage OC patients who undergo IDS after NAC, the dynamic change in NLR values can be examined.

Management Driven Structured Reporting in Ovarian Cancer

Since majority (80%) of ovarian cancer patients present at an advanced stage, imaging performed on these patients have numerous findings. The combination of multiple findings on imaging, complexity of anatomical structures which are involved in ovarian cancer, and the need to perceive certain subtle imaging features which would impact management often makes it challenging to systematically review images of these patients. Similarly, it is difficult to effectively communicate these findings in radiology reports. Structured reporting that is geared toward clinical decision-making has been an area of recognized need. An understanding of the review areas, which aid clinical decision-making in a multidisciplinary team setting at our institution led us to the proposed structured reporting template for ovarian cancer. Through this review, the authors would like to share this reporting template with examples.

Preoperative Risk Score for Predicting Incomplete Cytoreduction: A 12-Institution Study from the US HIPEC Collaborative

BACKGROUND

For patients with peritoneal carcinomatosis undergoing cytoreductive surgery with heated intraperitoneal chemotherapy (CRS/HIPEC), incomplete cytoreduction (CCR2/3) confers morbidity without survival benefit. The aim of this study is to identify preoperative factors which predict CCR2/3.

METHODS

All patients who underwent curative-intent CRS/HIPEC of low/high-grade appendiceal, colorectal, or peritoneal mesothelioma cancers in the 12-institution US HIPEC Collaborative from 2000 to 2017 were included (n = 2027). The primary aim is to create an incomplete-cytoreduction risk score (ICRS) to predict CCR2/3 CRS utilizing preoperative data. ICRS was created from a randomly selected cohort of 50% of patients (derivation cohort) and verified on the remaining patients (validation cohort).

RESULTS

Within our derivation cohort (n = 998), histology was low-grade appendiceal neoplasms in 30%, high-grade appendiceal tumor in 41%, colorectal tumor in 22%, and peritoneal mesothelioma in 8%. CCR0/1 was achieved in 816 patients and CCR 2/3 in 116 patients. On multivariable analysis, preoperative factors associated with incomplete cytoreduction were male gender [odds ratio (OR) 3.4, p = 0.007], presence of ascites (OR 2.8, p = 0.028), cancer antigen (CA)-125 ≥ 40 U/mL (OR 3.4, p = 0.012), and carcinoembryonic antigen (CEA) ≥ 4.2 ng/mL (OR 3.2, p = 0.029). Each preoperative factor was assigned a score of 0 or 1 to form an ICRS from 0 to 4. Scores were grouped as zero (0), low (1-2), or high (3-4). Incidence of CCR2/3 progressively increased by risk group from 1.6% in zero to 13% in low and 39% in high. When ICRS was applied to the validation cohort (n = 1029), this relationship was maintained.

CONCLUSION

The incomplete cytoreduction risk score incorporates preoperative factors to accurately stratify the risk of CCR2/3 resection in CRS/HIPEC. This score should not be used in isolation, however, to exclude patients from surgery.

Pre-operative prediction of residual disease after interval cytoreduction for epithelial ovarian cancer using HE4

BACKGROUND

Presence of residual disease after cytoreductive surgery is an important negative prognostic factor for patients with advanced stage epithelial ovarian cancer. Surgery is of limited benefit when the diameter of residual disease is >1 cm. Residual disease is difficult to predict before surgery. The multivariate model Cancer Ovarii Non-invasive Assessment of Treatment Strategy (CONATS) index, based on serum biomarker HE4, age, and World Health Organization performance status, predicted no visible residual disease in patients undergoing primary cytoreductive surgery with an area under the curve (AUC) of 0.85. The AUC of predicting residual disease >1 cm was not reported, although this can be of importance for pre-operative decision making, especially in fragile patients. We tested this model for predicting residual disease >1 cm in patients undergoing interval cytoreduction.

METHODS

We retrospectively included patients with advanced epithelial ovarian cancer who underwent interval cytoreduction between January 2010 and December 2017 in two tertiary centers in the Netherlands. HE4 was measured with electrochemiluminescence in pre-operative samples. The CONATS index was used to predict residual disease. AUCs were calculated to predict residual disease >1 cm.

RESULTS

A total of 273 patients were included. Mean (SD) age was 64 (11) years. Median number of cycles of neoadjuvant chemotherapy was 3 (range 3-6) and the most common regimen used consisted of carboplatin and paclitaxel. Before interval cytoreduction, 19 patients (7%) showed complete response to chemotherapy, 251 patients (92%) showed partial response, and 3 patients (1%) showed stable disease at imaging. Following surgery, 232 patients (85%) had residual disease ≤1 cm and 41 patients (15%) had residual disease >1 cm. The AUC was 0.80 for predicting residual disease >1 cm. In patients ≥70 years of age the AUC was 0.82.

CONCLUSION

The CONATS index predicts surgical outcome after interval cytoreduction and is useful in counseling patients about the chance of whether an optimal interval cytoreduction can be achieved. This could be especially helpful in counseling elderly patients in whom surgery has a high risk of complications.

Pathological Chemotherapy Response Score in Patients Affected by High Grade Serous Ovarian Carcinoma: The Prognostic Role of Omental and Ovarian Residual Disease

Background: The chemotherapy response score (CRS) has emerged as a simple and reproducible histopathological grading system for assessing chemotherapy response in patients affected by ovarian high-grade serous carcinoma.

Objective: To evaluate the prognostic impact of histological tumor response in ovarian and omental surgical specimens from patients with advanced stage ovarian high-grade serous carcinoma.

Study Design: A cohort of 161 women were identified from the database of Department of Gynecology, “Fondazione Policlinico Universitario Agostino Gemelli IRCCS” of Rome, Italy between January 2014 and December 2017 with a follow-up of 65 months. All the omentum, the ovarian tissue and peritoneal samples, defined as “other sites,” were reviewed by gynecological pathologists to assign a CRS of 1–3 to the omentum and ovarian sites and a score of 0–1 to the peritoneal tissue. The Cox proportional hazards regression and the log-rank test were used to assess the survival pattern and the prognostic value of the CRS adjusting for age and stage. The Kaplan-Meier method was applied to estimate the progression free and overall survival.

Results: The evaluation of adnexal disease showed significant differences in PFS, both in univariate and in multivariate analyses. On PFS univariate analysis, ovCRS1 vs. ovCRS3: HR, 2.27; 95% CI, 1.37–3.77; p = 0.001; ovCRS2 vs. ovCRS3: HR, 1.83; 95% CI, 1.03–3.23; p = 0.04, and on PFS multivariate model ovCRS1 vs. ovCRS3; HR, 2.53; 95% CI, 1.5–4.24; p = 0.001 and ovCRS2 vs. ovCRS3; HR, 1.90; 95% CI, 1.08–3.37; p = 0.03. Regarding the omental residual disease, as expected, CRS showed a significant prognostic value for OS and PFS; in detail the median PFS of patients with CRS1, 2 and 3 was 15, 15, and 22 months, respectively, the median OS was 41 and >50 months, respectively. Moreover, the univariate analysis for OS suggested that in our cohort the “other sites” score of 0 was significantly associated with an improvement in overall survival compared to score 1.

Conclusions: We demonstrated for the first time the prognostic significance of adnexal CRS confirming also the prognostic role of omental CRS.

An update on preoperative assessment of the resectability of advanced ovarian cancer

The best prognosis for advanced ovarian cancer is provided by no residual disease after primary cytoreductive surgery. It is thus important to be able to predict resectability that will result in complete cytoreduction, while avoiding unnecessary surgery that may leave residual disease. No single procedure appears to be sufficiently accurate and reliable to predict resectability. The process should include a preoperative workup based on clinical examination, biomarkers, especially tumor markers, and imaging, for which computed tomography, as well as sonography, magnetic resonance imaging and positron-emission tomography, can be used. This workup should provide sufficient information to determine whether complete cytoreduction is possible or if not, to propose neoadjuvant chemotherapy which is preferable in this case. For the remaining patients, laparoscopy is broadly recommended as an ultimate triage step. However, its modalities are still debated, and several scores have been proposed for standardization and improving accuracy. The risk of false negatives requires a final assessment of resectability as the first stage of cytoreductive surgery by laparotomy. Composite models, consisting of several criteria of workup and, sometimes, laparoscopy have been proposed to improve the accuracy of the predictive process. Regardless of the modality, the process appears to be accurate and reliable for predicting residual disease but less so for predicting complete cytoreduction and thus avoiding unnecessary surgery and an inappropriate treatment strategy. Overall, the proposed procedures are heterogeneous, sometimes unvalidated, or do not consider advances in surgery. Future techniques and/or models are still needed to improve the prediction of complete resectability.

Lymphopenia after induction chemotherapy correlates with incomplete surgical resection in patients with advanced ovarian cancer

BACKGROUND

Lymphopenia is associated with poor outcomes in patients with various cancers, but little is known about the prognostic impact of lymphopenia in patients with epithelial ovarian cancer (EOC) after induction chemotherapy (IC). This study investigated the prognostic significance of pre- and post-IC lymphopenia in patients with advanced EOC.

METHODS

We reviewed medical records of 68 patients with stage III/IV ovarian, fallopian tube, or peritoneal cancer treated with IC at our institution between 2009 and 2017. We assessed the associations of pre- and post-IC inflammatory markers, including lymphocyte counts, with several oncological outcomes, such as the implementation of interval debulking surgery (IDS), complete resection, progression-free survival (PFS), and overall survival (OS).

RESULTS

Lymphocyte counts increased significantly post-IC compared with the pre-IC values (P = 0.009). Pre-IC lymphopenia was observed in 27 patients (40%), whereas only 16 patients (24%) displayed lymphopenia post-IC (P = 0.020). Among several inflammatory markers, only post-IC lymphopenia was significantly associated with incomplete resection outcome during IDS (P = 0.012). Moreover, post-IC lymphopenia was significantly associated with poor PFS (log-rank test, P = 0.009), whereas pre-IC lymphopenia was associated with neither PFS nor OS.

CONCLUSIONS

Post-IC lymphopenia may predict incomplete resection during IDS and poor prognosis in patients with advanced EOC.