Aggressive surgical strategies in advanced ovarian cancer: A monocentric study of 203 stage IIIC and IV patients
Introduction
The standard treatment for advanced ovarian cancer consists of cytoreductive surgery associated with a platinum/paclitaxel-based chemotherapy.1, 2 Several studies have demonstrated that the result of the surgery, defined by the amount of residual disease (RD), was the most important factor impacting on survival.3, 4, 5, 6, 7, 8, 9 However, these results have not been tested by randomized studies, comparing maximal surgery with a minor radical surgical approach or chemotherapy alone. Progress in chemotherapy regimens and advances in surgical techniques have developed concurrently, making it impossible to determine their respective impact on the improvement of the prognosis. Therefore, there are still questions as to the role of surgery in the therapeutic sequence. For some authors, the increase in survival associated with optimal debulking is limited to patients with a less advanced disease, and the results of the surgical studies could be related to the biology of the cancer.10, 11 For others, initial aggressive surgery is associated with an important morbidity delaying chemotherapy or results in a poor quality of life.12 Additionally, some studies were recently published concerning the results of interval surgery13 and the adoption of neoadjuvant chemotherapy (NAC) in the management of advanced ovarian cancer.14, 15, 16, 17, 18 Consequently, the prescription of NAC has increased over the last years; the first debulking is now often attempted only after 3–6 cycles of chemotherapy.
The purpose of the present study was to evaluate the position of cytoreductive surgery in the therapeutic sequence in a series of ovarian cancers treated in our institution. We tried to answer to the following questions: which patients could benefit from initial surgery, at what cost and for what oncological results? What are the indications and the results of interval surgery after NAC?
Section snippets
Patients
All the patients diagnosed with primary ovarian cancer operated on at our institute between 1990 and 2005 were recorded. Patients with stage IIIC or IV, undergoing primary or interval surgery for epithelial ovarian cancer, were consecutively included in this study.
Surgery
Surgical staging and grading were defined according to the FIGO criteria. The initial extent of the disease at the start of each intervention was quantified using the peritoneal cancer index, derived from Sugarbaker's publication.19
Patients
During the indicated period, 203 patients at stage IIIC (160) or IV (43), underwent primary or interval surgery at our institution and were eligible for inclusion. The average age at diagnosis was 60 years (range: 28–88), and the average follow-up duration was 70 months. Most of them presented an extended disease (Table 1). Considering all patients with FIGO stage IIIC and IV disease, the median survival was 35 months (overall survival at 5 years: 27%).
Surgery
One hundred and four patients had their
Cytoreductive surgery
The concept of cytoreductive surgery in advanced ovarian cancer is based on several theoretical and clinical aspects.3, 20 The removal of large masses of tumor has been reported to improve the patients' general status and to enhance the efficacy of chemotherapy.21 According to Griffiths,20 several studies have demonstrated that successful cytoreduction to a small-volume disease increases the frequency of complete response and survival.22, 23, 24, 25, 26, 27 In a meta-analysis of 6885 patients
Conclusion
The survival of patients with advanced ovarian cancer is mainly influenced by 3 factors: the extent of the disease at the time of diagnosis, the biology of the tumor and its chemosensitivity and, lastly, the size of the RD after surgery. Today, this latter factor is the only 1 modifiable by therapeutic approach. The removal of all macroscopic tumors as soon as possible in the therapeutic sequence seems to be primordial for improving chemotherapy efficacy and survival. For patients with advanced
Conflict of interest
The authors declare that they have no proprietary, financial or other personal interest of any nature.
Acknowledgements
The authors thank Dr Sharon Lynn Salhi and Brian Hawkins for presubmission editorial assistance.
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