Douglas peritonectomy compared to recto-sigmoid resection in optimally cytoreduced advanced ovarian cancer patients: Analysis of morbidity and oncological outcome

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Abstract

Background

Rectosigmoidectomy (RR) with primary anastomosis or pelvic peritonectomy (PP) are often part of an optimal en bloc tumor resection in advanced ovarian cancer (AOC) patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. We report our experience with two different surgical approaches in optimally cytoreduced AOC patients evaluating oncologic outcome and surgically associated morbidities

Methods

Data from all consecutive AOC patients undergoing PP or RR as part of the surgical procedure during primary cytoreduction from 2004 through 2009 were extrapolated and analyzed using the chi-squared test, Cox proportional hazard model and Kaplan-Meier method including log-rank test.

Results

During the study period, we identified 187 AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. The estimated mean disease-free survival (DFS) was 30.7 months (95% CI 24.6–36.8) in the RR arm vs. 25.9 months in the PP arm (95% CI 21.9–29.9) (p 0.299); similarly, the estimated mean overall survival (OS) was 38.8 months (95% CI 33.4–44.2) in the RR arm and 48.2 months in the PP arm (95% CI 43.1–53.3) (p = 0.122). No statistically significant differences were found in terms of DFS and OS according to the mesocolic lymphnode status (p = 0.65 and p = 0.81, respectively).

Conclusions

In conclusion, the current study clearly supports evidence that survival rates are similar for patients who achieved optimal residual tumor (RT), independent to whether they had RR or PP.

Introduction

Advanced ovarian cancer (AOC) commonly spreads along the peritoneal surfaces in the abdomen and often involves the serosa of the rectosigmoid colon by direct extension or implantation. In most cases, tumors can twist pelvic anatomy and the cul de sac can be completely involved by carcinomatosis implants. Maximal cytoreductive surgery to remove all visible areas of cancerous lesions followed by taxol-platinum combination chemotherapy is the current standard treatment in AOC. In fact, post-operative residual tumor (RT) and chemosensitivity remain the only proved prognostic factors of such disease.1, 2, 3

Two different surgical approaches have been described to remove tumor from the pelvis: pelvic peritonectomy (PP), if only the peritoneum of the Douglas pouch is involved, or rectosigmoid resection (RR), in the case of bowel wall infiltration. Some published data support an association between improved survival and optimal residual disease status in patients undergoing bowel resection during ovarian cancer cytoreduction.4, 5, 6, 7, 8, 9, 10, 11 Nevertheless, the collective bowel-related morbidity from these studies, although acceptable, is certainly not inconsequential, ranging from 2% to 30.5%.12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 Moreover, some studies have suggested that other factors related to “innate tumor biology” may influence prognosis and consequently the use of bowel resection and aggressive surgery would not improve survival.33, 34, 35, 36

In the present study we report our experience with these two different surgical approaches (RR and PP) in optimally cytoreduced AOC patients, in order to identify a recommended surgical procedure to remove tumor from the pelvis with respect to: 1) oncological outcomes, in terms of incidence of pelvic recurrence, disease-free survival (DFS) and overall survival (OS); 2) morbidity and the rate of short-term complications. In addition, histopathological prognostic factors influencing surgical and clinical outcome have been investigated.

Section snippets

Methods

All women with a diagnosis of primary epithelial AOC referred to the Division of Gynaecological Oncology of the Catholic University of Rome and Campobasso between January 2004 and December 2009, were identified. An Institutional Review Board approval was obtained for the study.

Surgical and clinical records were reviewed retrospectively for demographic and clinical data, surgical-pathological characteristics, type of surgery (primary cytoreduction (PC) or interval debulking surgery (IDS) after

Results

During the study period, we identified 187 advanced AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. Complete clinico-pathological characteristics of these patients are shown in Table 1. 129 women (69%) were submitted to PC and 58 (31%) to IDS.

Colonoscopy was performed in 40 (21.4%) cases, and showed rectal mucosa infiltration in four patients.

Surgical procedures for debulking included: 182 (97.3%) hysterectomies ± bilateral

Discussion

RR with primary anastomosis or PP are often part of an optimal en bloc tumor resection12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 in AOC patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. However, percentages of RR in the literature range widely from 16 to 58% of AOC patients,12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 and whether RR is

References (37)

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