Elsevier

Gynecologic Oncology

Volume 130, Issue 3, September 2013, Pages 487-492
Gynecologic Oncology

Upper abdominal procedures in advanced stage ovarian or primary peritoneal carcinoma patients with minimal or no gross residual disease: An analysis of Gynecologic Oncology Group (GOG) 182,☆☆,

https://doi.org/10.1016/j.ygyno.2013.06.017Get rights and content

Highlights

  • In high tumor burden patients, performing an UAP and not achieving CR had minimal impact on survival.

  • UAPs are frequently needed to obtain microscopic residual disease in advanced ovarian cancer.

Abstract

Purpose

To examine the utility of upper abdominal procedures (UAPs) performed in a cohort of optimally cytoreduced patients with advanced stage epithelial ovarian cancer (EOC) or primary peritoneal cancer (PPC) and identify potential areas where aggressive surgery may impact survival.

Patients and methods

We reviewed 2655 patients enrolled in Gynecologic Oncology Group (GOG) 182 who had complete resection (CR) or minimal residual (MR) disease < 1 cm. Demographic, pathologic, surgical, and outcome data were collected. UAPs included diaphragm stripping or resection, liver resection, splenectomy, pancreatectomy, and porta hepatis surgery. Effect of UAP and CR on PFS/OS was assessed by Kaplan–Meier and proportional hazards methods.

Results

Four-hundred eighty-two patients (18.1%) underwent a total of 590 UAPs. There were 351 (13.1%) diaphragm surgeries, 112 (4.2%) liver surgeries, 108 (4%) splenectomies, 12 (0.5%) pancreatectomies, and 7 (0.2%) porta hepatis surgeries. Comparing patients who did not have UAPs to patients who had UAPs, the PFS was 18.2 months (mos) and 14.8 mos (p < 0.01) and OS was 49.8 mos v. 43.7 mos (p = 0.01), respectively. However, in the multivariable analysis this survival benefit did not remain (PFS HR = 1.03, 95% CI 0.91–1.15; OS HR = 0.92, 95%CI 0.81–1.04). The OS of the 141 patients who had an UAP and achieved CR compared to the 341 patients who had an UAP with MR was 54.6 compared to 40.4 mos (p = 0.0005).

Conclusions

UAP procedures should only be performed when CR is attainable. A significant proportion of patients with MR were left with diaphragmatic disease that could potentially be completely resected.

Introduction

Epithelial ovarian carcinoma (EOC) is the leading cause of death due to a gynecologic malignancy in the United States. The American Cancer Society estimates approximately 22,240 new ovarian cancer cases and 14,030 deaths in 2013. Over 60% of women with newly diagnosed EOC present with advanced stage disease [1]. Primary debulking surgery (PDS) followed by platinum based chemotherapy is the standard of care for advanced ovarian cancer [2], [3], [4], [5], [6]. Several studies support a survival advantage in patients who have been optimally cytoreduced (< 1 cm residual) compared to patients who have been suboptimally cytoreduced [7], [8], [9], [10].

Optimal cytoreduction rates can vary widely between institutions and studies with a reported range of 15–85%. Achieving the highest rates of optimal cytoreduction often requires surgeons skilled in upper abdominal procedures (UAPs) such as diaphragm stripping or resection, splenectomy, distal pancreatectomy, liver resection, cholecystectomy, and resection of tumor from the porta hepatis [10], [11], [12], [13], [14]. Much of the current guiding literature describing UAPs utilized to achieve optimal cytoreduction is limited by their small sample size, retrospective nature, and often single institution experience [15], [16].

In the current report, we examined the number and types of UAPs performed in a cohort of optimally cytoreduced patients with advanced stage epithelial ovarian cancer (EOC) or primary peritoneal cancer (PPC) from a large, multi-institutional clinical trial. In addition, we sought to identify potential areas where upper abdominal surgery might impact survival.

Section snippets

Patients and methods

All patient data for this study was abstracted from Gynecologic Oncology Group-182 (GOG-182), a prospective, multi-institutional clinical trial which enrolled 4312 women between February 2001 and September 2004 [15]. All patients enrolled in GOG-182 were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage III or IV histologically confirmed EOC or PPC. All patients underwent primary cytoreductive surgery (PCS) to either optimal (< 1 cm) or suboptimal residual disease

Results

Of the 4312 patients enrolled on GOG-182, 2655 (61.5%) underwent optimal cytoreduction and were analyzed for this study. Two-thousand three-hundred sixty-four had stage III disease and 291 patients had stage IV disease while 1636 had DS-H. Eight-hundred sixty patients had CR to no visible disease while 1795 had MR disease of < 1 cm. Table 2 shows the patient demographics and characteristics of the patients and subgroups included in this study.

Four-hundred eighty-two patients (18.1%) underwent a

Discussion

Several studies have demonstrated that incorporating UAPs in the cytoreductive effort can increase the rate of optimally debulked patients with advanced EOC [11], [12], [13]. The current study represents the largest multi-institutional analysis of the impact of UAPs on the survival of women with advanced EOC or PPC. Among 4312 patients enrolled on GOG-182, 2655 (62%) were optimally cytoreduced with nearly 20% of patients undergoing an UAP to achieve optimal cytoreduction. Diaphragm surgery was

Conflict of interest statement

Dr. Michael Bookman has no financial relationships relevant to this manuscript. However, he currently serves as Chair, Ovarian Committee, GOG, and also serves as Principal Investigator for GOG0182-ICON5. All other co-authors have no conflicts of interest to declare.

References (22)

Cited by (63)

  • Splenectomy at the time of primary or interval cytoreductive surgery for epithelial ovarian carcinoma: A review of outcomes

    2022, Gynecologic Oncology
    Citation Excerpt :

    This supports prior data that demonstrates higher morbidity with patients requiring splenectomy as part of cytoreductive surgery compared to those not requiring splenectomy. However, such morbidity has been argued to be worthwhile for the survival benefit associated with complete or optimal cytoreduction [6,9,13]. With 9 out of 13 cases of Stage IVB disease in the splenectomy group being attributed to splenic parenchymal involvement, and the fact that performing splenectomy did not diminish the capacity for complete or optimal cytoreduction, one could argue that performing splenectomy should be strongly considered especially when complete resection is otherwise achievable.

  • Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review

    2020, European Journal of Surgical Oncology
    Citation Excerpt :

    In the end, 18 studies were selected [2–19]. Of these 5 studied were not considered for the final analysis given the potential overlap [3,5,7–9], while 2 studies were not considered for the final analysis as they does not report complications [13,15]. The selection process is summarized in Fig. 1.

View all citing articles on Scopus

Presented in part at the Society of Gynecologic Oncology 2012 Annual Meeting on Women's Cancer, March 24–27, 2011, Austin, TX.

☆☆

The opinions or assertions expressed in this article represent the private views of the authors and should not be construed as reflecting the official views of the Department of the Air Force, Department of the Navy, Department of the Army or the Department of Defense.

This study was supported by National Cancer Institute grants to the Gynecologic Oncology Group (GOG) Administrative Office (CA 27469) and the Gynecologic Oncology Group Statistical Office (CA 37517). The following Gynecologic Oncology Group member institutions participated in the primary treatment studies: University of Alabama at Birmingham, Oregon Health Sciences University, Duke University Medical Center, Abington Memorial Hospital, University of Rochester Medical Center, Walter Reed Army Medical Center, Wayne State University, University of Minnesota Medical School, University of Southern California at Los Angeles, University of Mississippi Medical Center, Colorado Gynecologic Oncology Group P.C., University of California at Los Angeles, University of Washington, University of Pennsylvania Cancer Center, University of Miami School of Medicine, Milton S. Hershey Medical Center, Georgetown University Hospital, University of Cincinnati, University of North Carolina School of Medicine, University of Iowa Hospitals and Clinics, University of Texas Southwestern Medical Center at Dallas, Indiana University School of Medicine, Wake Forest University School of Medicine, Albany Medical College, University of California Medical Center at Irvine, Tufts-New England Medical Center, Rush-Presbyterian-St. Luke's Medical Center, University of Kentucky, Eastern Virginia Medical School, The Cleveland Clinic Foundation, Johns Hopkins Oncology Center, State University of New York at Stony Brook, Eastern Pennsylvania GYN/ONC Center, P.C., Southwestern Oncology Group, Washington University School of Medicine, Memorial Sloan-Kettering Cancer Center, Columbus Cancer Council, University of Massachusetts Medical School, Fox Chase Cancer Center, Medical University of South Carolina, Women's Cancer Center, University of Oklahoma, University of Virginia Health Sciences Center, University of Chicago, University of Arizona Health Science Center, Tacoma General Hospital, Eastern Collaborative Oncology Group, Thomas Jefferson University Hospital, Case Western Reserve University, and Tampa Bay Cancer Consortium.

1

Present address: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Loma Linda University Medical Center, Loma Linda School of Medicine, Loma Linda, CA, USA.

2

Current address: Arizona Cancer Center; Tucson, AZ 85724, USA.

View full text