Aggressive surgical effort and improved survival in advanced-stage ovarian cancer

OBJECTIVE: Residual disease after initial surgery for ovarian cancer is the strongest prognostic factor for survival. However, the extent of surgical resection required to achieve optimal cytoreduction is controversial. Our goal was to estimate the effect of aggressive surgical resection on ovarian cancer patient survival. METHODS: A retrospective cohort study of consecutive patients with International Federation of Gynecology and Obstetrics stage IIIC ovarian cancer undergoing primary surgery was conducted between January 1, 1994, and December 31, 1998. The main outcome measures were residual disease after cytoreduction, frequency of radical surgical resection, and 5-year disease-specific survival. RESULTS: The study comprised 194 patients, including 144 with carcinomatosis. The mean patient age and follow-up time were 64.4 and 3.5 years, respectively. After surgery, 131 (67.5%) of the 194 patients had less than 1 cm of residual disease (definition of optimal cytoreduction). Considering all patients, residual disease was the only independent predictor of survival; the need to perform radical procedures to achieve optimal cytoreduction was not associated with a decrease in survival. For the subgroup of patients with carcinomatosis, residual disease and the performance of radical surgical procedures were the only independent predictors. Disease-specific survival was markedly improved for patients with carcinomatosis operated on by surgeons who most frequently used radical procedures compared with those least likely to use radical procedures (44% versus 17%, P < .001). CONCLUSION: Overall, residual disease was the only independent predictor of survival. Minimizing residual disease through aggressive surgical resection was beneficial, especially in patients with carcinomatosis

Stage IV ovarian cancer: Disease site-specific rationale for postoperative treatment

Objectives: We aimed to define the site-specific patterns of treatment failure in stage IV ovarian cancer. Methods: Data from all consecutive Mayo Clinic patients with stage IV epithelial ovarian cancer, from 1994 through 2003, were collected and analyzed. Statistical analyses included the \u3c72test and Kaplan-Meier curves with log-rank tests. Results: Review of our patient database identified 109 patients with stage IV ovarian cancer: mean age, 62\ua0years (range, 36-83\ua0years); 5-year overall survival, 15%. Most patients (74%) had intraperitoneal disease at the time of relapse, 36% had pleural effusion, and 49% had extraperitoneal metastases. At the time of death 75% had intraperitoneal localizations, 51% had pleural effusion, and 46% had extraperitoneal metastases. Patients with pleural effusion were more likely to have pleural disease at relapse and at last follow-up. Extrapleural disease at the time of diagnosis predicted extrapleural disease at relapse and at last follow-up. Most patients classified as having stage IV disease by pleural cytology only, as opposed to all other patients, had intraperitoneal disease at relapse (88% vs 58.7%, P = .001) and last follow-up (88.5% vs 59.6%, P = .001). Patients having stage IV disease by pleural cytology only had survival benefit when disease was optimally debulked in the abdomen and pelvis (median survival, 3.1\ua0years vs 1.3\ua0years; P = .001). Patients with multiple unresectable liver metastases had poor prognosis (median survival, 1.2\ua0years) owing to progression of liver disease. Conclusions: Clinical trials for stage IV ovarian cancer should reflect the site-specific risks for recurrence according to disease location at diagnosis

Ovarian cancer surgical resectability: Relative impact of disease, patient status, and surgeon

Objectives. Currently, we are unable to predict which patients are most likely to undergo successful debulking of ovarian cancer. We investigated the impact of clinical and surgical-pathologic factors at the time of initial exploration on the ability to achieve optimal cytoreduction. Methods. All consecutive patients with IIIC epithelial ovarian cancer operated at Mayo Clinic between 1994 and 1998 were included. The following pre- and intraoperative factors were included as dichotomous variables: age, ASA, CA125, ascites volume, carcinomatosis, diaphragm and mesentery involvement, and tendency of the operating surgeon (defined by the performance of radical procedures in more vs. less than 50% of patients operated). Pearson \u3c72test and logistic regression analysis were used for statistical analysis. Results. ASA, ascites, carcinomatosis, diaphragmatic tumor, mesentery involvement, and surgeon tendency all significantly correlated with residual disease (RD) in univariate analysis. However, only ASA, carcinomatosis and surgeon were independently associated with optimal RD. The subset of patients having ASA 3 or 4 and carcinomatosis comprised a high-risk group with just 46% achieving optimal RD overall. Even within this high-risk group, the rate of optimal cytoreduction ranged from 67% to 42% dependent upon surgeon tendency to employ radical procedures. Conclusions. High-risk factors such as patient condition and extent of disease impact the ability to achieve optimal RD. However, this is greatly influenced by surgical effort. Models to predict optimal surgical outcomes based only on tumor and patient characteristics will be highly practice-dependent: thus, their utility in selecting patient for non-traditional primary approach to ovarian cancer must be looked at cautiously

Quality Improvement in the Surgical Approach to Advanced Ovarian Cancer: The Mayo Clinic Experience

Background: After observing disparate rates of cytoreduction, we initiated efforts to improve outcomes through feedback and education, and we reassessed outcomes. Study Design: Outcomes from group A (2006 and 2007, n = 105) were compared with those from the cohort predating quality-improvement efforts (group B, 2000 to 2003, n = 132). All stage IIIC ovarian cancer patients at our institution were evaluated for tumor dissemination, age, performance status, surgical complexity, residual disease (RD), morbidity, and mortality. A surgical complexity score previously described was used to categorize extent of operation. Results: No significant differences in age, performance status, or extent of disease were observed between cohorts. Surgical complexity increased after initiation of quality improvement (mean surgical complexity score, 5.5 to 7.1; p < 0.001), rates of optimal RD (< 1 cm) improved from 77% to 85% (p = 0.157), and rates of complete resection of all gross disease rose from 31% to 43% (p = 0.188). In the subset of patients with carcinomatosis most likely to benefit from extended surgical resection, radical procedures were used more frequently (63% versus 79%; p = 0.028), rates of optimal debulking (RD < 1 cm) increased (64% to 79%), and the rate of RD = 0 increased from 6% to 24% (p = 0.006). When disease was noted on the diaphragm, procedures to remove the disease were more frequently used (38% to 64%; p = 0.001). The rates of major perioperative morbidity (group B, 21% versus group A, 20%; p = 0.819) and 3-month mortality (8% versus 6%; p = 0.475) were not affected despite this more aggressive surgical approach. Conclusions: Analysis of outcomes with appropriate feedback and education is a powerful tool for quality improvement. We observed improvements in rates of cytoreduction and use of specific radical procedures, with no increase in morbidity as a result of this process