Efficacy and Safety of Minimally Invasive Surgery Versus Open Laparotomy for Interval Debulking Surgery of Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: A Systematic Review and A Meta-Analysis

Abstract

ObjectiveThe selection of minimally invasive surgery (MIS) or open laparotomy for ovarian cancer (OC) after neoadjuvant chemotherapy still remains controversial. This study aimed to assess the efficacy and safety of MIS versus open laparotomy following neoadjuvant chemotherapy for advanced OC, so as to provide another option to select optimal surgical procedures for patients with OC.MethodsRelevant literature studies about the risks of progression or mortality between women receiving MIS and open laparotomy for interval debulking surgery (IDS) were searched in the online databases, including PubMed, Embase, and the Cochrane Library with the following keywords: “ovarian neoplasms”, “minimally invasive surgical procedures”, “laparotomy”, and “neoadjuvant therapy”. Eligible studies were screened out for further meta-analysis.ResultsSix eligible literature studies, with 643 patients in the MIS group and 2,885 patients in the open laparotomy group, were included in this meta-analysis. No significant differences were detected in the overall survival (OS) of patients with OC who were treated with MIS or open laparotomy [hazard ratio (HR) = 0.85; 95% confidence interval (CI) = 0.59–1.23; heterogeneity: P = 0.051, I2 = 57.6%]. However, the progression-free survival (PFS) was significantly higher in patients with OC treated with MIS than those treated with laparotomy (HR = 0.73; 95% CI = 0.57 to 0.92; heterogeneity: P = 0.276, I2 = 22.4%). The completeness of debulking removal (R0 rate) in the open laparotomy group was not statistically higher compared with the control group (RR = 1.07; 95% CI = 0.93 to 1.23; heterogeneity: P = 0.098, I2 = 52.3%), and no significant differences in residual disease of ≤1 cm (R1) (RR = 1.08; 95% CI = 0.91 to 1.28; heterogeneity: P = 0.330, I2 = 12.6%) and postoperative complications were found between the two groups (RR = 0.72; 95% CI = 0.34 to 1.54; heterogeneity: P = 0.055, I2 = 60.6%). Furthermore, the length of stays in hospital was significantly shorter in patients with OC treated with MIS than those treated with open laparotomy (Standard Mean Difference (SMD) = −1.21; 95% CI = −1.78 to −0.64; heterogeneity: P < 0.001, I2 = 92.7%].ConclusionsFor IDS after NACT in patients with advanced OC, complete cytoreductive surgery with MIS is another feasible and effective choiceSystematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022298519, identifier CRD42022298519

An overview of the current debate between using minimally invasive surgery versus laparotomy for interval cytoreductive surgery in epithelial ovarian cancer

“…Patients in this meta-analysis were carefully selected for a minimally invasive approach based on complete clinical response to NACT and low tumor burden seen with diagnostic laparoscopy [ 15 ]. Another meta-analysis by Zeng et al [ 10 ] reviewing 6 studies, with 643 patients in the minimally invasive surgery group and 2,885 patients in the open laparotomy group, similarly found no significant differences in CGR (relative risk [RR]=1.07; 95% CI=0.93–1.23). Residual disease of ≤1 cm was also evaluated and found to be similar in the minimally invasive surgery and laparotomy groups [ 10 ].…”

“…Another meta-analysis by Zeng et al [ 10 ] reviewing 6 studies, with 643 patients in the minimally invasive surgery group and 2,885 patients in the open laparotomy group, similarly found no significant differences in CGR (relative risk [RR]=1.07; 95% CI=0.93–1.23). Residual disease of ≤1 cm was also evaluated and found to be similar in the minimally invasive surgery and laparotomy groups [ 10 ].…”

“…Minimally invasive surgery has numerous benefits, including reduction in intraoperative blood loss, postoperative pain, length of hospital stay, and time interval to initiation of adjuvant chemotherapy [ 8 10 ]. Prior to the LANCE Trial, data evaluating a minimally invasive approach for IDS in epithelial ovarian cancer were limited to small feasibility trials and retrospective studies [ 9 11 ].…”

“…Another recent meta-analysis by Zeng et al found no difference in OS between patients who underwent laparotomy versus minimally invasive surgery (hazard ratio [HR]=0.85; 95% CI=0.59–1.23), but did find significantly increased PFS in the minimally invasive surgery group (HR=0.73; 95% CI=0.57–0.92) [ 10 ]. The PFS advantage, however, disappeared with the removal of one study during sensitivity analysis, in which only patients with high likelihood of achieving CGR based on imaging and clinical review by a single institution’s tumor board were included in the minimally invasive surgery cohort [ 10 19 ]. Multiple factors such as differences in surgical technique, study design, and duration of follow-up likely impacted these results [ 10 ].…”

“…The PFS advantage, however, disappeared with the removal of one study during sensitivity analysis, in which only patients with high likelihood of achieving CGR based on imaging and clinical review by a single institution’s tumor board were included in the minimally invasive surgery cohort [ 10 19 ]. Multiple factors such as differences in surgical technique, study design, and duration of follow-up likely impacted these results [ 10 ]. One included study demonstrated that time to chemotherapy and administration of bevacizumab following surgery had an independent prognostic role on PFS, likely reducing or negating the impact of surgical approach alone on survival data [ 20 ].…”