Role of minimally invasive secondary cytoreduction in patients with recurrent ovarian cancer

Abstract

ObjectiveRetrospective series have shown minimally invasive secondary cytoreductive surgery is a feasible approach in selected cases of recurrent ovarian cancer. However, no predictors of minimally invasive secondary cytoreductive surgery feasibility are currently available. This study aims to identify predictive factors of minimally invasive secondary cytoreductive surgery feasibility and to compare perioperative and survival outcomes in a matched series of recurrent ovarian cancer patients who underwent secondary cytoreduction via an open or minimally invasive surgical approach.MethodsWe retrospectively identified all platinum-sensitive recurrent epithelial ovarian cancer patients who underwent minimally invasive or laparotomic secondary cytoreductive surgery between January 2013 and July 2020. Each patient underwent a preoperative positron emission tomography (PET) computerized tomography (CT) scan and diagnostic laparoscopy before secondary cytoreductive surgery. A 1:2 propensity score-matched analysis was performed to balance predictive factors of minimally invasive secondary cytoreductive surgery.ResultsOverall, 276 patients were identified (62 minimally invasive and 214 open), and a complete gross resection was achieved in 262 (94.9%) patients. At multivariate analysis, predictive factors for minimally invasive secondary cytoreductive surgery were neoadjuvant chemotherapy at first diagnosis (p=0.007), site of recurrence (p=0.031), and number of lesions (p=0.001). In the 1:2 propensity-matched population (39 minimally invasive and 78 open), complete gross resection was similar for both groups (p=0.082). Early post-operative complications were significantly higher in the laparotomy (33.3%) than in the minimally invasive surgery (10.3%) group (p=0.004). Only one (2.6%) patient experienced a grade >3 early post-operative complication in the minimally invasive surgery group compared with 13 (16.7%) patients in the open cohort (p<0.001). The median follow-up period was 32 months (range: 1–92) in the propensity-matched population. The median post-recurrence survival was 81 months in the minimally invasive surgery group and was not reached in the open group (p=0.11).ConclusionsPatients with single or oligometastatic recurrences can be offered minimally invasive secondary cytoreductive surgery, mainly if localized in the lymph-nodes, and/or if they received neoadjuvant chemotherapy at primary diagnosis. Minimally invasive secondary cytoreductive surgery is associated with favorable perioperative outcomes with no differences in terms of post-recurrence survival with respect to open approach.

Tertiary Cytoreduction for Isolated Lymphnode Recurrence (ILNR) Ovarian Cancer in a BRCA2 Mutated Patient: Our Experience and Prevalence of BRCA 1 or 2 Genes Mutational Status in ILNR

“…For these reasons, surgical treatment assumes a crucial role. The repeated surgery for ILNR, even in platinum-sensitive ovarian cancer, remains an important tool and this has been confirmed by several previous studies which highlighted the prognostic benefit in those patients [ 13 , 14 , 15 , 22 , 26 , 28 ]. Diagnostic laparoscopy also plays an important role in identifying a more diffuse disease and preventing unnecessary laparotomies delaying the chemotherapy [ 29 ].…”

“…ILNR is actually considered as a rare entity in the context of EOC since it affects only 1–5% of relapsed EOC [ 16 , 17 ]. These ILNR has been described as a unique clinical disease entity, moreover, several studies underline a better prognosis in terms of PFS and OS compared to peritoneal or parenchymal forms of recurrence [ 20 , 23 , 24 , 25 , 26 ]. Furthermore, the idea that the lymph-node metastases in ovarian cancers are more chemoresistance has already been proposed by Morice et al in an analysis of 105 patients [ 27 ] and confirmed by several studies [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ].…”

“…These ILNR has been described as a unique clinical disease entity, moreover, several studies underline a better prognosis in terms of PFS and OS compared to peritoneal or parenchymal forms of recurrence [ 20 , 23 , 24 , 25 , 26 ]. Furthermore, the idea that the lymph-node metastases in ovarian cancers are more chemoresistance has already been proposed by Morice et al in an analysis of 105 patients [ 27 ] and confirmed by several studies [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. The lower chemosensitivity of ILNRs can be justified by a lower percentage of cells in S-phase [ 18 ] and a greater CD3 + and CD8 + cell infiltration compared to extranodal relapse [ 20 ].…”

Minimally-Invasive Secondary Cytoreduction in Recurrent Ovarian Cancer

“…Neoadjuvant chemotherapy at primary diagnosis, peritoneal and lymph-nodal pattern of recurrence, and single and oligometastatic disease at preoperative PET/CT scan were significantly correlated with MI-SCS feasibility. In the multivariate analysis, single disease (OR = 4.17, 95% CI: 1.83-9.53, p < 0.001) and oligometastatic disease at recurrence (OR = 3.46, 95% CI: 1.48-8.07, p = 0.004), neo-adjuvant chemotherapy at primary diagnosis (OR = 2.46, 95% CI: 1.27-4.78, p = 0.007), and lymph-nodal site (OR = 2.67, 95% CI: 1.09-6.53, p = 0.031) were confirmed to be independent predictors of MI-SCS [40]. They showed, for the first time, a surprisingly higher rate of neoadjuvant chemotherapy and interval debulking surgery (IDS) at first diagnosis (p = 0.030) in the MIS group.…”

Laparoscopic secondary cytoreductive surgery: let’s not make the same assumptions

“…In this month's issue of International Journal of Gynecological Cancer, Conte et al 5 retrospectively evaluated the feasibility and survival outcomes in patients with recurrent ovarian cancer who underwent secondary cytoreduction via an open versus minimally invasive surgical approach. The authors included platinum sensitive patients with recurrent epithelial ovarian cancer and had preoperative positron emission tomography (PET)/computed tomography (CT) and diagnostic laparoscopy before embarking on the secondary cytoreduction.…”