Clinical outcomes of neoadjuvant chemotherapy and primary debulking surgery in advanced ovarian carcinoma

Background: Primary debulking surgery (PDS) and paclitaxel-platinum chemotherapy remains the mainstay of treatment for advanced ovarian cancer. However, there is considerable morbidity and even mortality associated with this approach. The concept of primary chemotherapy followed by interval debulking surgery (IDS) has emerged for advanced stage disease with the aim of improving sensitivity to chemotherapy and improving survival. The purpose of our study was to examine the impact of IDS on clinical outcomes of patients considered unsuitable for PDS and compare them with outcomes of women that had conventional PDS followed by chemotherapy.

Patients and methods: A non-randomised prospective cohort study of 35 patients who underwent IDS and 29 patients treated with PDS were included. All patients had Stage IIIC or IV disease. The IDS patients were considered unresectable based on an initial laparoscopy or preoperative computed tomography findings. All patients were treated by the same lead surgeons and received the same regimen of chemotherapy.

Results: The median intraoperative blood loss, the incidence of pelvic lymphadenectomies, the median hospital stay and the possibility of admission to the Intensive Care Unit were significantly less in the IDS group. Optimal cytoreduction was higher in the IDS compared to the PDS group, but did not reach statistical significance.

Conclusions: IDS for advanced ovarian cancer may be associated with less morbidity compared to PDS and appears to require less use of hospital resources. If the ongoing randomised studies confirm that IDS does not adversely affect the long-term survival of these patients, morbidity related to ovarian cancer surgery may evolve as a crucial factor for choosing treatment options.

Advanced Ovarian Cancer; Interval debulking surgery; Morbidity

[1] Griffiths T.C., Parker L.M., Fuller A.F.: "Role of cytoreductive surgical treatment in the management of advanced ovarian cancer". Cancer Treat. Rep., 1979, 63, 235.

[2] Michel G., DeiLaco P., Castaigne D.: "Extensive cytoreductive surgery in advanced ovarian carcinoma". Eur. J. Gynaecol. Oneal., 1997, 18, 9.

[3] Hacker N.F., Berek J.S., Lagasse L.D.: "Primary cytoreductive surgery for epithelial ovarian cancer". Obstet. Gynecol., 1983, 61, 413.

[4] Hoskins W.J., McGuire W.P., Brady M.F.: "The effect of the diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma". Am. J. Obstet. Gynecol., 1994, 170, 974.

[5] Eisenkop S.M., Friedman R.L., Wang H.J.: "Complete cytoreductive surgery is feasible and maximizes survival in patients with advanced epithelial ovarian cancer: a prospective study". Gynecol Oneal., 1998, 69, 103.

[6] Shimada M., Kigawa J., Minagawa Y.: "Significance of cytoreductive surgery including bowel resection for patients with advanced ovarian cancer". Am. J. Clin. Oneal., 1999, 22, 481.

[7] Cuidoizi F., Ball J.H.: "Extensive primary cytoreductive surgery for advanced epithelial ovarian cancer". Gynecol. Oneal., 1994, 53, 326.

[8] Shimada M., Ktgawa J., Mtnagawa Y.: "Significance of cytoreductive surgery including bowel resection for patients with advanced ovarian cancer". Am. J. Clin. Oneal. 1999, 22, 481.

[9] Donato D., Angelides A., Irani H.: "Infectious complications after gastrointestinal surgery in patients with ovarian carcinoma and malignant ascites". Gynecol. Oneal., 1992, 44, 40.

[10] Vergote I.B., De Wever I., Decloedt J.: "Neoadjuvant chemotherapy or primary debulking surgery in advanced ovarian carcinoma: a retrospective analysis of 285 patients". Gynecol. Oneal., 1998, 71. 431.

[11] Jemal A., Tiwari C., Murray T.: "Cancer statistics, 2004". CA Cancer J. Clin., 2004, 54.

[12] Boente P., Chi S., Hoskins J.: "The role of surgery in the management of ovarian cancer: primary and interval cytoreductive surgery". Semin. Oneal., 1998, 25, 326.

[13] Canis M., Rabischong B., Botchorishvili R.: "Risk of spread of ovarian cancer after laparoscopic surgery". Curr. Opin. Obst et. Gynecol., 2001, 13, 9.

[14] Ansquer Y., Leblanc E., Clough K.: "Neoadjuvant chemotherapy for unresectable ovarian carcinoma". Cancer 2001, 91, 23.

[15] Vergote I., De Wever I., Decloedt J.: "Neoadjuvant chemotherapy versus primary debulking surgery in advanced ovarian cancer". Semin. Oneal., 2000, 27, 31.

[16] Jacob H., GershensoJ:1 M., Morris M.: "Neoadjuvant chemotherapy and interval Debulking for advanced epithelial ovarian cancer". Gynecol. Oneal., 1991, 42, 146.

[17] Schwartz E., Rutherford J., Chambers T.: "Neoadjuvant chemotherapy for advanced ovarian cancer: long-term survival". Gynecol. Oneal., 1999, 72, 93.

[18] Van der Burg L., Van Lent M., Buyse M.: "The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer". N. Engl. J. Med., 1995, 332.

[19] Rose G., Nerenstone S., Brady F.: "Secondary surgical cytoreduction for advanced ovarian carcinoma". N. Engl. J. Med., 2004, 351, 2489.

[20] Morice P., Dubernard G., Rey A.: "Results of interval debulking surgery compared with primary debulking surgery in advanced stage ovarian cancer". J. Am. Coll. Surg., 2003, 197, 955.

[21] Rose G., Nerenstone S., Brady M.: "A phase III randomized study of interval secondary cytoreduction in patients with advanced stage ovarian carcinoma with suboptimal residual disease: a Gynecologic Oncology Group study". Proceedings of the American Association of Cancer Research, 2002, 802.

[22] Vergote I., De Wever I., Tjalma W.: "Interval debulking surgery: an alternative for primary surgical debulking?". Semin. Surg. Oneal., 2000, 19, 49.

[23] Shimada M., Kigawa J., Minagawa Y.: "Significance of cytoreductive surgery including bowel resection for patients with advanced ovarian cancer". Am. J. Clin. Oneal., 1999, 22, 481.

[24] Jacob H., Gershenson M., Morris M.: "Neoadjuvant chemotherapy and interval debulking for advanced epithelial ovarian cancer". Gynecol. Oneal., 1991, 42, 146.

[25] Morice P., Leblanc E., Narducci F., Pomel C., Pautier P., Chevalier A. et al.: "Initial or interval debulking surgery for advanced stage ovarian cancer: state-of-the-art. How to select patients?" Gynecol. Obstet. Fertil., 2005, 33, 55.

[26] Arwit E., Childers J., Atlas I.: "Neoadjuvant chemotherapy for advanced ovarian cancer". Int. J. Gynecol. Cancer, 1996, 6, 356.

[27] Schwartz E., Rutherford , Champers A.: "Neoadjuvant chemotherapy for advanced ovarian cancer. Long-term survival". Gynecol Oneal., 1999, 72, 93.

[28] Van Dam A., DeCloedt J., Tjalma A., Buytaert P., Becquart D., Vergote I.: "Trocar implantation metastasis after laparoscopy in patients with advanced ovarian cancer: can this risk be reduced?". Am. J. Obstet. Gynecol., 181, 3, 536.

[29] Morice P., Viala J., Pautier P.: "Port site metastasis after laparoscopic surgery for gynecological cancer. Report of 6 cases and surgical implications for prevention". J. Reprod. Med., 2000, 45, 837.

[30] Canis M., Rabischong B., Botchorishvili R.: "Risk of spread of ovarian cancer after laparoscopic surgery". Curr. Opin. Ob stet. Gynecol., 2001, 13, 9.

[31] V rscaj U., Rakar S.: "Neoadjuvant chemotherapy for advanced epithelial ovarian carcinoma: a retrospective case-control study" Eur. J. Gynaecol. Oneal., 2002, 23, 405.

[32] Morice P., Dubemard G., Atallah D., Pautier P., Duvillard P., Castaigne D.: "Results of interval debul灼ng surgery compared with primary debulking surgery in advanced stage ovarian cancer". J Am. Coll. Surg., 2003, 197, 955.

[33] Schwartz P., Rutherford J., Chambers T.: "Induction chemotherapy for advanced ovarian cancer: Long-term survival". Gynecol. Oneal., 1999, 72, 93.

[34] Surwit E., Childers J., Atlas I. et al.: "Neoadjuvant chemotherapy for advanced ovarian cancer". Int. J. Gynecol. Cancer, 1996, 6, 356.