The effect of maximal surgical cytoreduction on sensitivity to platinum-taxane chemotherapy and subsequent survival in patients with advanced ovarian cancer☆
Introduction
Of the 22,430 women estimated to be diagnosed with ovarian cancer in 2007, the majority will present at an advanced stage [1]. For these patients, standard initial therapy will entail primary cytoreductive surgery followed by combination platinum-taxane chemotherapy [2]. Of the many pretreatment prognostic factors associated with improved survival, few have had the durable effect of optimal primary cytoreduction [3].
The benefit of optimal primary cytoreduction is dependent on the availability of highly active chemotherapy, which should be more effective when tumor volume is reduced below a certain threshold. The Gynecologic Oncology Group (GOG) has used the threshold of ≤ 1 cm residual disease in greatest dimension to define “optimal” cytoreduction since 1986 [4]. Increasingly, reports have demonstrated that there may be an additional survival advantage associated with cytoreduction to no visible residual disease [5], [6], [7], [8], [9], [10]. It remains unresolved as to whether this improvement is due to increased chemotherapy sensitivity, more favorable “tumor biology,” and/or simply “re-setting the clock,” such that those with less residual disease take longer to recur and succumb to their disease.
The objective of this study was to explore the associations between residual disease categories after primary cytoreduction on initial chemotherapy response and resistance in patients with advanced ovarian cancer, and whether these associations had subsequent relevance to their time to recurrence and ultimate survival.
Section snippets
Methods
After obtaining Institutional Review Board approval, we identified all patients who underwent primary cytoreductive surgery at our institution between 1/98 and 12/04. The records of all patients with stage IIIC–IV epithelial ovarian cancer who subsequently received intravenous platinum-taxane chemotherapy were reviewed and compared as three groups based on residual disease at the completion of primary cytoreduction—no visible tumor, 1–10 mm residual, and > 10 mm residual disease. Exclusion
Results
During the study period, 296 patients met criteria for inclusion and were compared as three groups—no visible residual, 64 patients (22%); 1–10 mm residual, 145 patients (49%); and > 10 mm residual, 87 patients (29%). Patient characteristics, tumor features, and intraoperative findings between the three groups were compared (Table 1). The majority of patients in all three groups had stage IIIC disease, grade 3 tumors, and serous histology. Age at the time of surgery was equivalent, but patients
Discussion
Since the initial observations by Meigs, expanded more completely by Griffiths, a growing body of literature has supported the association between surgical cytoreduction and improved survival in advanced ovarian cancer [5], [6], [7], [8], [9], [10], [18], [19], [20], [21]. Two meta-analyses have summarized many of the reported studies thus far, and have demonstrated the longest survival in patients cytoreduced to no visible tumor [3], [22]. In their study, Bristow et al. evaluated 81 studies
References (32)
Epithelial ovarian carcinoma: principles of primary surgery
Gynecol Oncol
(1994)- et al.
The prognostic significance of residual disease, FIGO substage, tumor histology, and grade in patients with FIGO stage III ovarian cancer
Gynecol Oncol
(1995) - et al.
Does debulking surgery improve survival in biologically aggressive ovarian carcinoma?
Gynecol Oncol
(1997) - et al.
Complete cytoreductive surgery is feasible and maximizes survival in patients with advanced epithelial ovarian cancer: a prospective study
Gynecol Oncol
(1998) - et al.
Complete surgical cytoreduction of advanced ovarian carcinoma using the argon beam coagulator
Gynecol Oncol
(2001) - et al.
Relative influences of tumor volume before surgery and the cytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study
Gynecol Oncol
(2003) - et al.
Defining progression of ovarian carcinoma during follow-up according to CA 125: a North Thames Ovary Group Study
Ann Oncol
(1996) - et al.
What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)?
Gynecol Oncol
(2006) - et al.
Delaying the primary surgical effort for advanced ovarian cancer: a systematic review of neoadjuvant chemotherapy and interval cytoreduction
Gynecol Oncol
(2007) - et al.
Is it justified to classify patients to stage IIIC epithelial ovarian cancer based on nodal involvement only?
Gynecol Oncol
(2006)
Improved optimal cytoreduction rates for stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal cancer: a change in surgical approach
Gynecol Oncol
The addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival in patients with stages IIIC–IV epithelial ovarian cancer
Gynecol Oncol
Cancer statistics, 2007
CA Cancer J Clin
Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study
J Clin Oncol
Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis
J Clin Oncol
Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience
J Clin Oncol
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Presented in part at the 11th Biennial International Gynecologic Cancer Society Meeting; Santa Monica, CA; October 14–18, 2006.