Radical surgery versus standard surgery for primary cytoreduction of bulky stage IIIC and IV ovarian cancer: an observational study

Abstract

Background: The aim of this study was to evaluate the survival benefit of radical surgery with additional extensive upper abdominal procedures (EUAS) for the treatment of stage IIIC and IV ovarian cancer with bulky upper abdominal disease (UAD).

Methods: An observational study was conducted between 2009 and 2012 involving two different surgical teams. Team A was composed of the "believers" in EUAS and Team B the "non-believers" in EUAS. Patients were divided into a radical surgery group (EUAS group) or a standard surgery group (non-EUAS group) according to whether or not they had received EUAS. All patients underwent primary cytoreductive surgery with the goal of optimal debulking (≤ 1 cm); this was reviewed in the pelvis, middle abdomen, and upper abdomen. The baseline for the two groups was optimal cytoreduction in both the pelvis and middle abdomen. Progression-free survival (PFS) was evaluated.

Results: Radical surgery was performed in 70.7% (82/116) and 12.7% (30/237) of the patients by Teams A and B, respectively. The study groups had similar clinicopathologic characteristics. The median PFS and OS were significantly improved in the radical surgery group, compared with standard surgery groups (PFS: 19.5 vs. 13.3 months, HR: 0.61; 95% CI: 0.46-0.80, P < 0.001; OS: not reached vs. 39.3 months, HR: 0.47; 95% CI: 0.30-0.72, P < 0.001). Positive predictors of complete cytoreduction were treatment with neoadjuvant chemotherapy, improved American Society of Anesthesiologists performance status, and the absence of bowel mesenteric carcinomatosis.

Conclusions: Radical surgery lengthens the PFS and overall survival times of ovarian cancer patients with bulky UAD. However, a well-designed randomized trial is needed to confirm the present results.

Fig. 1

Survival analysis of EUAS group vs. non-EUAS group in bulky stage IIIC and IV EOC. a: Progression-free survival curve; b: Overall survival curve (Analysis as of May 6, 2014)

Fig. 2

PFS by residual disease in the upper abdomen after primary cytoreductive surgery. a: comparison of residual disease between <0.5 cm vs. >0.5 cm; b: comparison of residual disease between 0 cm vs. >0 cm

Fig. 3

PFS by residual disease in upper abdomen after primary cytoreductive surgery. A comparison of residual disease among 0 cm, 0–0.5 cm, 0.5–1 cm, >1 cm

Fig. 4

Survival analysis by residual disease in overall after primary cytoreductive surgery. a: PFS comparison of residual disease in overall among 0 cm, 0–0.5 cm, 0.5–1 cm, >1 cm; b: PFS comparison of residual disease in overall between <0.5 cm vs. >0.5 cm; c: PFS by residual disease in overall after primary cytoreductive surgery in patients with FIGO stage IIIC. d Progression-free survival by residual disease in overall after primary cytoreductive surgery in patients with FIGO stage IV

Fig. 5

Overall survival by residual disease in upper abdomen after primary cytoreductive surgery. a: OS by residual disease in upper abdomen after primary cytoreductive surgery; b: OS by residual disease in upper abdomen with a comparison of cut-off point R0.5 cm; c: OS by residual disease in upper abdomen with a comparison of cut-off point R0 cm

Fig. 6

Overall survival by residual disease in overall after primary cytoreductive surgery. a: OS by residual disease in overall after primary cytoreductive surgery; b: OS by residual disease in overall with a comparison of cut-off point R0.5 cm; c: OS by residual disease in overall with a comparison of cut-off point R0 cm