Laparoscopic Surgical Algorithm to Triage the Timing of Tumor Reductive Surgery in Advanced Ovarian Cancer

Abstract

Objective: To estimate the effects of a laparoscopic scoring algorithm to triage patients with advanced ovarian cancer to immediate or delayed debulking to improve complete gross surgical resection rates and determine the resulting clinical outcomes.

Methods: We prospectively performed laparoscopic assessment on patients with suspected advanced-stage ovarian cancer from April 2013 to December 2016 to determine primary resectability at tumor reductive surgery. Patients with medically inoperable or distant metastatic disease received neoadjuvant chemotherapy. Two-surgeon scoring was performed in a blinded fashion using a validated scoring method. Patients with predictive index value scores less than 8 were offered primary surgery and those with scores 8 or greater received neoadjuvant chemotherapy. Univariate and multivariate analysis was performed for effects on progression-free survival.

Results: Six hundred twenty-one patients presenting with presumed advanced ovarian cancer were evaluated during the study period and 488 patients met inclusion criteria. Two hundred fifteen patients underwent laparoscopic scoring, of whom 125 had predictive index value scores less than 8 and 84 had predictive index value scores 8 or greater. Blinded two-surgeon predictive index value scoring resulted in bivariate discordance in only 2% of patients. Tumor cytoreduction led to no gross residual disease (R0 resection) in 88% of patients in the primary surgery group and 74% in the neoadjuvant chemotherapy group. Patients triaged to primary surgery had an improved progression-free survival of 21.4 months versus 12.9 months in those patients undergoing neoadjuvant chemotherapy (P<.001). Median progression-free survival by treatment group and residual disease status was as follows: primary surgery-R0 23.5 months; primary surgery-R1 (any gross residual disease) 17.6 months; neoadjuvant chemotherapy-R0 15.5 months; and neoadjuvant chemotherapy-R1 12.9 months (P<.001). On multivariate analysis for progression-free survival, baseline CA 125 (P=.001) and gross residual disease at tumor reductive surgery (P=.01) were significantly associated with progression-free survival.

Conclusion: Laparoscopic triage assessment allowed for a personalized approach to the management of patients with advanced ovarian cancer and resulted in high complete surgical resection rates at tumor reductive surgery.

Conflict of interest statement

Financial Disclosure

Larissa A. Meyer has received research funding from AstraZeneca for unrelated research, and she participated in an advisory board for Clovis Oncology in October of 2016. The other authors did not report any potential conflicts of interest.

Conflict of Interest Disclosures:

The authors have no conflicts of interest to disclose.

Figures

Figure 1

Flow diagram. *3 patients were lost to follow-up and not included in subgroup analysis (n=485). NACT, neoadjuvant chemotherapy; PIV, predictive index value.

Figure 2

Progression-free survival in patients undergoing laparoscopic scoring assessment by treatment group (A). Median progression-free survival was 21.4 months for primary surgery compared to 12.9 months for the NACT group (P<.001). Progression-free survival in patients undergoing laparoscopic scoring assessment by residual disease and treatment group (B). Median progression-free survival was 23.5 months for primary surgery–R0, 17.6 months for primary surgery–R1, 15.5 months for NACT–R0, and 12.9 months for NACT–R1 (P<.001). NACT, neoadjuvant chemotherapy; R0, no gross residual disease; R1, any gross residual disease remaining (≤1 cm or >1 cm). Numbers in parentheses represent the number of events (deaths or progressions) between the two time points.