Advanced cytoreductive surgery: American perspective

doi:10.1016/j.ygyno.2008.11.033

Gynecologic Oncology

Volume 114, Issue 2, Supplement, August 2009, Pages S3-S9

https://doi.org/10.1016/j.ygyno.2008.11.033 Get rights and content

Abstract

Over the past 3 to 4 decades a special knowledge and understanding of the pathophysiology and behavior of gynecologic peritoneal surface malignancies has led to a significant improvement of the relevant treatment modalities, mirroring advances in chemotherapy approaches and improved knowledge of tumor biology. The surgical management of advanced ovarian, primary peritoneal, and fallopian tube cancers has evolved from the performance of basic gynecologic procedures to the incorporation of more comprehensive surgical procedures. This extensive surgical approach is of great importance for estimating the prognosis and guiding further treatment of affected patients. These complex procedures involving multi-organ resections are generally long and require excellent knowledge of upper abdominal anatomy. This article will focus on the role and program development of advanced cytoreductive surgery in patients with gynecologic peritoneal malignancies.

This review is an attempt to provide guidance for the rationale and strategic approach to develop the surgical skill set, meet institutional requirements, and implement the concept of a comprehensive cytoreductive surgical team.

Section snippets

Primary cytoreductive surgery

Ovarian cancer is the second most common gynecologic malignancy in the United States, with an estimated 21,650 new cases diagnosed in 2008, and the most lethal, with an estimated 15,520 deaths during the same year [1]. The overall poor prognosis can be explained by the fact that the majority of patients (60% to70%) present at an advanced stage (International Federation of Gynecology and Obstetrics [FIGO] stage III or IV) [2], [3].

The natural history of advanced-stage (III and IV) epithelial

Conflict of interest statement

DSC has served on the Speaker's Bureau for Genzyme. All other authors have no conflicts of interest to declare.

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Membrane cholesterol enrichment and folic acid functionalization lead to increased accumulation of erythrocyte-derived optical nano-constructs within the ovarian intraperitoneal tumor implants in mice
2024, Nanomedicine: Nanotechnology, Biology, and Medicine
Cytoreductive surgery remains as the gold standard to treat ovarian cancer, but with limited efficacy since not all tumors can be intraoperatively visualized for resection. We have engineered erythrocyte-derived nano-constructs that encapsulate the near infrared (NIR) fluorophore, indocyanine green (ICG), as optical probes for NIR fluorescence imaging of ovarian tumors. Herein, we have enriched the membrane of these nano-constructs with cholesterol, and functionalized their surface with folic acid (FA) to target the folate receptor-α. Using a mouse model, we show that the average fraction of the injected dose per tumor mass for nano-constructs with both membrane cholesterol enrichment and FA functionalization was ~ sixfold higher than non-encapsulated ICG, ~ twofold higher than nano-constructs enriched with cholesterol alone, and 33 % higher than nano-constructs with only FA functionalization at 24-h post-injection. These results suggest that erythrocyte-derived nano-constructs containing both cholesterol and FA present a platform for improved fluorescence imaging of ovarian tumors.
Impact of postoperative morbidity on outcomes in patients with advanced epithelial ovarian cancer undergoing intestinal surgery at the time of primary or interval cytoreductive surgery: A Memorial Sloan Kettering Cancer Center Team Ovary study
2023, Gynecologic Oncology
To assess the impact of short-term postoperative complications on oncologic outcomes for patients with epithelial ovarian cancer undergoing primary cytoreductive surgery (PCS) or interval cytoreductive surgery (ICS) with intestinal resection.
A retrospective chart review was performed for patients with ovarian cancer who underwent PCS or ICS with at least one intestinal resection at our institution from 1/1/2015 to 12/31/2020. Progression-free survival (PFS) and overall survival (OS) were analyzed for the PCS and ICS cohorts separately. Short-term complications within 30 days of surgery (surgical secondary events [SSEs]) were graded by a validated institutional SSE system.
Among 437 patients who underwent intestinal resections during PCS (n = 289) or ICS (n = 148), 183 (42%) had one, 180 (41%) had two, and 74 (17%) had three intestinal resections. Six (1.4%) of 437 patients experienced an anastomotic leak postoperatively. There were no perioperative deaths. There was no difference in PFS and OS for patients who underwent PCS with any SSE vs. no SSE within 30 days of surgery (HR, 1.05; 95% CI: 0.76–1.47; p = 0.75 and HR, 0.79; 95% CI: 0.49–1.26; p = 0.32, respectively). There was no difference in PFS and OS for patients who underwent ICS with any SSE vs. no SSE within 30 days of surgery (HR, 1.43; 95% CI: 0.99–2.07; p = 0.055 and HR. 1.18; 95% CI: 0.72–1.93; p = 0.52, respectively.
Short-term postoperative morbidity for patients who underwent intestinal surgery during primary surgical management for advanced ovarian cancer did not impact oncologic outcomes.
Ovarian Cancer: Towards Personalizing Ovarian Cancer Treatments Using Patient-Derived Organoids
2022, Comprehensive Pharmacology
Accelerating the development of emergent therapeutic strategies is urgently needed to improve the dismal survival rates in ovarian cancer. Ovarian cancer remains one of the deadliest cancer types, with a 5-year survival rate of just 30% for the majority of patients; yet the standard of care has barely changed in decades. The high tumor heterogeneity and frequency of relapse with drug-resistant tumors has made both research and treatment especially challenging. Cancer stem cells represent a small tumor cell population proposed to drive tumor relapses and resistance in several cancer types, including ovarian. Patient-derived tumor organoids recapitulate tumor heterogeneity and drug responses, including inter- and intra-patient differences, and are amenable to high-throughput screening. For many solid cancers like ovarian, ex vivo drug testing using patient-derived tumor organoids has been implemented, creating the opportunity to establish precision medicine platforms for preclinical therapeutic testing including in racial and ethnic minorities underrepresented in clinical trials. In this article, we will first discuss the complexity of ovarian cancer biology along with current and emerging therapeutic strategies. We will then describe tumor organoid technologies, highlighting evidence to date in predicting patient drug responses as well as current efforts to realize the promise of organoid platforms for improving ovarian cancer treatment.
Survival outcomes of acute normovolemic hemodilution in patients undergoing primary debulking surgery for advanced ovarian cancer: A Memorial Sloan Kettering Cancer Center Team Ovary study
2021, Gynecologic Oncology
Citation Excerpt :
Cytoreductive surgery, whether performed before chemotherapy as primary debulking surgery (PDS) or after neoadjuvant chemotherapy as interval debulking surgery (IDS), is a well-established cornerstone in the primary treatment of advanced ovarian, tubal, and primary peritoneal cancer [1]. These lengthy procedures require extensive surgical exploration, often including removal of multiple organs, and are frequently accompanied by substantial blood loss necessitating perioperative allogenic blood transfusion (ABT) [1,2]. Although the risk of infection has declined with improved donor screening, other risks persist, including immunosuppression, transfusion reactions, cardiovascular events, acute kidney injury, and higher postoperative morbidity/mortality [3,4].
To describe oncologic outcomes after using acute normovolemic hemodilution (ANH) to reduce requirement for allogenic red blood cell transfusions (ABT) in patients undergoing primary debulking surgery (PDS) for advanced ovarian cancer.
We performed a post-hoc analysis of a recent prospective trial investigating the safety and feasibility of ANH during PDS for advanced ovarian cancer. We report long-term survival outcomes. We compared demographics, clinicopathological characteristics, survival outcomes in this cohort of Stage IIIB-IVB high-grade serous ovarian cancer patients undergoing ANH (ANH group), with a retrospective cohort of all other patients (standard group) undergoing PDS during the same time period (01/2012–04/2017). Standard statistical tests were used.
There were no demographic or clinicopathological differences between ANH (n = 33) and standard groups (n = 360), except for higher median age at diagnosis (57 vs. 62 years, respectively; p = 0.044) and shorter operative time (357 vs. 446 min, respectively; p < 0.001) in the standard group. Cytoreductive outcomes (ANH vs. standard): 0 mm, 69.7 vs. 63.9%; gross residual disease (RD) ≤1 cm, 21.2 vs. 26.9%; >1 cm, 9.1 vs. 9.2% (p = 0.78). RD after PDS was the only independent factor associated with worse progression-free survival (PFS) on multivariable analysis (p < 0.001). Patients with BRCA mutations trended towards improved PFS (p = 0.057). Significant factors for overall survival (OS) on multivariable analysis: preoperative CA125 (p = 0.004), ascites (p = 0.018), RD after PDS (p = 0.04), BRCA mutation status (p < 0.001). After adjustment for potential confounders, ANH was not independently associated with PFS or OS [PFS: HR 0.928 (0.618–1.395); p = 0.721; OS: HR 0.588 (95%CI: 0.317–1.092); p = 0.093].
ANH is an innovative approach in intraoperative management. It was previously proven to decrease need for ABT while maintaining the ability to achieve complete gross resection and associated benefits.
Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: A systematic review
2020, European Journal of Surgical Oncology
Citation Excerpt :
In the end, 18 studies were selected [2–19]. Of these 5 studied were not considered for the final analysis given the potential overlap [3,5,7–9], while 2 studies were not considered for the final analysis as they does not report complications [13,15]. The selection process is summarized in Fig. 1.
In ovarian cancer (OC), survival benefit in case of complete cytoreduction with absence of residual tumor has been clearly demonstrated; however, it often requires extensive surgery. Particularly, pancreatic resection during cytoreduction, may severely impact perioperative morbidity and mortality.
The aim of this systematic review is to evaluate complication rates and related optimal management of ovarian cancer patients undergoing pancreatic resection as part of cytoreductive surgery.
Literature was searched for relevant records reporting distal pancreatectomy for advanced ovarian cancer. All cohorts were rated for quality. We focused our analysis on complications related to pancreatic surgical procedures evaluating the following outcomes: pancreatic fistula (PF), abdominal abscess, pancreatitis, iatrogenic diabetes, hemorrhage from splenic vessels and pancreatic-surgery-related mortality.
The most frequent complication reported was PF. Similar rates of PF were reported after hand-sewn (20%) or stapled closure (24%). Continued drainage is the standard treatment, and often, the leak can be managed conservatively and does not require re-intervention. Abdominal abscess is the second most frequent complication and generally follows a non-adequately drained PF and often required re-laparotomy. Pancreatitis is a rare event that could be treated conservatively; however, death can occur in case of necrotic evolution. Cases of post-operative hemorrhage due to splenic vessel bleeding have been described and represent an emergency.
Knowledge of pancreatic surgery and management of possible complications ought to be present in the oncologic-gynecologic armamentarium. All patients should be referred to specialized, dedicated, tertiary centers in order to reduce, promptly recognize and optimally manage complications.
Surgical Treatment and Outcome of Ovarian Cancer Patients With Liver Metastases: Experience of a Tertiary Hepatic and Peritoneal Surface Malignancy Center
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Advanced cytoreductive surgery: American perspective

Abstract

Section snippets

Primary cytoreductive surgery

Conflict of interest statement

Int. J. Gynaecol. Obstet.

Int. J. Gynaecol. Obstet.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Am. J. Obstet. Gynecol.

J. Am. Coll. Surg.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Cancer statistics, 2008

CA Cancer J. Clin.