Secondary cytoreductive surgery in the management of platinum-sensitive recurrent epithelial ovarian cancer
April 2010
Commentary by Associate Professor Jim Nicklin
The article:
Park JY., Eom JM., Kim DY., et al. Secondary cytoreductive surgery in the management of platinum-sensitive recurrent epithelial ovarian cancer. J Surg Oncol 2010 101(5):418-24
The reviewers:
Associate Professor Jim Nicklin is Clinical Director of Gynaecologic Oncology at Royal Brisbane and Women's Hospital, Queensland.
Abbreviations
Disease Free Interval (DFI), Disease Free Survival (DFS), Epithelial Ovarian Cancer (EOC), Overall Survival (OS), Secondary Cytoreductive Surgery (SCRS)
Summary
Study Design
This retrospective study aimed to assess surgical and survival outcomes in patients with platinum-sensitive recurrent epithelial ovarian cancer (EOC) who underwent secondary cytoreductive surgery (SCRS), and to identify patients who would most benefit from SCRS. Patients were identified who underwent SCRS at Asan Medical Centre, Seoul Korea, between 1992 and 2008. The inclusion criteria were (1) patients with recurrent EOC; (2) primary treatment consisting of maximal cytoreductive surgery followed by platinum-based adjuvant chemotherapy; (3) disease free interval (DFI) >6mths after completion of primary treatment; and (4) SCRS with therapeutic intention followed by adjuvant chemotherapy.
Findings
Sixty-seven patients met the inclusion criteria and were included in the analysis. Mean age at tumour recurrence was 55yrs. The mean DFI from completion of primary treatment to recurrence was 28mths. At SCRS, 41 of the 67 patients (61.2%) achieved optimal cytoreduction. Median time in surgery was 240min and median blood loss was 100ml. There was no significant perioperative complication requiring reoperation. After a mean follow-up of 41mths, 43 patients (64.2%) had recurrent disease, including 30 patients who died of disease. The 2yr and 5yr disease free survival (DFS) rates were 32% and 10% respectively. The 2yr and 5yr overall survival (OS) rates were 58% and 26%, respectively. In multivariable analysis, DFI >24mths and residual tumour ≤1cm were significant predictors of DFS and OS.
Conclusion
The authors conclude that SCRS in patients with platinum-sensitive recurrent epithelial ovarian cancer is safe and effective, with a low rate of complications. SCRC was most beneficial in patients with a DFI >24mths and those who achieved optimal cytoreduction.
Commentary
What does this article add to existing clinical evidence in this area?
This article contributes to a moderate body of evidence supporting the utility and feasibility of secondary cytoreductive surgery (SCRS). Multiple retrospective and a few prospective non-randomized series have all demonstrated that SCRS can be achieved in selected patients with morbidity and mortality rates comparable to primary surgery. In a recent meta-analysis, the weighted mean proportion of patients with recurrent ovarian cancer undergoing SCRS where complete cytoreductive surgery was achieved was 52.2%.1 In this series from Park et al, complete surgical cytoreduction was achieved in 55.2% of patients and cytoreduction to ≤ 1cm in 61% of patients. Statistical analysis demonstrated optimal survival in patients with a disease-free interval (DFI) of >24 months and optimal cytoreduction (residual tumour ≤ 1 cm). The literature would suggest significant benefit from SCRS in patients with ≥12 months DFI and that complete cytoreduction is of paramount importance. 1,2 There are now two active, prospective randomized trials underway evaluating the role of SCRS in patients with platinum-sensitive recurrent epithelial ovarian cancer (EOC), namely GOG 213 and EORTC 55963.
How adequate was the methodology used in addressing the aim of this study?
This was a small, retrospective series from a single institution, accrued over 16 years (4 patients per year). There are no data regarding patients eligible for, but not treated with SCRS over the study period. Consequently there is a risk of selection bias and caution is necessary when attempting to extrapolate results to all patients with platinum-sensitive EOC. Statistical analysis was appropriate and uncomplicated.
What are the implications of this study for clinical practice in Australia?
This study, viewed in the context of the international literature, supports a role for SCRS in selected patients with platinum-sensitive EOC, particularly where there is a DFI of over 12-24 months and a high expectation of optimal cytoreduction. This is of particular interest in view of the EORTC 55955 study where early results have shown no statistical difference in overall survival (OS) between unblinded and blinded CA125 results and associated early or late instigation of chemotherapy.3 EORTC 55955 may provide further information on the role of SCRS in recurrent ovarian cancer and further results of this randomised study are awaited with interest. From the studies of SCRS it is apparent that there is little difference in OS unless optimal cytoreduction is achieved prior to secondary chemotherapy. Until the results of GOG 213 and EORTC 55963 become available, SCRS for selected patients with platinum-sensitive EOC remains a valid and appropriate treatment option.
References
- Bristow RE, Puri I, Chi DS. Cytoreductive surgery for recurrent ovarian cancer: a meta-analysis. Gynecol Oncol. 2009 Jan;112(1):265-74. Epub 2008 Oct 19. Review. PubMed PMID: 18937969.
- Chi DS, McCaughty K, Diaz JP, Huh J, Schwabenbauer S, Hummer AJ, Venkatraman ES, Aghajanian C, Sonoda Y, Abu-Rustum NR, Barakat RR. Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer. 2006 May 1;106(9):1933-9. PubMed PMID: 16572412.
- Rustin GJ., van der Burg ME., on behalf of MRC and EORTC Collaborators. A randomized trial in ovarian cancer (OC) of early treatment of relapse based on CA125 level alone versus delayed treatment based on conventional clinical indicators (MRC OV05/EORTC 55955 trials). J Clin Oncol. 2009;27:18S:1.
Editor: Dr Anne Nelson, Evidence Review and Research Leader, National Breast and Ovarian Cancer Centre.
Clinical Update - Ovarian Cancer Editorial Committee: Prof Michael Friedlander – Medical Oncologist, Prof Neville Hacker – Gynaecological Oncologist, Ms Kim Hobbs – Social Worker, Dr Gillian Mitchell – Medical Oncologist, Dr Deborah Neesham – Gynaecological Oncologist, Ms Georgie Richter – Gynaecological Nurse.
Disclaimer
Clinical Update - Ovarian Cancer is produced by the National Breast and Ovarian Cancer Centre (NBOCC) and is intended to provide health professionals with timely expert commentary on new research in ovarian cancer. Commentaries included in Clinical Update - Ovarian Cancer do not replace recommendations included in NBOCC clinical practice guidelines.
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