Splenectomy and surgical cytoreduction in epithelial ovarian cancer: a review

HANPRASERTPONG J. & FUJIWARA K. (2011) European Journal of Cancer Care 20 , 287–293
Splenectomy and surgical cytoreduction in epithelial ovarian cancer: a review Surgical cytoreduction and platinum/taxane combination chemotherapy are the mainstay for the treatment of epithelial ovarian cancer patients. In order to minimise the tumour mass before chemotherapy, cytoreductive surgery is usually performed first. Currently, a splenectomy is included as part of surgical cytoreduction in epithelial ovarian cancer, but it is rarely performed. A splenectomy is also performed as part of secondary cytoreduction surgery. Although there are many reports on surgical techniques, safety and associated clinical outcomes of a splenectomy as a standard adjunct of ovarian cytoreductive surgery, most evidence is from case(s) reports, with only a few studies. Thus, we conducted a review of the literature on this unusual procedure in the context of primary and secondary cytoreduction of epithelial ovarian cancer to assess the published evidence for its efficacy and safety.     

结肠、直肠手术在肿瘤细胞减灭术中的作用

目的　探讨结肠、直肠手术在治疗卵巢上皮性癌和原发腹膜癌患者的手术指征和治疗效果。方法　对 1988年 6月～2 0 0 1年 5月在我院妇科接受开腹手术同时行结肠、直肠手术的 18例妇科恶性肿瘤进行回顾性分析 ,其中卵巢上皮性癌 16例和原发腹膜癌 2例。结果　有 8例在初次手术中完成结肠、直肠手术 ,10例在处理复发性癌或者姑息性手术中进行。 18例中接受结肠切除或者部分乙状结肠直肠手术 ,肠吻合术 14例 ,接受结肠造瘘术 4例 ,其中 1例于结肠造瘘术后 14个月行结肠造瘘还纳术。 18例中有 17例切除肠管 ,术后病理显示肿瘤侵犯至肠浆膜层 7例 ,至浆肌层 5例 ,至粘膜下层 3例 ,至粘膜层 2例。有 7例术后残留癌 <2cm ,10例 >2cm ,1例行姑息性手术未切除肠管。术后 1年生存率为 76 % ,2年为 2 9% ,3年为 19%。有 2例术后存活已超过 5年。结论　对卵巢上皮性癌或者原发性腹膜癌患者实施结肠、直肠手术的主要目的是为达到肿瘤细胞减灭或者为缓解肠梗阻症状。选择一组合适的妇科恶性肿瘤病人术前最好肠道准备 ,术中尽量采用肠切除肠吻合术 ,减少结肠造瘘术 ,对提高治疗效果 ,延长病人寿命是有益的。     

间歇性肿瘤细胞减灭术与初始肿瘤细胞减灭术对晚期上皮性卵巢癌的疗效评价

目的探讨间歇性肿瘤细胞减灭术(IDS)与初始肿瘤细胞减灭术(PDS)对晚期上皮性卵巢癌(EOC)的疗效。方法根据手术方法的不同将132例晚期EOC患者分为PDS组(n=87例)和IDS组(n=45)。PDS组患者行PDS手术后接受6~8个疗程的化疗。IDS组患者行PDS手术后接受3个疗程的化疗,然后再行IDS手术后化疗3~5个疗程。观察两组患者的PDS切除范围,比较两组患者的减瘤满意率、疗效、血清CA125水平和不良反应发生情况。结果IDS组患者的PDS切除范围明显小于PDS组(P﹤0.01)。IDS组患者的减瘤满意率高于PDS组(P﹤0.05)。IDS组患者的临床疗效明显优于PDS组(P﹤0.01)。术前和第3次化疗后,两组患者的血清CA125水平比较,差异均无统计学意义(P﹥0.05)。IDS组患者PDS后的血清CA125水平高于PDS组,完成化疗后的血清CA125水平低于PDS组(P﹤0.05)。IDS组患者的不良反应总发生率低于PDS组(P﹤0.05)。结论IDS有助于提高晚期EOC患者的手术减瘤满意率和近期疗效,且不会显著增加不良反应。     

晚期上皮性卵巢癌术后辅助化疗与放疗

对晚期上皮性卵巢癌减瘤术后辅助化疗及放疗的结果进行比较分析。材料与方法对５２例已行初次减瘤术的Ⅲｃ、Ⅳ期上皮性卵巢癌病人随机分成腹腔化疗＋静脉化疗（化疗组）和放疗＋静脉化疗（放疗组）２组，给予药物及放射治疗。结果化疗及放疗２组病人５年生存率分别是２７．３％和３６．７％，无明显差异。无严重并发症。结论对控制晚期上皮性卵巢癌减瘤术后腹腔残余癌，腹腔化疗＋静脉化疗及放疗＋静脉化疗同样有效，且较术后单纯静脉化疗效果好。     

新辅助化疗结合间隔减瘤术治疗晚期卵巢癌的探讨

目的：探讨新辅助化疗结合间隔减瘤术治疗晚期卵巢癌的效果。方法：对我院在1998年1月至2003年12月间收治的51例晚期卵巢癌进行回顾性分析,先行新辅助化疗,CP方案全身化疗3疗程后行间隔减瘤术,术后继续化疗6疗程,分析3年及5年生存率。结果：明显提高肿瘤细胞减灭术的满意率,3年生存率80．4％,5年生存率58．8％。结论：新辅助化疗结合间隔减瘤术治疗晚期卵巢癌可以明显提高晚期卵巢癌患者手术满意率和生存率。     

新辅助化疗结合间隔减瘤术治疗晚期卵巢癌的探讨

目的:探讨新辅助化疗结合间隔减瘤术治疗晚期卵巢癌的效果.方法: 对我院在1998年1月至2003年12月间收治的51例晚期卵巢癌进行回顾性分析,先行新辅助化疗,CP方案全身化疗3疗程后行间隔减瘤术,术后继续化疗6疗程,分析3年及5年生存率.结果: 明显提高肿瘤细胞减灭术的满意率,3年生存率80.4%,5年生存率58.8%.结论: 新辅助化疗结合间隔减瘤术治疗晚期卵巢癌可以明显提高晚期卵巢癌患者手术满意率和生存率.     

The role of neoadjuvant chemotherapy in ovarian cancer

Introduction: Ovarian cancer is mostly diagnosed at advanced stage. Better survival is achieved through complete debulking surgery and chemotherapy. Historically, neoadjuvant chemotherapy (NAC) has been introduced for unresectable disease to decrease tumor load and perform a unique complete surgery. Four randomized control trials have compared primary debulking surgery to NAC, but there is still controversy about the use of neoadjuvant chemotherapy and questions about its modalities.

Areas covered: We made a review of knowledge on benefits of NAC compared to primary debulking chemotherapy, in terms of survival and morbidity, methods of administration, new drugs in early and late phase trials, the selection of patients. Similar survival was observed after NAC and interval debulking surgery or primary debulking surgery. Morbidity of surgery was decreased after interval debulking compared primary debulking surgery. Conventional drugs are carboplatin and paclitaxel. Safety of bevacizumab was evaluated in phase 2 trials associated with conventional drugs. Immunotherapy trials are enrolling patients in phase 1 study.

Expert commentary: NAC followed by debulking surgery is the best treatment for patients with advanced ovarian cancer.     

The potential therapeutic role of lymph node resection in epithelial ovarian cancer: a study of 13918 patients

The aim of the study is to determine the role of lymphadenectomy in advanced epithelial ovarian cancer. The data were obtained from the Surveillance, Epidemiology and End Results (SEER) program reported between 1988 and 2001. Kaplan-Meier estimates and Cox proportional hazards regression models were used for analysis. Of 13 918 women with stage III-IV epithelial ovarian cancer (median age: 64 years), 87.9% were Caucasian, 5.6% African Americans, and 4.4% Asians. A total of 4260 (30.6%) underwent lymph node dissections with a median number of six nodes reported. For all patients, a more extensive lymph node dissection (0, 1, 2-5, 6-10, 11-20, and >20 nodes) was associated with an improved 5-year disease-specific survival of 26.1, 35.2, 42.6, 48.4, 47.5, and 47.8%, respectively (P<0.001). Of the stage IIIC patients with nodal metastases, the extent of nodal resection (1, 2-5, 6-10, 11-20, and >20 nodes) was associated with improved survivals of 36.9, 45.0, 47.8, 48.7, and 51.1%, respectively (P=0.023). On multivariate analysis, the extent of lymph node dissection and number of positive nodes were significant independent prognosticators after adjusting for age, year at diagnosis, stage, and grade of disease. The extent of lymphadenectomy is associated with an improved disease-specific survival of women with advanced epithelial ovarian cancer.     

The role of secondary cytoreductive surgery for recurrent mucinous epithelial ovarian cancer (mEOC)

Background

Mucinous epithelial ovarian cancer (mEOC) may exhibit a distinct biological behavior in epithelial ovarian cancer (EOC). The role of secondary cytoreductive surgery was evaluated in patients with recurrent mEOC, and the prognosis was assessed.

Methods

Twenty-one patients with stages IIc to IV mEOC who experienced disease recurrence and received secondary cytoreductive surgery at Fudan University Cancer Hospital between Jan. 1997 and Dec. 2005 were retrospectively reviewed. Survival curves were generated using the Kaplan–Meier method and the significant comparison of survival rate was estimated by the log-rank test.

Results

The median progression-free interval (PFI) was 14 months (range, 5–46 months) after the first cytoreduction. Seven patients (33%) who received secondary cytoreductive surgery were optimally cytoreduced with residual disease less than or equal 1 cm, and the other 14 patients (67%) underwent suboptimal surgical cytoreduction. The overall median survival time was 27 months (range, 8–64 months). The median survival time after recurrence was 10 months (range, 3–32 months). There was no significant statistical difference in median survival between patients with optimal and suboptimal secondary surgical cytoreduction, with an estimated survival of 10 months and 9.8 months, respectively (P > 0.05).

Conclusion

Optimal primary cytoreductive surgery for advanced mEOC was very important. Once it recurs, the prognosis is very poor. Patients with recurrent mEOC should be carefully assessed before performing secondary cytoreductive surgery, as this may have limited impact on the overall survival rates.     

Fertility preservation in patients with early epithelial ovarian cancer

Objective

To assess the role of fertility preservation in the treatment of patients with early epithelial ovarian cancer (EOC).

Methods

We retrospectively analyzed the medical records of 21 patients with early EOC from January 1995 to December 2006. All eligible patients with a strong desire to preserve fertility were younger than 35 years and underwent fertility-sparing surgery with or without adjuvant chemotherapy.

Results

Twenty-one eligible patients with a median age of 26.7 years (range, 20 to 33 years) were identified, and the mean follow-up period was 43 months (range, 5 to 86 months). Only one patient with stage IC recurred 34 months after the first operation. A total of five patients were able to become pregnant at least once after the first fertility preserving treatment, with or without adjuvant chemotherapy. All five patients succeeded in full-term vaginal delivery with healthy infants. No patients died of their disease.

Conclusion

Fertility preserving treatment in patients with early EOC can be considered as a proper treatment strategy in patients with early EOC, who have the strong desire for fertility preservation.     

Fluorescence guided surgery to improve peritoneal cytoreduction in epithelial ovarian cancer: A systematic review of available data

During surgery for advanced epithelial ovarian cancer (EOC), the most important prognostic factor is the absence of residual tumor. Invisible microscopic peritoneal metastasis (mPM) are not removed during surgery and can be responsible of peritoneal recurrences. The aim of this current systematic review is to assess the role of fluorescence in evaluating mPM in EOC.We performed a systematic review using bibliographic citations from PubMed, Clinical Trials.gov, Embase, Cochrane Library, and Web of Science databases. MeSH terms for fluorescence, EOC and peritoneal carcinomatosis were combined and not restricted to the English language. The final search was performed on September 1rst, 2021. The primary outcome was to determine the diagnostic accuracy of fluorescence. We also reviewed the different techniques used.Eighty-seven studies were identified. Of these, 10 were included for analysis. The sensitivity and specificity of fluorescence ranged between 66.7-100% and 54.2–100%, respectively. Most importantly, the negative predictive value (NPV) ranged from 90 to 100% Due to the heterogeneity of the studies, no consensus was reached concerning the optimal use of fluorescence in terms of type of dye, type and timing of injection and imager to use. No adverse event was reported.Fluorescence can safely be used in EOC to evaluate mPM with a high NPV. However, a randomized controlled trial is needed to homogenize current practice.     

Continuous mitoxantrone infusion in pretreated epithelial ovarian cancer

Mitoxantrone has shown moderate activity in advanced epithelial ovarian cancer following intermittent i.v. administration. Experiments and clinical data suggest that long-term continuous drug infusion may achieve a better therapeutic result with less toxicity. This hypothesis was tested in patients with advanced ovarian cancer who had been pretreated with other agents. Mitoxantrone was infused continuously in 21-day courses beginning every 6 weeks. If severe toxicity did not occur, the infusion rate was increased by 0.1–0.2 mg/m² per day. The mitoxantrone solution proved to be stable over the 21-day infusion period. For ethical reasons an optimal two-stage design was employed. The trial was interrupted at the end of the first recruitment stage because the target of 3 responses out of 13 patients had not been achieved (only 1 patient had a partial response). Hematologic toxicity was observed in 11 patients, and 2 of them had a catheter occlusion. In conclusion, we found that 21-day of infusion of mitoxantrone apparently has no clinical benefit as compared with bolus administration in patients with advanced ovarian cancer.     

Secondary cytoreduction surgery improves prognosis in platinum-sensitive recurrent ovarian cancer

Background

There is no consensus regarding the secondary cytoreduction surgery (CRS) in recurrent ovarian cancer patients. The present study aims to determine the value of secondary CRS and the eligible subgroup for this procedure.

Methods

96 platinum-sensitive recurrent ovarian cancer patients were recruited from Jiangsu Institute of Cancer Research between 1992 and 2011. Follow-up was conducted based on the surveillance protocol of MD Anderson Cancer Center. Cox proportional hazards model and log-rank test were used to assess the associations between the survival durations and covariates. Logistic regression analysis was used to explore optimal secondary CRS related factors.

Results

Optimal secondary CRS was associated with time to progression (TTP) and overall survival (OS) in patients (p < 0.01 both). Optimal secondary CRS and asymptomatic recurrent were similarly associated with longer OS (median: 79.2 vs. 53.9 and 76.1 vs. 56.0 months with p = 0.02 and p = 0.04, respectively) and TTP (median: 13.9 vs. 10.5 and 19.3 vs. 9.0 months with p = 0.02 and p = 0.03, respectively) than counterparts. Optimal initial CRS (p = 0.01), asymptomatic recurrent (p = 0.02) and longer progression-free survival duration (p = 0.02) were the independent indicators of optimal secondary CRS.

Conclusions

Optimal secondary CRS had survival benefit for platinum-sensitive epithelial ovarian cancer. Asymptomatic recurrent was one of the recruited factors for this procedure.