"Cytoreductive Surgery for Peritoneal Recurrences Arising From Ovarian Cancer: Presented at ESSO"
By Chris Berrie
VENICE, ITALY -- December 5, 2006 -- As with their first treatment, the effectiveness of cytoreductive surgery is the most significant predictive factor in patients with relapsing ovarian cancer, whereby aggressive cytoreductive surgery associated with intraperitoneal chemohyperthermia (IPCH) can increase overall and relapse-free survival for these patients.
In a prospective, non-randomised, single-centre study presented here at the 13[th Congress of the European Society of Surgical Oncology (ESSO), researchers evaluated the feasibility and value of IPCH for treatment of relapsing ovarian cancer.
In a presentation on December 1st, principal investigator Gerard Lorimier, MD, general surgeon and visceral surgery specialist, surgical oncology, Cancer Istitut Paul Papin, Angers, France, said the study tried to answer some key questions: "Is there gain to be made from performing aggressive cytoreductive surgery in a relapsing ovarian carcinomatosis; is there a place for perioperative chemotherapy; and is it desirable to practice intraperitoneal chemohyperthermia?"
At present, half of patients with epithelial ovarian cancer (EOC) of International Federation of Gynaecology and Obstetrics (FIGO) stages 3 and 4 experience relapse within 5 years after first treatment. This interval to relapse depends on the quality of the initial surgery and resistance to chemotherapy. However, there is no standard treatment for recurrent peritoneal carcinomatosis from ovarian cancer, as results from second-line chemotherapy show little promise to date.
This study included 31 patients with histologically confirmed diagnosis of peritoneal relapse arising from ovarian epithelial cancer, irrespective of their first treatment. The procedure was aggressive cytoreductive surgery with IPCH, and a precise evaluation of the extent of carcinomatosis and of the effectiveness of this cytoreduction was performed, as defined by a completeness of cytoreductive surgery score (CCS).
The evaluation score was set as follows: CCS 0, no tumour left; CCS 1, 1 tumour <0.25 cm; CCS 2, 2 tumours from 0.25 cm to 2.5 cm; CCS 3, 3 tumours >2.5 cm. Follow-up was set according to these CCS scores, as follows: CCS 0, surveillance; CCS 1 or greater, new systemic chemotherapy. If there was relapse, the follow-up was also set for new systemic chemotherapy. The follow-up status was monitored every 4 months with computed tomography scans and CA125 blood test.
In this cohort of 31 patients with a mean age of 56.3 years, all had primary surgery and had undergone at least one line of previous systemic chemotherapy with platinum; 5 patients had undergone complete surgery, and 16 had been treated with 2 or more chemotherapy regimens. The delay to relapse was less than 10 months in 14 patients, and more than 10 months in 17 patients.
Two patients had an initial FIGO tumour stage of 2 and 29 patients had stage 3 or 4 tumours; these were seen as 16 seropapillar, 7 mucinous and 8 undifferentiated. According to the peritoneal cancer index, the extent of carcinomatosis was a mean of 16.2.
The quality of the cytoreduction reached with these patients was classified as CCS 0 in 16 patients, and CCS 1 in 15, with a mean change in PCI of 13.8. Twenty patients had at least 2 major visceral removals, and 2 or more anastomoses.
Mortality was seen as 2 deaths postsurgery, 1 haemorrhagic shock after 9 days and 1 aplasia with enteric fistula after 32 days. The overall morbidities (48.3%) were 8 haemoperitoneums, 3 renal failures with toxic coma, 3 pleurisies, and 2 anastomotic fistulas.
At a mean follow-up of 20.6 months from IPCH (range, 1-81 months), 17 patients were alive at 20 months; 9 were disease free. Mean relapse-free survival was 27.3 months and mean overall survival was 21.6 months. The estimated median overall survival predicted that 13% of patients would be alive 60 months from the IPCH.
The first predictive factor for survival was for completeness of cytoreductive surgery, as the CCS score. Mean survival for CCS 0 was 28 months, which fell significantly to 12 months for CCS >1 (P = .03). A second significant predictive factor for survival was delay to relapse after first treatment: <10 months, mean survival 17.8 months; 10 months or more, mean survival 26.8 months (P = .03).
"So, we can conclude that as in the first treatment, optimal cytoreduction in relapsing ovarian cancer is the most predictive factor of survival, and aggressive cytoreductive surgery associated with IPCH increases overall and relapse-free survival for patients with CCS 0," Dr. Lorimier said.
Furthermore, patients who relapse within 10 months of their first treatment do not appear to gain much benefit from this type of chemohyperthermia.
[Presentation title: Peritoneal Recurrences Arising From Ovarian Cancer. Results of Cytoreductive Surgery and Intraperitoneal Chemohyperthermia. Abstract 250]
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