abstract: Cochrane Review: Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer

Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer [Cochrane Database Syst Rev. 2012] - PubMed - NCBI

Cochrane Database Syst Rev. 2012 Mar 14;3:CD004706.

Abstract

BACKGROUND:

Epithelial ovarian cancer is diagnosed in 4500 women in the UK each year of whom 1700 will ultimately die of their disease.Of all cases 10% to 15% are diagnosed early when there is still a good possibility of cure. The treatment of early stage disease involves surgery to remove disease often followed by chemotherapy. The largest clinical trials of this adjuvant therapy show an overall survival (OS) advantage with adjuvant platinum-based chemotherapy but the precise role of this treatment in subgroups of women with differing prognoses needs to be defined.

OBJECTIVES:

To systematically review the evidence for adjuvant chemotherapy in early stage epithelial ovarian cancer to determine firstly whether there is a survival advantage of this treatment over the policy of observation following surgery with chemotherapy reserved for treatment of disease recurrence, and secondly to determine if clinical subgroups of differing prognosis based on histological sub-type, or completeness of surgical staging, have more or less to gain from chemotherapy following initial surgery.

SEARCH METHODS:

We performed an electronic search using the Cochrane Gynaecological Cancer Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL 2011, Issue 3), MEDLINE (1948 to Aug week 5, 2011) and EMBASE (1980 to week 36, 2011). We developed the search strategy using free-text and medical subject headings (MESH).

SELECTION CRITERIA:

We selected randomised clinical trials that met the inclusion criteria set out based on the populations, interventions, comparisons and outcome measures.

DATA COLLECTION AND ANALYSIS:

Two review authors independently extracted data and assessed trial quality. Disagreements were resolved by discussion with a third review author. We performed random-effects meta-analyses and subgroup analyses.

MAIN RESULTS:

Five randomised controlled trials (RCTs), enrolling 1277 women, with a median follow-up of 46 to 121 months, met the inclusion criteria. Four trials were included in the meta-analyses and we considered them to be at a low risk of bias. Meta-analysis of five-year data from three trials indicated that women who received adjuvant platinum-based chemotherapy had better overall survival (OS) than those who did not (1008 women; hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.53 to 0.93). Likewise, meta-analysis of five-year data from four trials indicated that women who received adjuvant chemotherapy had better progression-free survival (PFS) than those who did not (1170 women; HR 0.67; 95% CI 0.53 to 0.84). The trials included in these meta-analyses gave consistent estimates of the effects of chemotherapy. In addition, these findings were robust over time (10-year PFS: two trials, 925 women; HR 0.67; 95% CI 0.54 to 0.84).

Subgroup analysis suggested that women who had optimal surgical staging of their disease were unlikely to benefit from adjuvant chemotherapy (HR for OS 1.22; 95% CI 0.63 to 2.37; two trials, 234 women) whereas those who had sub-optimal staging did (HR for OS 0.63; 95% CI 0.46 to 0.85; two trials, 772 women).

One trial showed a benefit from adjuvant chemotherapy among women at high risk (HR for OS 0.48; 95% CI 0.32 to 0.72) but not among those at low/medium risk (HR for OS 0.95; 95% CI 0.54 to 1.66). However, these subgroup findings could be due to chance and should be interpreted with caution.

AUTHORS' CONCLUSIONS:

Adjuvant platinum-based chemotherapy is effective in prolonging the survival of the majority of patients who are assessed as having early (FIGO stage I/IIa) epithelial ovarian cancer. However, it may be withheld from women in whom there is well-differentiated encapsulated unilateral disease (stage 1a grade 1) or those with comprehensively staged Ib, well or moderately differentiated (grade 1/2) disease. 

Others with unstaged early disease or those with poorly differentiated tumours should be offered chemotherapy. A pragmatic approach may be necessary in clinical settings where optimal staging is not normally performed/achieved. In such settings, adjuvant chemotherapy may be withheld from those with encapsulated stage Ia grade 1 serous and endometrioid carcinoma and offered to all others with early stage disease.

abstract: The effect of hysterectomy on survival of patients with borderline ovarian tumors (repost)

The effect of hysterectomy on survival of patients with borderline ovarian tumor

Objective
The classically recommended surgical treatment of borderline ovarian tumors (BOTs) includes hysterectomy in addition to bilateral adnexectomy. Possible reasons for hysterectomy might be a high frequency of uterine involvement and its favorable effect on survival. The purpose of the present study was to assess the frequency of uterine involvement in patients with BOTs and the effect of hysterectomy on survival.

Methods
All incident cases of histological confirmed BOTs diagnosed in Israeli Jewish women between March 1 1994 and June 30 1999, were identified. Clinical and pathological characteristics were abstracted from medical records. Patients with tumors grossly confined to the ovaries (apparently stage I) were considered to have had surgical staging when at least hysterectomy, bilateral salpingooophorectomy, omentectomy and pelvic lymph node sampling were done.

Results 
The study group comprised 225 patients. Hysterectomy was performed in 147 (65.31%) patients and uterine involvement was present in only 3 (2.0%) of them. The 13 year survival of the total group of patients was 85.8% and of those in apparent stage I, 88.5%. Among patients with tumors apparently confined to the ovaries, no significant survival difference was observed between unstaged and surgically staged patients. There was also no survival difference between the overall staged and unstaged patients and between patients in stages II–III who did and did not undergo hysterectomy.

Conclusions 
Our data indicate that the rate of uterine involvement in BOT is low and that hysterectomy does not favorably affect survival. The necessity of hysterectomy in BOT patients is questioned.

abstract: Changes in serum CA-125 can predict optimal cytoreduction to no gross residual disease in patients with advanced stage ovarian cancer treated with neoadjuvant chemotherapy

Changes in serum CA-125 can predict optimal cytoreduction to no gross residual disease in patients with advanced stage ovarian cancer treated with neoadjuvant chemotherapy

Objective 

To evaluate the predictive power of serum CA-125 changes in the management of patients undergoing neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) for a new diagnosis of epithelial ovarian carcinoma (EOC).


Conclusions 
Patients who undergo NACT-IDS achieve a high rate of optimal cytoreduction. In our series, after treatment with taxane and platinum-based chemotherapy, patients with a preoperative CA-125 of ≤100U/mL were highly likely to be cytoreduced to no residual disease.

Bridging Anticoagulation: Is it Needed When Warfarin Is Interrupted Around the Time of a Surgery or Procedure?

Bridging Anticoagulation
 Cardiology Patient Page

Is it Needed When Warfarin Is Interrupted Around the Time of a Surgery or Procedure?

1. The BRIDGE Study Investigators

REPOST: open access: Neoadjuvant Chemotherapy or Primary Surgery in Stage IIIC or IV Ovarian Cancer — NEJM (multi-national study)

Neoadjuvant Chemotherapy or Primary Surgery in Stage IIIC or IV Ovarian Cancer — NEJM

Original Article

Neoadjuvant Chemotherapy or Primary Surgery in Stage IIIC or IV Ovarian Cancer

N Engl J Med 2010; 363:943-953September 2, 2010

Letters

In most women with ovarian carcinoma, the disease is not diagnosed until it is at an advanced stage. Primary cytoreductive surgery is considered the standard of care for advanced ovarian carcinoma.1-4 However, data from prospective, randomized, controlled trials assessing the role of primary surgery in the treatment of such cases are lacking. Interval debulking surgery has not been viewed as beneficial in women with residual tumor that exceeds 1 cm in diameter after primary debulking surgery performed with the objective of maximal surgical effort by a gynecologic oncologist.5-7 As an alternative to primary debulking surgery followed by chemotherapy, some authors have investigated the use of neoadjuvant chemotherapy before cytoreductive surgery. However, results of a meta-analysis involving 835 patients suggested that neoadjuvant chemotherapy, as compared with primary debulking surgery, was associated with a worse outcome.8
We report on a randomized trial in which we compared primary debulking surgery followed by platinum-based chemotherapy and platinum-based neoadjuvant chemotherapy followed by interval debulking surgery and additional platinum-based chemotherapy in women with advanced ovarian carcinoma.............

abstract: Requirements to Assess Feasibility of Phase 0 Trials during Major Abdominal Surgery - Variability of Poly (ADP-Ribose) Polymerase Activity.

Wiki:  Poly ADP ribose polymerase: Poly (ADP-ribose) polymerase (PARP) is a family of proteins involved in a number of cellular processes involving mainly DNA repair and programmed cell death.

                   ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 Requirements to Assess Feasibility of Phase 0 Trials during Major Abdominal Surgery - Variability of Poly (ADP-Ribose) Polymerase Activity.

Abstract

Purpose: 

The aim of this study was to evaluate the feasibility of phase 0 trials in the setting of a routine surgical procedure. Logistic considerations, tissue sampling and handling, and variability of a biomarker during surgery, in here activity of poly(ADP-ribose) polymerase, were evaluated. 

Experimental design: 

Patients with highly suspicious or proven diagnosis of advanced ovarian cancer, planned for debulking surgery were asked to allow sequential tumor biopsies during surgery. Biopsies were frozen immediately and poly (ADP-ribose) polymerase activity was measured subsequently. 

Results: 

Baseline biopsies were obtained from eight patients after a median time of 88 minutes (minimum of 50 to maximum of 123 minutes). Second and third biopsies were obtained after a median of 60 (32-96) and 101 (79-130) minutes, respectively. Mean tumor load was 44% (5%-100%), with a cellular viability of 98% (85%-100%). Median baseline PARP activity was 1035 pg/ml (range: 429-2663 pg/ml). The observed inter-patient variability at baseline was large: standard deviation was 769 before and 0.59 after natural log transformation. 

Conclusions: 

Conducting phase 0 trials during surgery seems to be feasible in terms of logistic considerations. In preparation of a phase 0 trial during surgery, a feasibility study like this should be conducted to rule out major interactions of the surgical intervention with respect to the targeted biomarker.

MD News - HIPEC: Furthering Survivorship for GYN Cancer Patients

MD News - HIPEC: Furthering Survivorship for GYN Cancer Patients

Monday, March 12, 2012

A team of cancer specialists at the Seidman Cancer Center at University Hospitals (UH) Case Medical Center is among the first in the nation to launch a dedicated gynecologic program using Hyperthermic Intraperitoneal Chemotherapy (HIPEC) to treat ovarian, endometrial and select other malignancies.

 Q: What is HIPEC, and how is it delivered?
Q: What are the advantages of HIPEC over traditional IV chemotherapy?
Q: I understand UH is planning several research studies on HIPEC. What will they involve?
Q: What do you want physicians to know about HIPEC?
   

abstract: Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies

 Blogger's Note: the abstract does not differentiate types of gyn cancers, journal is subscriber based ($$$)

Lymphatic ascites following pelvic and paraaortic lymphadenectomy procedures for gynecologic malignancies

Objective 
Lymphatic ascites is an unusual complication in patients with cancer. In the gynecologic oncology patient population, the most common etiology is operative lymph node dissection. The purpose of this study was to explore the incidence, presenting symptoms, methods of diagnosis and treatment modalities utilized for lymphatic ascites in patients undergoing lymph node dissection for gynecologic cancers.

Methods 
This observational study retrospectively reviewed the charts of patients who underwent lymphadenectomy as part of the surgical management for a gynecologic cancer. Patients that developed postoperative lymphatic ascites between January 2000 and December 2010 were included for analysis. Data extracted from the medical records included tumor pathology, number of harvested lymph nodes, postoperative course, method of diagnosis and treatment.

Results
From a total of 300 surgical staging procedures, 12 patients with lymphatic ascites were identified (4%). The most common reported symptom was leakage of clear fluid per vagina (7, 58%), followed by abdominal distension (4, 33%). The median interval from surgery to development of symptoms was 12.5 days (range 0–22days). 5 patients had complete resolution of symptoms with dietary modifications alone while 7 patients required paracentesis. The median time from surgery to resolution of symptoms was 44days (range 9–99).

Conclusion 
Lymphatic ascites is an under recognized and infrequently reported postoperative complication. Although it usually resolves spontaneously or with conservative management without sequelae, this condition can significantly prolong postoperative recovery and cause patient discomfort. To our knowledge this is the largest group of patients undergoing gynecologic surgical staging procedures to be reviewed for the occurrence of lymphatic ascites.

Outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC)

Outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC):

Objective 
To describe the outcomes of surgical management of bowel obstruction in relapsed epithelial ovarian cancer (EOC) so as to define the criteria for patient selection for palliative surgery. Methods 90 women with relapsed EOC underwent palliative surgery for bowel obstruction between 1992 and 2008.

Conclusion 
Surgery for bowel obstruction in relapsed EOC is associated with a high morbidity and mortality rate especially in emergency cases when compared to other gynaecological oncological procedures. Palliation can be achieved in almost two thirds of cases, is equally likely in elective and emergency cases but is less likely in those with ascites.

Re-operation outcome in patients referred to a gynecologic oncology center with presumed ovarian cancer FIGO I-IIIA after sub-standard initial surgery

Re-operation outcome in patients referred to a gynecologic oncology center with presumed ovarian cancer FIGO I-IIIA after sub-standard initial surgery:

Publication year: 2012

Background 
Surgery is the mainstay of treatment for early ovarian cancer both as therapeutic and comprehensive staging. Only the latter allows appropriate tailoring of systemic treatment. However, the compliance with guidelines for comprehensive staging has been reported to be only moderate and, therefore, re-staging procedures are commonly indicated to avoid undertreatment. The purpose of our study was to evaluate re-operation in a tertiary gynecologic oncology unit after primary operation for presumably ovarian cancer FIGO I-IIIA in general gynecology departments.

Material and methods 
Forty consecutive patients after primary surgery in the outside institutions for presumed early ovarian cancer with assumed tumor spread limited to the pelvis (FIGO I-IIIA) admitted to our department between 1999 and 2007 were included. In 35 cases re-staging surgery in our unit was indicated. The intra- and post-operative results were compared with initial diagnosis and sites of undetected disease were evaluated. Reasons for re-staging and referral pattern were studied. Results 40 patients were enrolled of whom 53% came by self-referral. Only 18% were referred by the primary surgeon and the remaining patients were referred by their home gynecologist. Only 5 patients (13%) were classified as having had a comprehensive staging by surgical records and pathology reports and 35 patients underwent comprehensive re-staging laparotomy after which 20 patients (50%) experienced an upstaging including 13 patients with final diagnosis of FIGO stage IIIC. Most frequent sites of primarily undetected tumor were peritoneum (pelvic 34%, diaphragm 13%, paracolic 8%), lymph nodes (para aortic 32%, pelvic 11%), intestines 24%, and residual omental tissue 18%. The indication for post-operative chemotherapy was modified in 53% of patients.

Conclusion
Comprehensive staging of presumed early ovarian cancer has been described as major problem especially outside gynecologic oncology units. Re-staging results in our department confirmed this deficiency by showing a considerable proportion of upstaging associated with alterations of recommendations for systemic treatment. However, series like this may even underestimate the problem, because incomplete staging is unfortunately accompanied by non-systematic referral practices not reflecting staging quality.

abstract: Adjuvant Chemotherapy for Stage I Clear Cell Carcinoma of the Ovary: An Analysis of Fully Staged Patients

Adjuvant Chemotherapy for Stage I Clear Cell Carcinoma of the Ovary: An Analysis of Fully Staged Patients:

Objective: 

Although postoperative adjuvant chemotherapy is generally recommended for early-stage ovarian cancer, it remains unclear whether adjuvant chemotherapy is also effective for clear cell carcinoma (CCC).

Methods: 

Seventy-three patients with stage I CCC of the ovary who had undergone complete surgical staging formed the study population (stage IA, 20 patients; stage IC, 53 patients). Survival and multivariate analyses were retrospectively performed to determine the effectiveness of postoperative chemotherapy in these patients.

Results:

Of the total (73 patients), 30 patients received adjuvant chemotherapy (stage I C-positive), whereas 43 patients did not (stage I C-negative).

The 5-year progression-free survival (PFS) and 5-year overall survival (OS) rates for the stage I C-positive group were 80.1% and 87.4% compared with 73.9% and 81.7% for the stage I C-negative group.

The differences in survival between these groups were not significant (PFS: P = 0.610; OS: P = 0.557). Four of the patients with stage IA CCC underwent chemotherapy, whereas the remaining 16 patients received no additional therapy. No recurrence was observed in either group.

Of the patients with stage IC CCC, 26 patients underwent chemotherapy (stage IC C-positive) and 27 received no additional therapy (stage IC C-negative). There was no statistical difference in PFS and OS between the stage IC C-positive and stage IC C-negative groups.

Of the patients with stage IC without artificial rupture, the 5-year PFS rates of the C-positive and C-negative patients were 69.6% and 34.6%, respectively, but the 5-year OS rates were 75.0% and 70.0%, respectively (not significant).

Multivariate analyses confirmed that the presence or absence of adjuvant chemotherapy was not a prognostic indicator.

Conclusions:

The current study was performed only in fully staged patients, suggesting that postoperative adjuvant chemotherapy is not necessary for stage IA CCC patients.

For patients with stage IC CCC patients, adjuvant chemotherapy suppressed recurrence, but the effectiveness was insufficient in our limited study. Further studies are required to clarify this.

Fallopian Tube Removal as a Method of Ovarian Cancer Prevention: A Descriptive Study - Full Text View - ClinicalTrials.gov

Fallopian Tube Removal as a Method of Ovarian Cancer Prevention: A Descriptive Study

This study is currently recruiting participants.

Verified February 2012 by University of Washington

First Received on February 28, 2012. Last Updated on March 2, 2012 History of Changes

Purpose

The purpose of this study is to better understand why women choose to have their fallopian tubes removed as a method for ovarian cancer prevention. This will be done through a paper questionnaire and phone interviews. The investigators hope to gain information that will allow us to better counsel women about ovarian cancer prevention.

Sponsor:	University of Washington
Information provided by (Responsible Party):	Elizabeth Swisher, University of Washington
ClinicalTrials.gov Identifier:	NCT01544049

Neoadjuvant chemotherapy, interval debulking surgery or primary surgery in ovarian carcinoma FIGO stage IV? 10.1016/j.ejca.2012.01.031 : European Journal of Cancer

Abstract

Objectives

The aim of this study was to investigate the impact of surgical approach, the extent of surgery and chemotherapy on overall survival in patients with ovarian carcinoma (OC) stage IV.

Methods

We retrospectively collected population-based data from the Norwegian Radium Hospital code registry on the diagnosis and surgery of 238 patients diagnosed with OC stage IV from 1996–2005. All patients received platinum-based chemotherapy. Surgical approach was registered as primary debulking surgery (PDS), interval debulking surgery (IDS) and delayed primary surgery (DPS). Surgery level was classified as radical surgery (RS), standard surgery (SS) or suboptimal surgery (SUBS). Univariate and multivariate analyses identified prognostic factors in PDS, IDS and DPS groups and subgroups.

Results

There were no differences in overall survival between the PDS, IDS and DPS groups. Surgery level was significantly associated with overall survival in the whole cohort (p < 0.001), the PDS and IDS groups, but not in the DPS group. More patients with RS achieved no residual tumour (RT), but overall survival was not superior compared to no RT in the SS group. In 66 patients with no RT there were no differences in overall survival between those who underwent PDS, IDS and DPS. Chemotherapy with platinum/paclitaxel tended to improve survival. RT, World Health Organisation (WHO) performance status and histology were prognostic factors for overall survival in the whole cohort.

Conclusion

No RT remains the objective, whether PDS, IDS or DPS is performed, and no differences in overall survival were found in the three treatment groups.

abstract: Intraoperative Hypothermia During Cytoreductive Surgery for Ovarian Cancer and Perioperative Morbidity

hy·po·ther·mi·a

Noun:

The condition of having an abnormally low body temperature, typically one that is dangerously low.

Abstract

OBJECTIVE:

To evaluate intraoperative hypothermia as a predictor for morbidity after open abdominal surgery for ovarian cancer.

METHODS:

This cohort study included 146 women with stage IIIC and IV ovarian cancer who underwent debulking surgery at our institution from January 1, 2001, through December 31, 2003. Hypothermia was defined as end operative temperature lower than 36°C. Early complications (occurring within 30 days of surgery) included: mortality, infectious morbidities, cardiovascular events, venous thromboembolic (VTE) events, anastomotic leak, readmission, and reoperation. Survival was also evaluated. Logistic regression models were used to adjust for known confounders.

RESULTS:

The mean age was 63.9±11.7 years; 46 (32%) patients had a body mass index higher than 30; mean operative time was 239±85 minutes. There were five deaths perioperatively, all in the hypothermic group. Hypothermia was associated with an increased risk of any early complications (34 [42.0%] compared with 11 [16.9%]) with an adjusted odds ratio (OR) of 3.40 (95% confidence interval [CI] 1.48–8.33). For individual complications, hypothermic patients were at higher risk for VTE events with an adjusted OR of 3.53 (95% CI 1.02–16.44); infectious morbidity with an adjusted OR of 2.99 (95% CI 0.97–11.35); and reoperation with an adjusted OR of 4.96 (95% CI 0.80–95.7). The overall survival was shorter in hypothermic group with a median of 34 compared with 45 months (P=.045); this remained significant for an optimally resected subgroup with a median overall survival of 40 compared with 48 months (P=.049).

CONCLUSION:

Surgical hypothermia is an independent predictor of early perioperative complications and overall survival after cytoreductive surgery for ovarian cancer. This is a critically important finding, because maintaining normothermia is an inexpensive modifiable factor, which could result in reduced morbidity.

LEVEL OF EVIDENCE: II

Outcomes of Patients with Gynecologic Malignancies Undergoing Video-Assisted Thoracoscopic Surgery (VATS) and Pleurodesis for Malignant Pleural Effusion

Outcomes of Patients with Gynecologic Malignancies Undergoing Video-Assisted Thoracoscopic Surgery (VATS) and Pleurodesis for Malignant Pleural Effusion

Background
We evaluated the indications and outcomes of patients with known gynecologic malignancies that underwent video-assisted thoracoscopic surgery (VATS) and pleurodesis for malignant pleural effusion.

Methods
After IRB approval was obtained, a retrospective study of patients with gynecologic malignancies who underwent planned VATS/pleurodesis between 1/2000 and 7/2010 was performed. Abstracted data included demographics, diagnosis, disease status, treatment history, indication for VATS, complications, and outcomes

Results
42 patients (University of Alabama) with a gynecologic malignancy underwent VATS/pleurodesis. Median age was 63 years. 29 patients (69%) had ovarian cancer. 57% had recurrent disease at the time of VATS and 57% were undergoing chemotherapy at the time of VATS. 8 patients (19%) underwent perioperative VATS to improve pulmonary status. 7 patients (17%) underwent a palliative VATS. The median length of stay was 7 days (range 1–53). 62% had gross disease noted at the time of VATS. A mean of 1650 cc of fluid was drained at time of surgery (range 300–4500), and the majority (88%) of patients had a talc pleurodesis performed. 7 patients (17%) were readmitted within 30 days; 6 were for complications unrelated to their VATS............. Patients who underwent a perioperative VATS had the longest survival (845 days).

Conclusion

Patients with gynecologic malignancies may require a VATS/pleurodesis for symptomatic pleural effusions. This procedure appears to be safe and effective in this patient population.

Highlights

► Many patients with gynecologic malignancies will develop pleural effusion
► Few studies exclusively evaluate the role of VATS/pleurodesis in gynecologic oncology patients
► VATS/pleurodesis can safely and effectively ameliorate symptoms of recurrent malignant pleural effusion.

open access: Ports and complications for intraperitoneal chemotherapy delivery (ovarian cancer)

"Intraperitoneal access ports are essential to the delivery of chemotherapy agents into the peritoneal cavity of women with ovarian cancer, but their malfunction and adverse effects are frequently responsible for the failure to complete planned therapy. Complications, such as obstruction of the catheter, infection, leakage, rotation, retraction, and pain, together with bowel and vaginal perforation, cause delays in treatment, patient suffering and the expenditure of medical resources. A wide variety of ports have been used, including vascular access devices and intraperitoneal access devices. This paper reviews the development and use of ports for intraperitoneal chemotherapy, their complications and reported methods of prevention...."

(Blogger's Note: tables are included in the text of the paper)

Table 2.   Reported complications of ports used for IP access 
(years 1984 through to 2010)

Table 3.   Percentage of cases where IP chemotherapy was discontinued because of the port 
(years 1994 through to 2010)

Table 4.   Port complications causing the discontinuation of IP chemotherapy* 
(years 1991 through to 2010)

	Influence of surgeon and team experience "There is a lack of information in the literature with regard to the effect of the expertise of the surgeon placing the ports, and the experience of the support team (including doctors and nurses) in managing the ports and patients to reduce complications and improve completion rates...."

		Conclusion:

Port complications are significant, and overall, 15% (210/1945) of patients discontinued IP chemotherapy as a result of a port complication, with obstruction (37.6%) and infection (31.4%) being the most common reasons.

Complications such as leakage, retraction of the catheter, rotation of the portal, difficulties with access and perforation of the bowel can be kept to a minimum with careful technique, but they are still not completely avoidable. Although infection may theoretically be reduced by the avoidance of placement during grossly contaminated surgeries, hard data on the influence of associated bowel surgery at the time of placement are lacking, and there is no proven method of preventing the adhesions that cause obstruction to flow. There does not appear to be a difference in the rates of complications between fenestrated or unfenestrated ports, and the choice of port should be at the surgeon’s discretion.

Despite almost 30 years of experience, it remains difficult to identify which patients are going to experience port complications that impact on the completion of IP therapy. More effective methods of preventing complications and improving tolerability, and thus reducing discontinuation rates, are needed.

open access: paper/Editorial - Improvements in survival of gynaecological cancer in the Anglia region of England: are these an effect of centralisation of care and use of multidisciplinary management?

Blogger's Note:  search blog for additional information on centralization of ovarian cancer surgery (eg. Norway...)

 .........................................................
Setting 
In 1999 the DH (Department of Health) in England introduced the Improving Outcomes in Gynaecological Cancer guidance, advising case management by multidisciplinary teams with surgical concentration in specialist hospitals.

In conclusion, there was a highly significant step-change increase in survival in gynaecological cancers associated with the adoption of the 1999 national policy change. ......... These changes have been most marked within endometrial and ovarian cancers.

Editorial: 

"Finally, Crawford and Greenberg on page 160 present their detailed population-based analyses of the effects of centralisation of care on survival outcomes in endometrial and ovarian cancer. Introduced in the UK in the late 1990s, the development of Cancer Networks (the ‘hub and spoke’ model) met with considerable resistance. Although it seemed intuitively right, the evidence to support such health care re-organisations was best described as weak, and they not only needed a significant investment of resources, but also required people to travel away from their immediate locality, making it difficult for friends and families to visit. Now, a number of years on, data are beginning to emerge reassuring all of the interested parties, patients in particular, that the energies and efforts required to implement the principles of centralisation of cancer services appear to have been justified."

open access: Upper abdominal cytoreduction and thoracoscopy for advanced epithelial ovarian cancer: unanswered questions and the impact on treatment - 75 patient study

	Positive thoracoscopy	Negative thoracoscopy
GOG, Gynecologic Oncology Group.
n (%)	27 (36.0)	48 (64.0)
Median (range) age, years	60.5 (29–75)	63 (39–76)
GOG Performance Status (0,1)	100%	100%
Location of largest disease
Diaphragm	2/27 (7.4%)	1/48 (2.1%)
Omentum	7/27 (25.9%)	10/48 (20.8%)
Pelvis	15/27 (55.6%)	37/48 (77.1%)
Lymph nodes	2/27 (7.4%)	1/48 (2.1%)
Mesentery	2/27 (7.4%)	1/48 (2.1%)

Table 2.  Surgical Procedures

Table 3.   Morbidity and mortality (Positive/Negative thoracoscopy - complications)

Conclusions

Epithelial ovarian cancer is most commonly diagnosed in advanced stages. The prognostic value of complete cytoreduction has been reported and confirmed in several publications.^6,21,22 Similarly intraperitoneal chemotherapy is associated with improved overall survival in women with small-volume residual disease (<1 cm) and, as with cytoreductive surgery, carries with it increased morbidity.

It is therefore mandatory to do all that is necessary to identify disease that cannot be resected before undertaking a maximal cytoreductive effort for disease that will not benefit from the use of intraperitoneal chemotherapy.

Using the surgical approach described allows both of these goals to be met, thereby maximising the potential benefit to women with advanced-stage epithelial ovarian cancer.

abstract: Lymph node metastasis in stages I and II ovarian cancer: a review.

CONCLUSIONS:

The incidence of lymph node metastases in clinical early stage EOC is considerable. Based on the scarce literature data, omitting a systematic lymphadenectomy can only be considered in grade I mucinous tumors.

New (subspecialty) Certification for Complex Surgical Oncology - OncologySTAT

"A new subspecialty certification in complex general surgical oncology aims to provide surgeons with training in the diagnosis, treatment, and rehabilitation of patients with complex cancers such as sarcoma, melanoma, and esophageal malignancies - and hopefully will attract surgeons who want to focus on research...."