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Laparoscopic Surgical Algorithm to Triage the Timing of Tumor Reductive Surgery in Advanced Ovarian Cancer

Fleming, Nicole D., MD; Nick, Alpa M., MD; Coleman, Robert L., MD; Westin, Shannon N., MD; Ramirez, Pedro T., MD; Soliman, Pamela T., MD; Fellman, Bryan; Meyer, Larissa A., MD; Schmeler, Kathleen M., MD; Lu, Karen H., MD; Sood, Anil K., MD

doi: 10.1097/AOG.0000000000002796
Contents: Gynecologic Oncology: Original Research

OBJECTIVE: To estimate the effects of a laparoscopic scoring algorithm to triage patients with advanced ovarian cancer to immediate or delayed debulking to improve complete gross surgical resection rates and determine the resulting clinical outcomes.

METHODS: We prospectively performed laparoscopic assessment on patients with suspected advanced-stage ovarian cancer from April 2013 to December 2016 to determine primary resectability at tumor reductive surgery. Patients with medically inoperable or distant metastatic disease received neoadjuvant chemotherapy. Two-surgeon scoring was performed in a blinded fashion using a validated scoring method. Patients with predictive index value scores less than 8 were offered primary surgery and those with scores 8 or greater received neoadjuvant chemotherapy. Univariate and multivariate analysis was performed for effects on progression-free survival.

RESULTS: Six hundred twenty-one patients presenting with presumed advanced ovarian cancer were evaluated during the study period and 488 patients met inclusion criteria. Two hundred fifteen patients underwent laparoscopic scoring, of whom 125 had predictive index value scores less than 8 and 84 had predictive index value scores 8 or greater. Blinded two-surgeon predictive index value scoring resulted in bivariate discordance in only 2% of patients. Tumor cytoreduction led to no gross residual disease (R0 resection) in 88% of patients in the primary surgery group and 74% in the neoadjuvant chemotherapy group. Patients triaged to primary surgery had an improved progression-free survival of 21.4 months versus 12.9 months in those patients undergoing neoadjuvant chemotherapy (P<.001). Median progression-free survival by treatment group and residual disease status was as follows: primary surgery–R0 23.5 months; primary surgery–R1 (any gross residual disease) 17.6 months; neoadjuvant chemotherapy–R0 15.5 months; and neoadjuvant chemotherapy–R1 12.9 months (P<.001). On multivariate analysis for progression-free survival, baseline CA 125 (P=.001) and gross residual disease at tumor reductive surgery (P=.01) were significantly associated with progression-free survival.

CONCLUSION: Laparoscopic triage assessment allowed for a personalized approach to the management of patients with advanced ovarian cancer and resulted in high complete surgical resection rates at tumor reductive surgery.

Laparoscopic triage assessment of patients with advanced ovarian cancer leads to a personalized approach to surgical management and high complete surgical resection rates.

Department of Gynecologic Oncology and Reproductive Sciences and the Department of Biostatistics, the University of Texas MD Anderson Cancer Center, Houston, Texas; and St. Thomas Medical Partners, Gynecologic Oncology, Nashville, and the University of Tennessee Health Sciences Center, Memphis, Tennessee.

Corresponding author: Nicole D. Fleming, MD, 1155 Pressler, Unit 1362, Houston, TX 77030; email:

Supported in part by the Ovarian Cancer Moon Shot Program, National Institutes of Health through MD Anderson's Cancer Center Support Grant CA016672 and the SPORE in ovarian cancer (CA217685), the Blanton-Davis Ovarian Cancer Research Program, the Frank McGraw Memorial Chair in Cancer Research, and the American Cancer Society Research Professor Award.

Financial Disclosure Dr. Meyer has received research funding from AstraZeneca for unrelated research, and she participated in an advisory board for Clovis Oncology in October of 2016. The other authors did not report any potential conflicts of interest.

Each author has indicated that he or she has met the journal's requirements for authorship.

© 2018 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.