Definition of a dynamic laparoscopic model for the prediction of incomplete cytoreduction in advanced epithelial ovarian cancer: Proof of a concept


      • The chance of achieving complete PDS in women with AEOC showing a LPS-PIV ≥ 10 was 0.
      • The risk of unnecessary laparotomy in patients showing a LPS-PIV < 10 was 33.2%.
      • The overall discriminating performance of LPS-PI was very high, with an AUC = 0.885.



      To develop an updated laparoscopy-based model to predict incomplete cytoreduction (RT > 0) in advanced epithelial ovarian cancer (AEOC), after the introduction of upper abdominal surgery (UAS).

      Patients and methods

      The presence of omental cake, peritoneal extensive carcinomatosis, diaphragmatic confluent carcinomatosis, bowel infiltration, stomach and/or spleen and/or lesser omentum infiltration, and superficial liver metastases was evaluated by staging laparoscopy (S-LPS) in a consecutive series of 234 women with newly diagnosed AEOC, receiving laparotomic PDS after S-LPS. Parameters showing a specificity ≥ 75%, PPV ≥ 50%, and NPV ≥ 50% received 1 point score, with an additional one point in the presence of an accuracy of ≥60% in predicting incomplete cytoreduction. The overall discriminating performance of the LPS-PI was finally estimated by ROC curve analysis.


      No-gross residual disease at PDS was achieved in 135 cases (57.5%). Among them, UAS was required in 72 cases (53.3%) for a total of 112 procedures, and around 25% of these patients received bowel resection, excluding recto-sigmoid resection. We observed a very high overall agreement between S-LPS and laparotomic findings, which ranged from 74.7% for omental cake to 94.8% for stomach infiltration. At a LPS-PIV ≥ 10 the chance of achieving complete PDS was 0, and the risk of unnecessary laparotomy was 33.2%. Discriminating performance of LPS-PI was very high (AUC = 0.885).


      S-LPS is confirmed as an accurate tool in the prediction of complete PDS in women with AEOC. The updated LPS-PI showed improved discriminating performance, with a lower rate of inappropriate laparotomic explorations at the established cut-off value of 10.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gynecologic Oncology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Vergote I.
        • Tropé C.G.
        • Amant F.
        • et al.
        Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer.
        N. Engl. J. Med. 2012; 363: 943-953
        • Kehoe S.
        • Hook J.
        • Nankivell M.
        • et al.
        Chemotherapy or upfront surgery for newly diagnosed advanced ovarian cancer: results from the MRC CHORUS trial.
        in: 2013 ASCO Annual Meeting. Abstract 5500. Presented June 1, 2013. 2013
        • Bristow R.E.
        • Tomacruz R.S.
        • Armstrong D.K.
        • Trimble E.L.
        • Montz F.J.
        Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis.
        J. Clin. Oncol. 2002; 20: 1248-1259
        • Chi D.S.
        • Musa F.
        • Dao F.
        • et al.
        An analysis of patients with bulky advanced stage ovarian, tubal, and peritoneal carcinoma treated with primary debulking surgery (PDS) during an identical time period as the randomized EORTC-NCIC trial of PDS vs neoadjuvant chemotherapy (NACT).
        Gynecol. Oncol. 2012; 124: 10-14
        • du Bois A.
        • Reuss A.
        • Pujade-Lauraine E.
        • Harter P.
        • Ray-Coquard I.
        • Pfisterer J.
        Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d'Investigateurs Nationaux Pour les Etudes des Cancers de l'Ovaire (GINECO).
        Cancer. 2009; 115: 1234-1244
        • Peiretti M.
        • Zanagnolo V.
        • Aletti G.D.
        • et al.
        Role of maximal primary cytoreductive surgery in patients with advanced epithelial ovarian and tubal cancer: surgical and oncological outcomes. Single institution experience.
        Gynecol. Oncol. 2010; 119: 259-264
        • Eisenkop S.M.
        • Spirtos N.M.
        • Friedman R.L.
        • Lin W.C.
        • Pisani A.L.
        • Perticucci S.
        Relative influences of tumor volume before surgery and the cytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study.
        Gynecol. Oncol. 2003; 90: 390-396
        • Morrison J.
        • Haldar K.
        • Kehoe S.
        • Lawrie T.A.
        Chemotherapy versus surgery for initial treatment in advanced ovarian epithelial cancer.
        Cochrane Database Syst. Rev. 2012; 8: CD005343
      1. (Available at website) (accessed on 2nd July 2015)
        • Fagotti A.
        • Vizzielli G.
        • Fanfani F.
        • et al.
        Introduction of staging laparoscopy in the management of advanced epithelial ovarian, tubal and peritoneal cancer: impact on prognosis in a single institution experience.
        Gynecol. Oncol. 2013; 131: 341-346
        • Zapardiel I.
        • Morrow C.P.
        New terminology for cytoreduction in advanced ovarian cancer.
        Lancet Oncol. 2011; 12: 214
        • Eisenhauer E.L.
        • Abu-Rustum N.R.
        • Sonoda Y.
        • et al.
        The addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival in patients with stages IIIC–IV epithelial ovarian cancer.
        Gynecol. Oncol. 2006; 103: 1083-1090
        • Aletti G.D.
        • Dowdy S.C.
        • Podratz K.C.
        • Cliby W.A.
        Surgical treatment of diaphragm disease correlates with improved survival in optimally debulked advanced stage ovarian cancer.
        Gynecol. Oncol. 2006; 100: 283-287
        • Fanfani F.
        • Fagotti A.
        • Gallotta V.
        • et al.
        Upper abdominal surgery in advanced and recurrent ovarian cancer: role of diaphragmatic surgery.
        Gynecol. Oncol. 2010; 116: 497-501
        • Clavien P.A.
        • Barkun J.
        • de Oliveira M.L.
        • et al.
        The Clavien–Dindo classification of surgical complications: five-year experience.
        Ann. Surg. 2009; 250: 187-196
        • Fagotti A.
        • Ferrandina G.
        • Fanfani F.
        • et al.
        Prospective validation of a laparoscopic predictive model for optimal cytoreduction in advanced ovarian carcinoma.
        Am. J. Obstet. Gynecol. 2008; 199: 642.e1-642.e6
        • Fagotti A.
        • Vizzielli G.
        • De Iaco P.
        • et al.
        A multicentric trial (Olympia-MITO 13) on the accuracy of laparoscopy to assess peritoneal spread in ovarian cancer.
        Am. J. Obstet. Gynecol. 2013; 209: 462.e1-462.e11
        • Fagotti A.
        • Ferrandina G.
        • Fanfani F.
        • et al.
        A laparoscopy-based score to predict surgical outcome in patients with advanced ovarian carcinoma: a pilot study.
        Ann. Surg. Oncol. Aug 2006; 13: 1156-1161
        • Bristow R.E.
        • Duska L.R.
        • Lambrou N.C.
        • et al.
        A model for predicting surgical outcome in patients with advanced ovarian carcinoma using computed tomography.
        Cancer. 2000; 89: 1532-1540
        • Cowen J.S.
        • Kelley M.A.
        Errors and bias in using the predictive scoring systems.
        Crit. Care Clin. 1994; 10: 53
        • Petrillo M.
        • Ferrandina G.
        • Fagotti A.
        • et al.
        Timing and pattern of recurrence in ovarian cancer patients with high tumor dissemination treated with primary debulking surgery versus neoadjuvant chemotherapy.
        Ann. Surg. Oncol. 2013; 20: 3955-3960
        • Rauh-Hain J.A.
        • Nitschmann C.C.
        • Worley Jr., M.J.
        • et al.
        Platinum resistance after neoadjuvant chemotherapy compared to primary surgery in patients with advanced epithelial ovarian carcinoma.
        Gynecol. Oncol. 2013; 129: 63-68
        • Brun J.L.
        • Rouzier R.
        • Uzan S.
        • Daraï E.
        External validation of a laparoscopic-based score to evaluate resectability of advanced ovarian cancers: clues for a simplified score.
        Gynecol. Oncol. 2008; 110: 354-359
        • Rutten M.J.
        • Leeflang M.M.
        • Kenter G.G.
        • Mol B.W.
        • Buist M.
        Laparoscopy for diagnosing resectability of disease in patients with advanced ovarian cancer.
        Cochrane Database Syst. Rev. 2014; 2: CD009786
        • Tucker S.L.
        • Gharpure K.
        • Herbrich S.M.
        • et al.
        Molecular biomarkers of residual disease after surgical debulking of high-grade serous ovarian cancer.
        Clin. Cancer Res. 2014; 20: 3280-3288
        • Suidan R.S.
        • Ramirez P.T.
        • Sarasohn D.M.
        • et al.
        A multicenter prospective trial evaluating the ability of preoperative computed tomography scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer.
        Gynecol. Oncol. 2014; 134: 468-472