Complications associated with cytoreductive surgery for advanced ovarian cancer: Surgical timing and surmounting obstacles

  • Jill H. Tseng
    Corresponding author at: Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine-Medical Center, 333 City Blvd West, Suite 1400, Orange, CA 92868, USA.
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine-Medical Center, Orange, CA, USA
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  • Robert E. Bristow
    Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of California, Irvine-Medical Center, Orange, CA, USA
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      In 1975, C. Thomas Griffiths introduced the concept of surgical cytoreduction and the inverse relationship between residual tumor volume and survival for the treatment of advanced ovarian cancer [
      • Griffiths C.T.
      Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma.
      ]. In his landmark paper entitled Surgical Resection of Tumor Bulk in the Primary Treatment of Ovarian Carcinoma, Griffiths reported on 102 patients who underwent surgical removal of tumor. Half of the cohort was treated with a hysterectomy and bilateral salpingo-oophorectomy (BSO), while only 6 patients underwent more extensive surgery with a hysterectomy, BSO and removal of 2 metastatic masses greater than 1.5 cm. There were 3 post-operative deaths. Complete tumor resection was achieved in 28% of patients and the median overall survival (OS) was merely18 months. Griffiths concluded that “surgical bulk resection is of little value unless all or nearly all gross tumor is excised.”
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        • Griffiths C.T.
        Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma.
        Natl. Cancer Inst. Monogr. 1975; 42: 101-104
        • Eisenkop S.M.
        • Friedman R.L.
        • Wang H.J.
        Complete cytoreductive surgery is feasible and maximizes survival in patients with advanced epithelial ovarian cancer: a prospective study.
        Gynecol. Oncol. 1998; 69: 103-108
        • Chi D.S.
        • Eisenhauer E.L.
        • Zivanovic O.
        • Sonoda Y.
        • Abu-Rustum N.R.
        • Levine D.A.
        • Guile M.W.
        • Bristow R.E.
        • Aghajanian C.
        • Barakat R.R.
        Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm.
        Gynecol. Oncol. 2009; 114: 26-31
        • 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
        • Hoskins W.J.
        Epithelial ovarian carcinoma: principles of primary surgery.
        Gynecol. Oncol. 1994; 55: S91-S96
        • Bristow R.E.
        • Chi D.S.
        Platinum-based neoadjuvant chemotherapy and interval surgical cytoreduction for advanced ovarian cancer: a meta-analysis.
        Gynecol. Oncol. 2006; 103: 1070-1076
        • Vergote I.
        • Trope C.G.
        • Amant F.
        • Kristensen G.B.
        • Ehlen T.
        • Johnson N.
        • et al.
        European Organization for Research and Treatment of cancer-gynaecological cancer group; NCIC clinical trials group. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer.
        N. Engl. J. Med. 2010; 363: 943-953
        • Kehoe S.
        • Hook J.
        • Nankivell M.
        • Jayson G.C.
        • Kitchener H.
        • Lopes T.
        • Luesley D.
        • Perren T.
        • Bannoo S.
        • Mascarenhas M.
        • Dobbs S.
        • Essapen S.
        • Twigg J.
        • Herod J.
        • McCluggage G.
        • Parmar M.
        • Swart A.M.
        Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial.
        Lancet. 2015; 386: 249-257
        • Tseng J.H.
        • Cowan R.A.
        • Zhou Q.
        • Iasonos A.
        • Byrne M.
        • Polcino T.
        • Polen-De C.
        • Gardner G.J.
        • Sonoda Y.
        • Zivanovic O.
        • Abu-Rustum N.R.
        • Long Roche K.
        • Chi D.S.
        Continuous improvement in primary Debulking surgery for advanced ovarian cancer: do increased complete gross resection rates independently lead to increased progression-free and overall survival?.
        Gynecol. Oncol. 2018; 151: 24-31
        • Ghirardi V.
        • Moruzzi M.C.
        • Bizzarri N.
        • Vargiu V.
        • D'Indinosante M.
        • Garganese G.
        • Pasciuto T.
        • Loverro M.
        • Scambia G.
        • Fagotti A.
        Minimal residual disease at primary debulking surgery versus complete tumor resection at interval debulking surgery in advanced epithelial ovarian cancer: a survival analysis.
        Gynecol. Oncol. 2020; 157: 209-213
        • Angeles M.A.
        • Hernández A.
        • Pérez-Benavente A.
        • Cabarrou B.
        • Spagnolo E.
        • Rychlik A.
        • Daboussi A.
        • Migliorelli F.
        • Bétrian S.
        • Ferron G.
        • Gil-Moreno A.
        • Guyon F.
        • Martinez A.
        The effect of major postoperative complications on recurrence and long-term survival after cytoreductive surgery for ovarian cancer.
        Gynecol. Oncol. 2022; 166: 8-17
        • Xu Z.
        • Becerra A.Z.
        • Justiniano C.F.
        • Aquina C.T.
        • Fleming F.J.
        • Boscoe F.P.
        • Schymura M.J.
        • Sinno A.K.
        • Chaoul J.
        • Morrow G.R.
        • Minasian L.
        • Temkin S.M.
        Complications and survivorship trends after primary debulking surgery for ovarian cancer.
        J. Surg. Res. 2020; 246: 34-41
        • Ross M.S.
        • Burriss M.E.
        • Winger D.G.
        • Edwards R.P.
        • Courtney-Brooks M.
        • Boisen M.M.
        Unplanned postoperative intensive care unit admission for ovarian cancer cytoreduction is associated with significant decrease in overall survival.
        Gynecol. Oncol. 2018; 150: 306-310
        • Galata C.
        • Blank S.
        • Weiss C.
        • Ronellenfitsch U.
        • Reissfelder C.
        • Hardt J.
        Role of postoperative complications in overall survival after radical resection for gastric cancer: a retrospective single-center analysis of 1107 patients.
        Cancers (Basel). 2019; 11: 1890
        • Fernandez F.G.
        • Kosinski A.S.
        • Furnary A.P.
        • Onaitis M.
        • Kim S.
        • Habib R.H.
        • Tong B.C.
        • Cowper P.
        • Boffa D.
        • Jacobs J.P.
        • Wright C.D.
        • Putnam J.B.
        Differential effects of operative complications on survival after surgery for primary lung cancer.
        J. Thorac. Cardiovasc. Surg. 2018; 155: 1254-1264
        • Gamboa A.C.
        • Lee R.M.
        • Turgeon M.K.
        • Varlamos C.
        • Regenbogen S.E.
        • Hrebinko K.A.
        • Holder-Murray J.
        • Wiseman J.T.
        • Ejaz A.
        • Feng M.P.
        • Hawkins A.T.
        • Bauer P.
        • Silviera M.
        • Maithel S.K.
        • Balch G.C.
        Impact of postoperative complications on oncologic outcomes after rectal cancer surgery: an analysis of the US rectal cancer consortium.
        Ann. Surg. Oncol. 2021; 28: 1712-1721
        • Connor E.V.
        • Moulton L.J.
        • Costales A.B.
        • Vargas R.
        • Michener C.M.
        • AlHilli M.M.
        Intestinal surgery in gynecologic oncology: are we training for the future?.
        Int. J. Gynecol. Cancer. 2018; 28: 983-988
        • Aletti G.D.
        • Eisenhauer E.L.
        • Santillan A.
        • Axtell A.
        • Aletti G.
        • Holschneider C.
        • Chi D.S.
        • Bristow R.E.
        • Cliby W.A.
        Identification of patient groups at highest risk from traditional approach to ovarian cancer treatment.
        Gynecol. Oncol. 2011; 120: 23-28
        • Jiang C.
        • Li Z.
        Performance validation of the Mayo triage algorithm applied to individualize surgical management of advanced epithelial ovarian cancer.
        Gynecol. Oncol. 2021; 162: 339-344
        • Cowan R.A.
        • O'Cearbhaill R.E.
        • Gardner G.J.
        • Levine D.A.
        • Roche K.L.
        • Sonoda Y.
        • Zivanovic O.
        • Tew W.P.
        • Sala E.
        • Lakhman Y.
        • Vargas Alvarez H.A.
        • Sarasohn D.M.
        • Mironov S.
        • Abu-Rustum N.R.
        • Chi D.S.
        Is it time to centralize ovarian cancer care in the United States?.
        Ann. Surg. Oncol. 2016; 23: 989-993
        • Bristow R.E.
        • Santillan A.
        • Diaz-Montes T.P.
        • Gardner G.J.
        • Giuntoli 2nd, R.L.
        • Meisner B.C.
        • Frick K.D.
        • Armstrong D.K.
        Centralization of care for patients with advanced-stage ovarian cancer: a cost-effectiveness analysis.
        Cancer. 2007; 109: 1513-1522
        • National Oesophago-Gastric Cancer Audit
        Third Annual Report-Patient Summary [Internet].
        National Oesophago-Gastric Cancer Audit, Leeds2012 ([cited 2015 Mar 30]. Available from:)
        • Busweiler L.A.
        • Dikken J.L.
        • Henneman D.
        • van Berge Henegouwen M.I.
        • Ho V.K.
        • Tollenaar R.A.
        • et al.
        The influence of a composite hospital volume on outcomes for gastric cancer surgery: a Dutch population based study.
        J. Surg. Oncol. 2017; 115: 738-745
        • Morche J.
        • Mathes T.
        • Pieper D.
        Relationship between surgeon volume and outcomes: a systematic review of systematic reviews.
        Syst. Rev. 2016; 5: 204
        • Galvan-Turner V.B.
        • Chang J.
        • Ziogas A.
        • Bristow R.E.
        Observed-to-expected ratio for adherence to treatment guidelines as a quality of care indicator for ovarian cancer.
        Gynecol. Oncol. 2015; 139: 495-499