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Do patients with complete gross resection of advanced stage ovarian cancer benefit from lymphadenectomy?
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Abstracts / Gynecologic Oncology 125 (2012) S3–S167
fifty-one (13.1%) underwent diaphragm surgery, 112 (4.2%) had liver surgery, 108 (4%) had splenectomies, 12 (0.5%) had pancreatectomies, and 7 (0.2%) had porta hepatis surgery. Comparing patients who did not have UAP to patients who had UAP, the PFS and OS was 18.2 months (mos) and 14.8 mos (p b 0.01) and 49.8 mos v. 43.7 mos, (p = 0.01), respectively. However, this trend for improved outcomes was not significant after multivariate analysis (PFS HR = 1.03, 95% CI 0.91–1.15; OS HR = 0.92, 95%CI 0.81–1.04). In an exploratory analysis, the survival of the 141 patients who had UAP and achieved CR was compared to the 341 patients who had UAPs and had MR. The OS in those achieving CR was 54.6 mos compared to 40.4 mos in those with MR. Two hundred sixty-one (14.5%) of the 1795 patients with MR had diaphragmatic disease as their only site of gross residual disease and were identified as potential candidates for more aggressive surgery to achieve complete resection. Conclusions: Nearly one in five optimally debulked patients in GOG 182 underwent an upper abdominal procedure to achieve either CR or MR. A significant proportion of patients were left with diaphragmatic disease that could potentially be completely resected. Though upper abdominal disease may signal adverse biology, it also potentially presents a modifiable prognostic factor for surgeons skilled in advanced and upper abdominal cytoreductive techniques. doi:10.1016/j.ygyno.2011.12.055
55 Do patients with complete gross resection of advanced stage ovarian cancer benefit from lymphadenectomy? B. Cormier, K. Long, J. Ducie, E. Tanner, I. Wadhawan, E. Jewell, M. Leitao, R. Barakat, D. Chi, G. Gardner. Memorial Sloan-Kettering Cancer Center, New York, NY.
Objective: Optimal debulking to complete gross resection (CGR) but without a full lymphadenectomy (LND) leaves the potential for residual b1 cm nodal disease. The purpose of this study was to determine if LND is beneficial to patients otherwise achieving CGR for advanced stage ovarian cancer. Methods: We identified all stage IIIC–IV grade 3 serous ovarian cancer patients with complete gross resection of disease at primary debulking surgery performed at our institution from 10/2001 to 12/2009. Patients who had undergone neoadjuvant chemotherapy were excluded. The extent of LND at primary debulking was evaluated by the number of lymph nodes (LN) removed from the pelvic and paraaortic distribution. Group A: no LND performed; Group B: 1–19 LNs removed; Group C: ≥ 20 LNs removed. Multivariate Cox regression and Kaplan–Meier survival analysis were utilized. Results: Of 257 patients identified as optimally debulked, 109 achieved CGR; these included Group A, 34 (31%), Group B 35 (32%), and Group C 40 (37%). Of patients who had any LND, 56/75 (75%) had LN metastasis. Of patients with normal-appearing LNs at surgery, 20/63 (31%) had LN metastasis. All patients received postoperative platinum-based chemotherapy, and intra-peritoneal chemotherapy was administered in 41%, 53%, and 40% for Groups A, B, and C, respectively. There was no difference in the site of recurrent disease (isolated LN, peritoneal, both LN and peritoneal, or distant) relative to the extent of LND performed at the primary surgery. There was no significant difference on multivariate analysis in progression-free survival (PFS) or overall survival (OS) associated with the extent of
LND (Group A: OS HR = Ref; Group B: OS HR = 1.350 [95%CI 0.614– 2.969], P = 0.455; Group C: OS HR = 1.573 [95%CI 0.695–2.969], P = 0.277). Conclusions: Subcentimeter LN metastases were identified in 31% of cases; however, a complete lymphadenectomy did not appear to confer a survival advantage among patients otherwise achieving a CGR. Notably, there was no increased rate of nodal recurrence among patients without LND. The extent of LND required in patients otherwise achieving CGR for advanced stage ovarian cancer warrants further prospective evaluation.
doi:10.1016/j.ygyno.2011.12.056
56 Prognostic factors for stage III epithelial ovarian cancer treated with intraperitoneal chemotherapy: A Gynecologic Oncology Group study L. Landrum1, J. Java2, C. Mathews1, G. Lanneau3, L. Copeland4, D. Armstrong5, J. Walker1. 1University of Oklahoma, Oklahoma City, OK, 2 GOG Statistics & Data Center, Roswell Park Cancer Institute, Buffalo, NY, 3 Naval Medical Center San Diego, San Diego, CA, 4The Ohio State University, Columbus, OH, 5Johns Hopkins Hospital, Baltimore, MD.
Objective: To determine prognostic factors for improved survival in ovarian cancer patients treated with intraperitoneal (IP) chemotherapy using GOG ancillary data. Methods: Data were collected from 845 patients with stage III epithelial ovarian cancer who underwent optimal surgical cytoreduction (b1 cm) followed by paclitaxel/platinum chemotherapy on one of two GOG clinical trials (protocols 114 and 172). Primary endpoints were progression free survival (PFS) and overall survival (OS). Potential prognostic variables were included in Cox proportional hazard regression models. Multivariate analysis was conducted to identify independent prognostic factors. Kaplan–Meier survival curves were calculated and compared using log-rank tests. Statistical tests were two-tailed with significance level set at 5%. Results: For patients receiving IP chemotherapy (n = 428), 36% of patients had no visible residual disease. Bowel resection was completed in 29% of patients, with pelvic lymph node dissection in 52% and para-aortic lymph node dissection in 47%. No lymph nodes were removed in 42% of patients. Median PFS was 24.9 months (95% CI, 23.0–29.2) and median OS was 61.8 (95% CI, 55.5–69.8). Predictors for PFS were histology, surgical stage and size of residual disease. Age, histology, and size of residual disease were prognostic for OS. There were no differences in the hazard ratio for death or progression between patients with positive, negative, or unknown lymph node status. For IP patients with no residual disease following surgery, median PFS was 43.2 months (95% CI, 32.5–60.4) and median OS was 110 months (95% CI, 60.0–161.3). IP patients with no residual disease had median PFS of 41.1 months (95% CI 24.2–54.6) and 60.4 months (95% CI 36.9–N/A) and median OS of 83.8 months (95% CI 60.1–161.3) and 127.6 months (95% CI, 84.7–N/A), for GOG 114 and 172, respectively. Conclusions: Age, histology, and extent of residual disease were predictors of OS in Stage III patients treated with IP chemotherapy following optimal cytoreduction. Stage of disease was prognostic of PFS, but not OS. Patients with retroperitoneal disease did not have a poorer outcome than patients with no or
Abstracts / Gynecologic Oncology 125 (2012) S3–S167
fifty-one (13.1%) underwent diaphragm surgery, 112 (4.2%) had liver surgery, 108 (4%) had splenectomies, 12 (0.5%) had pancreatectomies, and 7 (0.2%) had porta hepatis surgery. Comparing patients who did not have UAP to patients who had UAP, the PFS and OS was 18.2 months (mos) and 14.8 mos (p b 0.01) and 49.8 mos v. 43.7 mos, (p = 0.01), respectively. However, this trend for improved outcomes was not significant after multivariate analysis (PFS HR = 1.03, 95% CI 0.91–1.15; OS HR = 0.92, 95%CI 0.81–1.04). In an exploratory analysis, the survival of the 141 patients who had UAP and achieved CR was compared to the 341 patients who had UAPs and had MR. The OS in those achieving CR was 54.6 mos compared to 40.4 mos in those with MR. Two hundred sixty-one (14.5%) of the 1795 patients with MR had diaphragmatic disease as their only site of gross residual disease and were identified as potential candidates for more aggressive surgery to achieve complete resection. Conclusions: Nearly one in five optimally debulked patients in GOG 182 underwent an upper abdominal procedure to achieve either CR or MR. A significant proportion of patients were left with diaphragmatic disease that could potentially be completely resected. Though upper abdominal disease may signal adverse biology, it also potentially presents a modifiable prognostic factor for surgeons skilled in advanced and upper abdominal cytoreductive techniques. doi:10.1016/j.ygyno.2011.12.055
55 Do patients with complete gross resection of advanced stage ovarian cancer benefit from lymphadenectomy? B. Cormier, K. Long, J. Ducie, E. Tanner, I. Wadhawan, E. Jewell, M. Leitao, R. Barakat, D. Chi, G. Gardner. Memorial Sloan-Kettering Cancer Center, New York, NY.
Objective: Optimal debulking to complete gross resection (CGR) but without a full lymphadenectomy (LND) leaves the potential for residual b1 cm nodal disease. The purpose of this study was to determine if LND is beneficial to patients otherwise achieving CGR for advanced stage ovarian cancer. Methods: We identified all stage IIIC–IV grade 3 serous ovarian cancer patients with complete gross resection of disease at primary debulking surgery performed at our institution from 10/2001 to 12/2009. Patients who had undergone neoadjuvant chemotherapy were excluded. The extent of LND at primary debulking was evaluated by the number of lymph nodes (LN) removed from the pelvic and paraaortic distribution. Group A: no LND performed; Group B: 1–19 LNs removed; Group C: ≥ 20 LNs removed. Multivariate Cox regression and Kaplan–Meier survival analysis were utilized. Results: Of 257 patients identified as optimally debulked, 109 achieved CGR; these included Group A, 34 (31%), Group B 35 (32%), and Group C 40 (37%). Of patients who had any LND, 56/75 (75%) had LN metastasis. Of patients with normal-appearing LNs at surgery, 20/63 (31%) had LN metastasis. All patients received postoperative platinum-based chemotherapy, and intra-peritoneal chemotherapy was administered in 41%, 53%, and 40% for Groups A, B, and C, respectively. There was no difference in the site of recurrent disease (isolated LN, peritoneal, both LN and peritoneal, or distant) relative to the extent of LND performed at the primary surgery. There was no significant difference on multivariate analysis in progression-free survival (PFS) or overall survival (OS) associated with the extent of
LND (Group A: OS HR = Ref; Group B: OS HR = 1.350 [95%CI 0.614– 2.969], P = 0.455; Group C: OS HR = 1.573 [95%CI 0.695–2.969], P = 0.277). Conclusions: Subcentimeter LN metastases were identified in 31% of cases; however, a complete lymphadenectomy did not appear to confer a survival advantage among patients otherwise achieving a CGR. Notably, there was no increased rate of nodal recurrence among patients without LND. The extent of LND required in patients otherwise achieving CGR for advanced stage ovarian cancer warrants further prospective evaluation.
doi:10.1016/j.ygyno.2011.12.056
56 Prognostic factors for stage III epithelial ovarian cancer treated with intraperitoneal chemotherapy: A Gynecologic Oncology Group study L. Landrum1, J. Java2, C. Mathews1, G. Lanneau3, L. Copeland4, D. Armstrong5, J. Walker1. 1University of Oklahoma, Oklahoma City, OK, 2 GOG Statistics & Data Center, Roswell Park Cancer Institute, Buffalo, NY, 3 Naval Medical Center San Diego, San Diego, CA, 4The Ohio State University, Columbus, OH, 5Johns Hopkins Hospital, Baltimore, MD.
Objective: To determine prognostic factors for improved survival in ovarian cancer patients treated with intraperitoneal (IP) chemotherapy using GOG ancillary data. Methods: Data were collected from 845 patients with stage III epithelial ovarian cancer who underwent optimal surgical cytoreduction (b1 cm) followed by paclitaxel/platinum chemotherapy on one of two GOG clinical trials (protocols 114 and 172). Primary endpoints were progression free survival (PFS) and overall survival (OS). Potential prognostic variables were included in Cox proportional hazard regression models. Multivariate analysis was conducted to identify independent prognostic factors. Kaplan–Meier survival curves were calculated and compared using log-rank tests. Statistical tests were two-tailed with significance level set at 5%. Results: For patients receiving IP chemotherapy (n = 428), 36% of patients had no visible residual disease. Bowel resection was completed in 29% of patients, with pelvic lymph node dissection in 52% and para-aortic lymph node dissection in 47%. No lymph nodes were removed in 42% of patients. Median PFS was 24.9 months (95% CI, 23.0–29.2) and median OS was 61.8 (95% CI, 55.5–69.8). Predictors for PFS were histology, surgical stage and size of residual disease. Age, histology, and size of residual disease were prognostic for OS. There were no differences in the hazard ratio for death or progression between patients with positive, negative, or unknown lymph node status. For IP patients with no residual disease following surgery, median PFS was 43.2 months (95% CI, 32.5–60.4) and median OS was 110 months (95% CI, 60.0–161.3). IP patients with no residual disease had median PFS of 41.1 months (95% CI 24.2–54.6) and 60.4 months (95% CI 36.9–N/A) and median OS of 83.8 months (95% CI 60.1–161.3) and 127.6 months (95% CI, 84.7–N/A), for GOG 114 and 172, respectively. Conclusions: Age, histology, and extent of residual disease were predictors of OS in Stage III patients treated with IP chemotherapy following optimal cytoreduction. Stage of disease was prognostic of PFS, but not OS. Patients with retroperitoneal disease did not have a poorer outcome than patients with no or