- Email: [email protected]
Management of ovarian cancer has changed
Letters to the Editor
As discussed in the manuscript, patients with a recurrent uterine malignancy limited to the pelvis who have received prior pelvic radiation are potential candidates for this procedure. In the absence of prospective controlled data due to the uncommon performance of this procedure for this indication, our study findings may offer some guidance regarding patient selection (endometrioid histology and low grade sarcoma, ability to achieve negative surgical margins). Ultimately, the decision for a physician and patient to proceed with an exenterative procedure should always be individualized and should rely on a multidisciplinary (medical, psychological, and social) evaluation of the patient while acknowledging the uncertainties about the expected outcome.
References [1] Khoury-Collado F, Einstein MH, Bochner BH, Alektiar KM, Sonoda Y, Abu-Rustum NR, et al. Pelvic exenteration with curative intent for recurrent uterine malignancies. Gynecol Oncol 2012;124(1):42–7. [2] Morris M, Alvarez RD, Kinney WK, Wilson TO. Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration. Gynecol Oncol 1996;60(2):288–91. [3] Barakat RR, Goldman NA, Patel DA, Venkatraman ES, Curtin JP. Pelvic exenteration for recurrent endometrial cancer. Gynecol Oncol 1999;75(1):99–102. [4] Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol Oct 2006;7(10):837–47 [Review]. [5] Shingleton HM, Soong SJ, Gelder MS, Hatch KD, Baker VV, Austin Jr JM. Clinical and histopathologic factors predicting recurrence and survival after pelvic exenteration for cancer of the cervix. Obstet Gynecol Jun 1989;73(6):1027–34.
Fady Khoury-Collado Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA M. Heather Einstein Department of Gynecologic Oncology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA Bernard H. Bochner Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA Kaled M. Alektiar Radiation Oncology, Brachytherapy Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA Yukio Sonoda Nadeem R. Abu-Rustum Carol L. Brown Ginger J. Gardner Richard R. Barakat Dennis S. Chi⁎ Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA ⁎Corresponding author. Fax: +1 212 717 3214. E-mail address: [email protected] (D.S. Chi). doi:10.1016/j.ygyno.2012.04.031
Management of ovarian cancer has changed
313
elements of the prognosis like residual tumour after primary surgery and histological type. However, in this study, the percentage of 38% of complete resectability for 478 patients with ovarian cancers is low when compared to the other studies [4]. It shows that the primary surgery performed by the authors in the rest of the 62% cases was not a good strategy. 294 women (171 patients with residual tumoursb 1 cm and 123 patients with more than 1 cm residual tumours) had a primary suboptimal debulking surgery which is a fundamental criterion of the prognosis. Indeed, women with residual tumours have a poor prognosis even if all the other factors of the nomogram presented by the authors are favourable. The absence of residual macroscopic tumours after surgery of ovarian cancers should be the objective in the majority of cases even in advanced stages. This objective could be attempted if a neoadjuvant chemotherapy was performed before the cytoreductive surgery [5,6] which was not the case in this study. Moreover, 57 women (12%) with stage IV ovarian cancers underwent a primary cyto-reductive surgery, though this strategy leads to incomplete resectability and delays chemotherapy which is efficient in many cases [5] and may allow to perform the surgery in better conditions and to obtain a better percentage of resectability. For advanced stages of ovarian cancers, the PET/computed tomography, by identifying mediastinal metastases as well as other parts of the whole body [2,3] could significantly contribute to select patients who will undergo primary surgery and those who will benefit from neoadjuvant chemotherapy (stages III C and IV) . In these cases primary surgery should have been used only as a diagnostic strategy and not as a curative surgery as it was presented in this study. Finally, the age and the ASA status (cited as specific variables by the authors) are not specific variables to predict mortality in women with ovarian cancers but they reflect the general status of the patient. In conclusion, this nomogram could not be applied in many cases as the preoperative staging of the patients should be completed by new imaging techniques and the curative surgery could not be the first step of treatment of advanced ovarian cancers when the complete resectability is not possible or when the patient presented metastases.
Conflict of interest statement No conflict of interest.
References [1] Barlin JN, Yu C, Hill EK, Zivanovic O, Kolev V, Levine DA, et al. Nomogram for predicting 5-year disease-specific mortality after primary surgery for epithelial ovarian cancer. Gynecol Oncol 2012;125:25–30. [2] Bats AS, Hugonnet F, Huchon C, Bensaid C, Pierquet-Ghazzar N, Faraggi M, et al. Prognostic significance of mediastinal (18)F-FDG uptake in PET/CT in advanced ovarian cancer. Eur J Nucl Med Mol Imaging 2012;39:474–80. [3] Kumar Dhingra V, Kand P, Basu S. Impact of FDG-PET and -PET/CT imaging in the clinical decision-making of ovarian carcinoma: an evidence-based approach. Womens Health 2012;8:191–203. [4] Chéreau E, Rouzier R, Gouy S, Ferron G, Narducci F, Bergzoll C, et al. Morbidity of diaphragmatic surgery for advanced ovarian cancer: retrospective study of 148 cases. Eur J Surg Oncol 2011;37:175–80. [5] Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson N, et al. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med 2010;363:943–53. [6] van Altena AM, Karim-Kos HE, de Vries E, Kruitwagen RF, Massuger LF, Kiemeney LA. Trends in therapy and survival of advanced stage epithelial ovarian cancer patients in the Netherlands. Gynecol Oncol 2012;125:649–54.
To the Editor: Barlin et al. [1], developed a nomogram with seven-variables to predict 5-year disease-specific mortality after primary cytoreductive surgery for all stages of epithelial ovarian carcinoma. These seven variables were the age, FIGO stage, residual tumour after primary surgery, histology, albumin level, ASA status and family history of ovarian or breast cancer. This nomogram was established with some pertinent
S. Alouini Department of Gynaecologic Surgery and Obstetrics, Regional Hospital Centre, Orleans, France E-mail address: [email protected]. doi:10.1016/j.ygyno.2012.04.044
As discussed in the manuscript, patients with a recurrent uterine malignancy limited to the pelvis who have received prior pelvic radiation are potential candidates for this procedure. In the absence of prospective controlled data due to the uncommon performance of this procedure for this indication, our study findings may offer some guidance regarding patient selection (endometrioid histology and low grade sarcoma, ability to achieve negative surgical margins). Ultimately, the decision for a physician and patient to proceed with an exenterative procedure should always be individualized and should rely on a multidisciplinary (medical, psychological, and social) evaluation of the patient while acknowledging the uncertainties about the expected outcome.
References [1] Khoury-Collado F, Einstein MH, Bochner BH, Alektiar KM, Sonoda Y, Abu-Rustum NR, et al. Pelvic exenteration with curative intent for recurrent uterine malignancies. Gynecol Oncol 2012;124(1):42–7. [2] Morris M, Alvarez RD, Kinney WK, Wilson TO. Treatment of recurrent adenocarcinoma of the endometrium with pelvic exenteration. Gynecol Oncol 1996;60(2):288–91. [3] Barakat RR, Goldman NA, Patel DA, Venkatraman ES, Curtin JP. Pelvic exenteration for recurrent endometrial cancer. Gynecol Oncol 1999;75(1):99–102. [4] Höckel M, Dornhöfer N. Pelvic exenteration for gynaecological tumours: achievements and unanswered questions. Lancet Oncol Oct 2006;7(10):837–47 [Review]. [5] Shingleton HM, Soong SJ, Gelder MS, Hatch KD, Baker VV, Austin Jr JM. Clinical and histopathologic factors predicting recurrence and survival after pelvic exenteration for cancer of the cervix. Obstet Gynecol Jun 1989;73(6):1027–34.
Fady Khoury-Collado Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA M. Heather Einstein Department of Gynecologic Oncology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102, USA Bernard H. Bochner Department of Surgery, Urology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA Kaled M. Alektiar Radiation Oncology, Brachytherapy Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA Yukio Sonoda Nadeem R. Abu-Rustum Carol L. Brown Ginger J. Gardner Richard R. Barakat Dennis S. Chi⁎ Department of Surgery, Gynecology Service, Memorial Sloan-Kettering Cancer Center, 1275 York Ave., New York, NY 10065, USA ⁎Corresponding author. Fax: +1 212 717 3214. E-mail address: [email protected] (D.S. Chi). doi:10.1016/j.ygyno.2012.04.031
Management of ovarian cancer has changed
313
elements of the prognosis like residual tumour after primary surgery and histological type. However, in this study, the percentage of 38% of complete resectability for 478 patients with ovarian cancers is low when compared to the other studies [4]. It shows that the primary surgery performed by the authors in the rest of the 62% cases was not a good strategy. 294 women (171 patients with residual tumoursb 1 cm and 123 patients with more than 1 cm residual tumours) had a primary suboptimal debulking surgery which is a fundamental criterion of the prognosis. Indeed, women with residual tumours have a poor prognosis even if all the other factors of the nomogram presented by the authors are favourable. The absence of residual macroscopic tumours after surgery of ovarian cancers should be the objective in the majority of cases even in advanced stages. This objective could be attempted if a neoadjuvant chemotherapy was performed before the cytoreductive surgery [5,6] which was not the case in this study. Moreover, 57 women (12%) with stage IV ovarian cancers underwent a primary cyto-reductive surgery, though this strategy leads to incomplete resectability and delays chemotherapy which is efficient in many cases [5] and may allow to perform the surgery in better conditions and to obtain a better percentage of resectability. For advanced stages of ovarian cancers, the PET/computed tomography, by identifying mediastinal metastases as well as other parts of the whole body [2,3] could significantly contribute to select patients who will undergo primary surgery and those who will benefit from neoadjuvant chemotherapy (stages III C and IV) . In these cases primary surgery should have been used only as a diagnostic strategy and not as a curative surgery as it was presented in this study. Finally, the age and the ASA status (cited as specific variables by the authors) are not specific variables to predict mortality in women with ovarian cancers but they reflect the general status of the patient. In conclusion, this nomogram could not be applied in many cases as the preoperative staging of the patients should be completed by new imaging techniques and the curative surgery could not be the first step of treatment of advanced ovarian cancers when the complete resectability is not possible or when the patient presented metastases.
Conflict of interest statement No conflict of interest.
References [1] Barlin JN, Yu C, Hill EK, Zivanovic O, Kolev V, Levine DA, et al. Nomogram for predicting 5-year disease-specific mortality after primary surgery for epithelial ovarian cancer. Gynecol Oncol 2012;125:25–30. [2] Bats AS, Hugonnet F, Huchon C, Bensaid C, Pierquet-Ghazzar N, Faraggi M, et al. Prognostic significance of mediastinal (18)F-FDG uptake in PET/CT in advanced ovarian cancer. Eur J Nucl Med Mol Imaging 2012;39:474–80. [3] Kumar Dhingra V, Kand P, Basu S. Impact of FDG-PET and -PET/CT imaging in the clinical decision-making of ovarian carcinoma: an evidence-based approach. Womens Health 2012;8:191–203. [4] Chéreau E, Rouzier R, Gouy S, Ferron G, Narducci F, Bergzoll C, et al. Morbidity of diaphragmatic surgery for advanced ovarian cancer: retrospective study of 148 cases. Eur J Surg Oncol 2011;37:175–80. [5] Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson N, et al. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med 2010;363:943–53. [6] van Altena AM, Karim-Kos HE, de Vries E, Kruitwagen RF, Massuger LF, Kiemeney LA. Trends in therapy and survival of advanced stage epithelial ovarian cancer patients in the Netherlands. Gynecol Oncol 2012;125:649–54.
To the Editor: Barlin et al. [1], developed a nomogram with seven-variables to predict 5-year disease-specific mortality after primary cytoreductive surgery for all stages of epithelial ovarian carcinoma. These seven variables were the age, FIGO stage, residual tumour after primary surgery, histology, albumin level, ASA status and family history of ovarian or breast cancer. This nomogram was established with some pertinent
S. Alouini Department of Gynaecologic Surgery and Obstetrics, Regional Hospital Centre, Orleans, France E-mail address: [email protected]. doi:10.1016/j.ygyno.2012.04.044