Obstet Gynecol Sci.  2020 Jan;63(1):64-71. 10.5468/ogs.2020.63.1.64.

Factors associated with surgical morbidity of primary debulking in epithelial ovarian cancer

• Günakan E
• Tohma YA
• Tunç M
• Akıllı H
• Åžahin H
• Ayhan A

• KMID: 2467933
• DOI: http://doi.org/10.5468/ogs.2020.63.1.64

Abstract

OBJECTIVE
Epithelial ovarian cancer (EOC) requires an aggressive surgical approach. The important part of literature on ovarian cancer surgery emphasize residual tumor and survival analyses. Morbidity issue keeps in background. Therefore, we aimed to report on morbidity of cytoreductive surgery for EOC in this study.
METHODS
EOC patients who underwent primary debulking were evaluated. Intraoperative and postoperative complications that occurred within 30 days after the surgery and factors that affect morbidity were considered.
RESULTS
The study involved 359 patients. Forty-six intraoperative complications occurred in 42 (11.6%) patients. Advanced stage and cancer antigen level of 125 were independently and significantly associated with operative complications (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.01-2,73; P=0.044, and HR, 1.47; 95% CI, 1.05-2.06; P=0.025, respectively). The need for intensive care unit admission was significantly higher in patients with intraoperative complications (28.6% vs. 8.8%, P=0.001). Intraoperative and postoperative complication rates were significantly higher in extended surgery than in standard surgery (18.9%vs. 8.5%, P=0.005 and 38.7% vs. 10.9%, P < 0.001, respectively). Intraoperative and postoperative transfusion need, hospital stay duration, and chemotherapy start day were also significantly higher in extended surgery than in standard surgery. Hundred postoperative complications occurred in 70 patients. Age, extended surgery, presence of ascites, and presence of operative complications were independently and significantly associated with postoperative complications.
CONCLUSION
Morbidity of extensive surgical approach should be kept in mind in ovarian cancer surgery aimed at leaving no residual tumor. Patient-based management with an appropriate preoperative evaluation may avoid morbidity of extended/extensive surgical approaches.

Keyword

Epithelial ovarian cancer; Cytoreduction; Morbidity; Ovarian cancer; Primary debulking

MeSH Terms

Ascites
Drug Therapy
Humans
Intensive Care Units
Intraoperative Complications
Length of Stay
Neoplasm, Residual
Ovarian Neoplasms*
Postoperative Complications

Reference

1. Zhang G, Yao W, Sun T, Liu X, Zhang P, Jin J, et al. Magnetic resonance imaging in categorization of ovarian epithelial cancer and survival analysis with focus on apparent diffusion coefficient value: correlation with Ki-67 expression and serum cancer antigen-125 level. J Ovarian Res. 2019; 12:59. PMID: 31242916.

2. Timmermans M, van der Aa MA, Lalisang RI, Witteveen PO, Van de Vijver KK, Kruitwagen RF, et al. Interval between debulking surgery and adjuvant chemotherapy is associated with overall survival in patients with advanced ovarian cancer. Gynecol Oncol. 2018; 150:446–450. PMID: 30001834.

3. Kumar A, Janco JM, Mariani A, Bakkum-Gamez JN, Langstraat CL, Weaver AL, et al. Risk-prediction model of severe postoperative complications after primary debulking surgery for advanced ovarian cancer. Gynecol Oncol. 2016; 140:15–21. PMID: 26541980.

4. Aletti GD, Santillan A, Eisenhauer EL, Hu J, Aletti G, Podratz KC, et al. A new frontier for quality of care in gynecologic oncology surgery: multi-institutional assessment of short-term outcomes for ovarian cancer using a risk-adjusted model. Gynecol Oncol. 2007; 107:99–106. PMID: 17602726.

5. Alphs HH, Zahurak ML, Bristow RE, Díaz-Montes TP. Predictors of surgical outcome and survival among elderly women diagnosed with ovarian and primary peritoneal cancer. Gynecol Oncol. 2006; 103:1048–1053. PMID: 16876237.

6. Stuart GC, Kitchener H, Bacon M, duBois A, Friedlander M, Ledermann J, et al. 2010 Gynecologic Cancer InterGroup (GCIG) consensus statement on clinical trials in ovarian cancer: report from the Fourth Ovarian Cancer Consensus Conference. Int J Gynecol Cancer. 2011; 21:750–755. PMID: 21543936.

7. Chi DS, Eisenhauer EL, Lang J, Huh J, Haddad L, Abu-Rustum NR, et al. What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol. 2006; 103:559–564. PMID: 16714056.

8. Colombo PE, Mourregot A, Fabbro M, Gutowski M, Saint-Aubert B, Quenet F, et al. Aggressive surgical strategies in advanced ovarian cancer: a monocentric study of 203 stage IIIC and IV patients. Eur J Surg Oncol. 2009; 35:135–143. PMID: 18289825.

9. Harter P, Muallem ZM, Buhrmann C, Lorenz D, Kaub C, Hils R, et al. Impact of a structured quality management program on surgical outcome in primary advanced ovarian cancer. Gynecol Oncol. 2011; 121:615–619. PMID: 21414656.

10. Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol. 2002; 20:1248–1259. PMID: 11870167.

11. Aletti GD, Dowdy SC, Podratz KC, Cliby WA. Relationship among surgical complexity, short-term morbidity, and overall survival in primary surgery for advanced ovarian cancer. Am J Obstet Gynecol. 2007; 197:676.e1–676.e7. PMID: 18060979.

12. Wright JD, Lewin SN, Deutsch I, Burke WM, Sun X, Neugut AI, et al. Defining the limits of radical cytoreductive surgery for ovarian cancer. Gynecol Oncol. 2011; 123:467–473. PMID: 21958535.

13. Hofstetter G, Concin N, Braicu I, Chekerov R, Sehouli J, Cadron I, et al. The time interval from surgery to start of chemotherapy significantly impacts prognosis in patients with advanced serous ovarian carcinoma - analysis of patient data in the prospective OVCAD study. Gynecol Oncol. 2013; 131:15–20. PMID: 23877013.

14. Cloven NG, Manetta A, Berman ML, Kohler MF, DiSaia PJ. Management of ovarian cancer in patients older than 80 years of age. Gynecol Oncol. 1999; 73:137–139. PMID: 10094894.

15. Chéreau E, Ballester M, Selle F, Rouzier R, Daraï E. Ovarian cancer in the elderly: impact of surgery on morbidity and survival. Eur J Surg Oncol. 2011; 37:537–542. PMID: 21511424.

16. Fanfani F, Fagotti A, Salerno MG, Margariti PA, Gagliardi ML, Gallotta V, et al. Elderly and very elderly advanced ovarian cancer patients: does the age influence the surgical management? Eur J Surg Oncol. 2012; 38:1204–1210. PMID: 22939013.

17. Langstraat C, Aletti GD, Cliby WA. Morbidity, mortality and overall survival in elderly women undergoing primary surgical debulking for ovarian cancer: a delicate balance requiring individualization. Gynecol Oncol. 2011; 123:187–191. PMID: 21794902.

18. Gerestein CG, Damhuis RA, de Vries M, Reedijk A, Burger CW, Kooi GS. Causes of postoperative mortality after surgery for ovarian cancer. Eur J Cancer. 2009; 45:2799–2803. PMID: 19615887.