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Liu X, Li M, Zhao Y, Jiao X, Yu Y, Li R, Zeng S, Chi J, Ma G, Huo Y, Peng Z, Liu J, Zhou Q, Zou D, Wang L, Li Q, Wang J, Yao S, Chen Y, Ma D, Hu T, Gao Q. The impact of preoperative immunonutritional status on postoperative complications in ovarian cancer. J Ovarian Res 2025; 18:88. [PMID: 40301987 PMCID: PMC12038932 DOI: 10.1186/s13048-025-01624-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2024] [Accepted: 02/13/2025] [Indexed: 05/01/2025] Open
Abstract
BACKGROUND Preoperative immunonutritional status can influence postoperative complications. Malnutrition in ovarian cancer patients diminishes the body's resilience to abdominal surgery, resulting in inferior surgical outcomes and increased postoperative complications. We aim to investigate the effect of preoperative immunonutritional status, including NLR, PLR, LMR, TCLR, FAR, FLR, SII, PNI and CONUT on postoperative complications in epithelial ovarian cancer (EOC) in a large population. METHODS A multicenter real-world study included 922 patients with histologically confirmed EOC who received comprehensive staged surgery or debulking surgery at seven tertiary hospitals in China between 2012 and 2023. Logistic regression and Lasso regression analyses were employed to identify variables associated with postoperative complications. A predictive nomogram model was developed based on multivariate modeling. RESULTS The study included a total of 922 patients diagnosed with epithelial ovarian cancer across seven medical centers with 565 (61.3%) patients experiencing postoperative complications. Significant differences were found in the distribution of inflammatory and nutritional risk indicators, including NLR, PLR, LMR, TCLR, FAR, FLR, SII, PNI and CONUT between the two groups (all P < 0.01). A multivariable model identified several predictive factors for postoperative complications: PNI > 46.73 (odds ratio [OR] = 0.49, P < 0.001), FAR > 10.77 (OR = 1.60, P = 0.019), LMR > 3.70 (OR = 0.68, P = 0.044), hydrothorax (OR = 2.60, P = 0.005), laparoscopy (OR = 0.59, P = 0.010 vs. laparotomy), enterectomy (OR = 2.50, P = 0.001). CONCLUSION Poor immunonutritional status can increase the risk of postoperative complications. These findings suggest that prompt nutritional interventions may reduce the incidence of postoperative complications and improve surgical outcomes. The risk prediction model, including PNI, FAR, LMR, hydrothorax, laparoscopy vs. laparotomy, and enterectomy, might facilitate patient-centered decision-making and risk stratification. CLINICAL TRIAL REGISTRATION The study was registered in the Clinical trial registry: NCT06483399. ( https://clinicaltrials.gov/study/NCT06483399 ).
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Grants
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 2022YFC2704200 National Key Research and Development Program of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 81772787, 82072889 National Natural Science Foundation of China
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- 20A0769 Major Project of Chinese Society of Medical Education
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
- Y-2019AZZD-0359, Y-2019AZQN-0385 Beijing Xisike Clinical Oncology Research Foundation
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Affiliation(s)
- Xingyu Liu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Ming Li
- Department of Gynaecology and Obstetrics, Henan Provincial People's Hospital, Henan, China
| | - Yingjun Zhao
- Department of Gynaecology and Obstetrics, Henan Provincial People's Hospital, Henan, China
| | - Xiaofei Jiao
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Yang Yu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Ruyuan Li
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shaoqing Zeng
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Jianhua Chi
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Guanchen Ma
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Yabing Huo
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Zikun Peng
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Jiahao Liu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Qi Zhou
- Department of Gynecologic Oncology, Chongqing University Cancer Hospital, Chongqing, China
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
- Key Laboratory for Biorheological Science and Technology of Ministry of Education (Chongqing University), Chongqing University Cancer Hospital, Chongqing, China
| | - Dongling Zou
- National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Gynecologic Oncology, Chongqing University Cancer Hospital, Chongqing, China
- Chongqing Key Laboratory of Translational Research for Cancer Metastasis and Individualized Treatment, Chongqing University Cancer Hospital, Chongqing, China
| | - Li Wang
- Department of Cancer Biology Immunotherapy, The Affiliated Cancer Hospital of Zhengzhou University and Henan Cancer Hospital, Zhengzhou, Henan, China
| | - Qingshui Li
- Department of Gynecologic Oncology, Shandong Cancer Hospital and Institute, Jinan, Shandong, China
| | - Jing Wang
- Hunan Clinical Research Center in Gynecologic Cancer, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
- Department of Gynecologic Cancer, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, China
| | - Shuzhong Yao
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Youguo Chen
- Department of Gynecology & Obstetrics, the First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province, China
| | - Ding Ma
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China
| | - Ting Hu
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China.
| | - Qinglei Gao
- Department of Gynecological Oncology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
- National Clinical Research Center for Obstetrics and Gynecology, Cancer Biology Research Center (Key Laboratory of the Ministry of Education), Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1095 Jiefang Ave, Wuhan, 430000, China.
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Chauhan S, Langstraat CL, Fought AJ, McGree ME, Cliby WA, Kumar A. Relationship between frailty and nutrition: Refining predictors of mortality after primary cytoreductive surgery for ovarian cancer. Gynecol Oncol 2024; 180:126-131. [PMID: 38091771 DOI: 10.1016/j.ygyno.2023.11.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 11/13/2023] [Accepted: 11/26/2023] [Indexed: 02/18/2024]
Abstract
OBJECTIVE We aimed to examine the interplay between frailty and nutritional status on 90-day mortality after primary cytoreductive surgery (PCS) for ovarian cancer (OC). METHODS Patients with OC who underwent PCS from 1/2/2006-4/30/2018 at a single institution were identified. Frailty index (FI) includes 30 items and is calculated summing across all the item scores and dividing by the total; frailty was defined as FI ≥0.15. Nutritional status was considered impaired when preoperative serum albumin was <3.5 g/dL. Logistic regression was used to analyze the association between FI (continuous) and albumin status (binary) and 90-day postoperative mortality. RESULTS A total of 533 patients (mean age, 64.4 years) were included, the majority were stage IIIC disease and serous histology. Albumin was <3.5 g/dL in 87 patients (16.3%) and 113 patients (21.2%) were considered frail. Median FI was 0.07 (IQR 0.03, 0.13). Postoperative 90-day mortality occurred in 24 patients (4.5%). Mortality within 90 days was higher amongst patients with low albumin (12/87, 13.8%), regardless of frailty status (13.8% [9/65] non-frail and 13.6% [3/22] frail patients). Ninety-day mortality in patients with normal albumin (n = 446) was over twice as likely in frail versus non-frail patients (5.5% [5/91] vs. 2.0% [7/355], respectively, p = 0.08). A model to assess 90-day mortality that included both FI and low albumin significantly improved the overall discrimination compared to low albumin alone (AUC 0.76 vs. 0.68 p = 0.03). CONCLUSION Our findings suggest that frailty and nutrition are both related to 90-day mortality. Preoperative interventions to improve functional and nutritional characteristics are needed.
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Affiliation(s)
- Shruti Chauhan
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Carrie L Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Angela J Fought
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - Michaela E McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN, United States
| | - William A Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, MN, United States.
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Polan RM, Slota JM, Barber EL. Postoperative complications in women with ovarian cancer stratified by cytoreductive surgery outcome. J Surg Oncol 2023; 128:891-901. [PMID: 37382209 PMCID: PMC10529113 DOI: 10.1002/jso.27380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 05/26/2023] [Accepted: 06/03/2023] [Indexed: 06/30/2023]
Abstract
OBJECTIVE To compare 30-day postoperative complications for patients with advanced ovarian cancer who underwent resection to no gross residual disease versus optimal and suboptimal cytoreduction. METHODS A retrospective cohort study of women drawn from the National Surgical Quality Improvement Program who underwent cytoreductive surgery for advanced ovarian cancer between 2014 and 2019 was performed. Exposure of interest was extent of surgical resection defined as no gross residual disease; residual disease <1 cm (optimal); and residual disease >1 cm (suboptimal). Primary outcome was postoperative complication. Associations were examined with bivariable tests and multivariable logistic regression. RESULTS A total of 2248 women underwent cytoreductive surgery; 68.4% (n = 1538) underwent resection to no gross residual disease, 22.4% (n = 504) had an optimal, and 9.2% (n = 206) had a suboptimal cytoreduction. Optimal cytoreduction patients had the highest rates of any postoperative complication (35.5%, p < 0.001). They also had the longest operative times and procedures that were most surgically complex (203 min, 43.6 relative value units, both p < 0.05). However, patients who underwent optimal cytoreduction did not have increased odds of major complications (adjusted odds ratio: 1.20, 95% confidence interval: 0.91-1.58). CONCLUSION Patients who underwent optimal cytoreduction had more postoperative complications, required the most operating room time, and represented more complex surgeries compared with suboptimal cytoreduction or resection to no gross residual disease.
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Affiliation(s)
- Rosa M Polan
- Division of Gynecology Oncology, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan, USA
| | - Jennifer M Slota
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University, Chicago, Illinois, USA
| | - Emma L Barber
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Northwestern University, Chicago, Illinois, USA
- Department of Oncology, Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
- Department of Gynecology, Surgical Outcomes and Quality Improvement Center, Institute for Public Health in Medicine, Chicago, Illinois, USA
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Rousseau F, Ranchon F, Bardin C, Bakrin N, Lavoué V, Bengrine-Lefevre L, Falandry C. Ovarian cancer in the older patient: where are we now? What to do next? Ther Adv Med Oncol 2023; 15:17588359231192397. [PMID: 37724138 PMCID: PMC10505350 DOI: 10.1177/17588359231192397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/19/2023] [Indexed: 09/20/2023] Open
Abstract
In recent years, major advances have been made toward the individualization of epithelial ovarian cancer care, leading to an overall improvement of patient outcomes. However, real-life data indicate that the oldest populations do not benefit from this, due to aspects related to cancer (more aggressive histopathological features), treatment (i.e. frequently suboptimal), and the host (increased toxicities in patients with lower physiological reserve). A specific risk-benefit perspective should therefore be taken when considering surgery, chemotherapy, and maintenance treatments: the decision for cytoreductive surgery should include geriatric vulnerability and surgical complexity, neo-adjuvant chemotherapy being an option when primary surgery appears at high risk; carboplatin paclitaxel association remains the standard even in vulnerable older patients; and bevacizumab and poly(ADP-ribose) polymerase inhibitors maintenance are interesting options provided they are prescribed according to their indications with a close monitoring of their toxicities. Future studies should aim to individualize care without limiting access of older patients to innovation. A specific focus is needed on age-specific translational analyses (focusing on tumor mutational burden and impaired biological pathways), a better patient stratification according to geriatric parameters, an adaptation of both oncological treatment and geriatric interventions, and treatment adaptations not a priori but according to formal pharmacokinetic data.
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Affiliation(s)
- Frédérique Rousseau
- Institut Paoli Calmettes Institute, Marseille, France
- Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Florence Ranchon
- Groupement Hospitalier Sud, Unité de Pharmacie Clinique Oncologique, Hospices Civils de Lyon, Pierre-Bénite, France
- CICLY Centre pour l’Innovation en Cancérologie de Lyon, Oullins, France
- Société Française de Pharmacie Oncologique (SFPO)
| | - Christophe Bardin
- Service de Pharmacie Clinique, Hôpital Cochin AP-HP Centre Université Paris Cité, Paris, France
- Société Française de Pharmacie Oncologique (SFPO)
| | - Naoual Bakrin
- Hospices Civils de Lyon, Service de Chirurgie Digestive, CHU Hôpital Lyon-Sud, Pierre-Bénite Cedex, France
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Vincent Lavoué
- Service de Gynécologie, CHU de Rennes, Hôpital Sud, Rennes, France
- UMR S1085, IRSET-INSERM, Université de Rennes, Rennes, France
- Groupe Français de chirurgie Oncologique et Gynécologique (FRANCOGYN)
| | - Leila Bengrine-Lefevre
- Département d’Oncologie Médicale, Centre Georges-Francois Leclerc, Dijon, France
- Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
| | - Claire Falandry
- Hospices Civils de Lyon, Unité de Gériatrie, Centre Hospitalier de la Croix Rousse, 103, Grande Rue de la Croix-Rousse, Lyon 69004, France
- Université de Lyon, CarMeN Laboratory, INSERM U.1060/Université Lyon 1/INRA U1397/INSA Lyon/Hospices Civils Lyon Bâtiment CENS-ELI 2D; Hôpital Lyon Sud Secteur 2; Pierre-Bénite 69310, France
- Université Claude Bernard Lyon 1, Pierre-Bénite 69310, France Société Francophone d'OncoGériatrie (SOFOG)
- Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO)
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Correa-Paris A, Gorraiz Ochoa V, Hernandez Gutiérrez A, Gilabert Estellés J, Díaz-Feijoo B, Gil-Moreno A. Simple radiologic assessment of visceral obesity and prediction of surgical morbidity in endometrial cancer patients undergoing laparoscopic aortic lymphadenectomy: A reliability and accuracy study. J Obstet Gynaecol Res 2023; 49:988-997. [PMID: 36593218 DOI: 10.1111/jog.15528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 12/05/2022] [Indexed: 01/04/2023]
Abstract
AIM To evaluate the reliability of sagittal abdominal diameter (SAD)-a surrogate of visceral obesity-in magnetic resonance imaging, and its accuracy to predict the surgical morbidity of aortic lymphadenectomy. METHODS We conducted a multicenter reliability (phase 1) and accuracy (phase 2) cohort study in three Spanish referral hospitals. We retrospectively analyzed data from the STELLA-2 randomized controlled trial that included high-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional versus robotic-assisted laparoscopy, and transperitoneal versus extraperitoneal technique. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, renal vein, and inferior mesenteric artery) and selected the most reliable one. In phase 2, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Surgical morbidity was the main outcome measure, it was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty. RESULTS In phase 1, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD (u-SAD) was the most reliable one. In phase 2, we included 136 patients. u-SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than body mass index and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56, specificity: 0.80). CONCLUSIONS u-SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.
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Affiliation(s)
- Alejandro Correa-Paris
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Verónica Gorraiz Ochoa
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Juan Gilabert Estellés
- Obstetrics and Gynecology Department, Hospital General de Valencia, Valencia, Spain.,University of Valencia, Valencia, Spain
| | - Berta Díaz-Feijoo
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Antonio Gil-Moreno
- Obstetrics and Gynecology Department, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain.,Biomedical Research Group in Gynecology, Vall d'Hebron Institut de Recerca, Barcelona, Spain
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Kengsakul M, Nieuwenhuyzen-de Boer GM, Udomkarnjananun S, Kerr SJ, van Doorn HC, van Beekhuizen HJ. Clinical validation and comparison of the Comprehensive Complication Index and Clavien-Dindo classification in predicting post-operative outcomes after cytoreductive surgery in advanced ovarian cancer. Int J Gynecol Cancer 2023; 33:263-270. [PMID: 36600504 DOI: 10.1136/ijgc-2022-003998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE The Comprehensive Complication Index (CCI) is an instrument used to measure cumulative post-operative complications. Our study aimed to validate the CCI after cytoreductive surgery for primary advanced-stage epithelial ovarian cancer, and to compare its diagnostic performance with the Clavien-Dindo classification. METHODS This prospective cohort study classified post-operative complications according to the Clavien-Dindo classification and the CCI. Logistic regression was used to determine the association between both classifications with intensive care unit admission, prolonged length of hospital stay (defined as stays longer than the 75th percentile of all stays in this study), 30-day readmission, and time to initiating chemotherapy after surgery >42 days. Area under the receiver operating characteristic curves (AUC) were used to assess the discriminative performance of each classification. RESULTS A total of 300 patients were included in the analysis. Most patients (n=255, 85%) underwent interval cytoreductive surgery. Complete cytoreduction was achieved in 235 (78%) patients. Overall, 30-day post-operative complications classified by the Clavien-Dindo classification occurred in 147 (49%) patients. Severe complications (grade ≥3a) occurred in 51 (17%) patients. Approximately 30% (n=82) had multiple complications. The CCI showed an excellent correlation with the Clavien-Dindo classification (r=0.906, p<0.001). In comparison with the Clavien-Dindo classification, the proportion of patients classified with severe complications increased from 17% to 30% when stratified with the CCI, and 20% of patients were diagnosed with a CCI score that correlated with a higher Clavien-Dindo classification grade. On regression analysis, both Clavien-Dindo classification and CCI had associations with intensive care unit admission, prolonged length of hospital stay, 30-day readmission, and time to chemotherapy >42 days (all p<0.05). AUC demonstrated that CCI (0.842, 95% CI 0.792 to 0.893) and Clavien-Dindo classification (0.813, 95% CI 0.762 to 0.864, p<0.001) had a good diagnostic performance for prolonged length of hospital stay. CONCLUSIONS Both the Clavien-Dindo classification and CCI showed significant associations with all surgical outcomes. However, the cumulative complications score of the CCI demonstrated a more superior discriminative performance than the Clavien-Dindo classification for prolonged length of hospital stay in advanced-stage epithelial ovarian cancer.
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Affiliation(s)
- Malika Kengsakul
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Srinakharinwirot University Panyananthaphikkhu Chonprathan Medical Center, Nonthaburi, Thailand
| | - Gatske M Nieuwenhuyzen-de Boer
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Stephen J Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Helena C van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heleen J van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Narasimhulu DM, Fagotti A, Scambia G, Weaver AL, McGree M, Quagliozzi L, Langstraat C, Kumar A, Cliby W. Validation of a risk-based algorithm to reduce poor operative outcomes after complex surgery for ovarian cancer. Int J Gynecol Cancer 2023; 33:83-88. [PMID: 36517075 PMCID: PMC9972179 DOI: 10.1136/ijgc-2022-003799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE We developed an algorithm that identifies patients at high risk of morbidity/mortality after cytoreductive surgery for advanced ovarian cancer. We have previously shown that the Mayo triage algorithm reduces operative mortality internally, followed by validation using an external low complexity national dataset. However, validation in a higher complexity surgical setting is required before widespread acceptance of this approach, and this was the goal of our study. METHODS We included patients who underwent debulking surgery (including primary or interval debulking surgery) for stage IIIC/IV ovarian cancer between October 2011 and November 2019 (SCORPION trial patients until May 2016 and non-trial patients thereafter) at Fondazione Policlinico A Gemelli, Italy. Using the algorithm, we classified patients as either high-risk or triage-appropriate and compared 30-day grade 3+ complications and 90-day mortality using a χ2 test or Fisher's exact test. RESULTS A total of 625 patients were included. The mean age was 58.7±11.4 years, 73.6% (n=460) were stage IIIC, and 63.0% (n=394) underwent primary debulking surgery. Surgical complexity was intermediate or high in 82.6% (n=516) of patients (95.7% (n=377) for primary surgery and 60.2% (n=139) for interval surgery), and 20.3% (n=127) were classified as high-risk. When compared with triage-appropriate patients, high-risk patients had (1) a threefold higher rate of 90-day mortality (6.3% vs 2.0%, p=0.02); (2) a higher likelihood of 90-day mortality following a grade 3+ complication (25.9% vs 10.0%, p=0.05); and (3) comparable rates of grade 3+ complications (21.3% vs 16.1%, p=0.17). CONCLUSION The evidence-based triage algorithm identifies patients at high risk of morbidity/mortality after cytoreductive surgery. Triage high-risk patients are poor candidates for surgery when complex surgery is required. This algorithm has been validated in heterogeneous settings (internal, national, and international) and degree of surgical complexity. Risk-based decision making should be standard of care when planning surgery for patients with advanced ovarian cancer, whether primary or interval surgery.
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Affiliation(s)
- Deepa Maheswari Narasimhulu
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Anna Fagotti
- Department of Gynecological Oncology, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Giovanni Scambia
- Department of Gynecological Oncology, Catholic University of the Sacred Heart, Milano, Lombardia, Italy
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Amy L Weaver
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Michaela McGree
- Department of Quantitative Health Sciences, Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Lorena Quagliozzi
- Department for Women's and Children's Health and Public Health, Gynecologic Oncology Unit, Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | - Carrie Langstraat
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Amanika Kumar
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - William Cliby
- Department of Obstetrics and Gynecology, Division of Gynecologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Jiang C, Liu Y, Tang J, Li Z, Min W. Nomogram to predict postoperative complications after cytoreductive surgery for advanced epithelial ovarian cancer: A multicenter retrospective cohort study. Front Oncol 2022; 12:1052628. [PMID: 36505869 PMCID: PMC9728142 DOI: 10.3389/fonc.2022.1052628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
Objective To establish nomograms to predict the risk of postoperative complications following cytoreductive surgery in patients with advanced epithelial ovarian cancer (AEOC). Methods A multicenter retrospective cohort study that included patients with FIGO stage IIIC-IV epithelial ovarian cancer who underwent cytoreductive surgery was designed. By using univariate and multivariate analyses, patient preoperative characteristics were used to predict the risk of postoperative complications. Multivariate modeling was used to develop Nomograms. Results Overall, 585 AEOC patients were included for analysis (training cohort = 426, extrapolation cohort = 159). According to the findings, the training cohort observed an incidence of postoperative overall and severe complications of 28.87% and 6.10%, respectively. Modified frailty index (mFI) (OR 1.96 and 2.18), FIGO stage (OR 2.31 and 3.22), and Surgical Complexity Score (SCS) (OR 1.16 and 1.23) were the clinical factors that were most substantially associated to the incidence of overall and severe complications, respectively. The resulting nomograms demonstrated great internal discrimination, good consistency, and stable calibration, with C-index of 0.74 and 0.78 for overall and severe complications prediction, respectively. A satisfactory external discrimination was also indicated by the extrapolation cohort, with the C-index for predicting overall and severe complications being 0.92 and 0.91, respectively. Conclusions The risk of considerable postoperative morbidity exists after cytoreductive surgery for AEOC. These two nomograms with good discrimination and calibration might be useful to guide clinical decision-making and help doctors assess the probability of postoperative complications for AEOC patients.
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Affiliation(s)
- Caixia Jiang
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China
| | - Yingwei Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Junying Tang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhengyu Li
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, China,*Correspondence: Zhengyu Li, ; Wenjiao Min,
| | - Wenjiao Min
- Psychosomatic Department, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China,*Correspondence: Zhengyu Li, ; Wenjiao Min,
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Kengsakul M, Nieuwenhuyzen-de Boer GM, Udomkarnjananun S, Kerr SJ, van Doorn HC, van Beekhuizen HJ. Factors Predicting 30-Day Grade IIIa-V Clavien-Dindo Classification Complications and Delayed Chemotherapy Initiation after Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: A Prospective Cohort Study. Cancers (Basel) 2022; 14:4181. [PMID: 36077721 PMCID: PMC9454550 DOI: 10.3390/cancers14174181] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 12/03/2022] Open
Abstract
Objective: The aim of this study was to evaluate factors associated with 30-day postoperative Clavien−Dindo classification (CDC) grade IIIa or greater complications and delayed initiation of chemotherapy after cytoreductive surgery (CRS) for primary advanced-stage epithelial ovarian cancer (AEOC). Methods: This was a prospective study involving 300 patients who underwent primary or interval CRS for AEOC between February 2018 and September 2020. Postoperative complications were graded according to the CDC. Logistic regression analysis was used to evaluate factors predicting CDC grade ≥IIIa and time to chemotherapy (TTC) >42 days. Results: Interval CRS was performed in 255 (85%) patients. CDC grade ≥IIIa occurred in 51 (17%) patients. In multivariable analysis, age (p = 0.036), cardiovascular comorbidity (p < 0.001), diaphragmatic surgery (p < 0.001), intraoperative urinary tract injury (p = 0.017), and upper-abdominal visceral injury (e.g., pancreas, stomach, liver, or spleen) (p = 0.012) were associated with CDC grade ≥IIIa. In 26% of cases, TTC was >42 days (median (IQR) 39 (29−50) days) in patients with CDC grade ≥IIIa versus 33 (25−41) days in patients without CDC grade ≥ IIIa (p = 0.008). The adjusted odds ratio of developing TTC >42 days was significantly higher in patients associated with WHO performance grade ≥2 (p = 0.045), intraoperative bowel injury (p = 0.043), upper-abdominal visceral injury (p = 0.008), and postoperative CDC grade ≥IIIa (p = 0.032). Conclusions: Patients with advanced age, with cardiovascular comorbidity, and who required diaphragmatic surgery had an increased adjusted odds ratio of developing CDC grade ≥IIIa complications. CDC grade ≥IIIa complications were independently associated with TTC >42 days. Proper patient selection and prevention of intraoperative injury are essential in order to prevent postoperative complications and delayed initiation of chemotherapy.
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Affiliation(s)
- Malika Kengsakul
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi 11120, Thailand
| | - Gatske M. Nieuwenhuyzen-de Boer
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok 10330, Thailand
| | - Stephen J. Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Helena C. van Doorn
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
| | - Heleen J. van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands
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Kengsakul M, Nieuwenhuyzen-de Boer GM, Udomkarnjananun S, Kerr SJ, Niehot CD, van Beekhuizen HJ. Factors predicting postoperative morbidity after cytoreductive surgery for ovarian cancer: a systematic review and meta-analysis. J Gynecol Oncol 2022; 33:e53. [PMID: 35712967 PMCID: PMC9250852 DOI: 10.3802/jgo.2022.33.e53] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 03/22/2022] [Accepted: 04/06/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE Advances in ovarian cancer cytoreductive surgery have enabled more extensive procedures to achieve maximal cytoreduction but with a consequent increase in postoperative morbidity and mortality. The aim of this study was to evaluate factors for postoperative morbidity after extensive cytoreductive surgery for primary epithelial ovarian cancer (EOC), particularly those which may be modifiable. METHODS Electronic databases were searched. Meta-analysis was conducted using random-effects models. RESULTS Fifteen relevant studies, involving 15,325 ovarian cancer patients, were included in this review. Severe 30-day postoperative complications occurred in 2,357 (15.4%) patients. The postoperative mortality rate was 1.92%. Meta-analysis demonstrated that patient with following risk factors; age (p<0.001), Eastern Cooperative Oncology Group score >0 (p=0.001), albumin level <3.5 g/dL (p<0.001), presence of ascites on CT scan (p=0.013), stage IV disease (p<0.001) and extensive surgical procedure (p<0.001) has a significantly increase risk of developing postoperative complications. Surgical procedures including peritonectomy (p=0.012), splenectomy (p<0.001) and colon surgery (p<0.001) were significant predictors for postoperative complications. Moreover, we found that patients who received neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) had a lower risk of developing severe complications compared to those who underwent primary debulking surgery (PDS) (p<0.001). CONCLUSION Our study demonstrated that patient performance status and hypoalbuminemia were the only significant adjustable preoperative risk factors associated with postoperative complications. Patients who underwent NACT-IDS had a lower risk of developing severe complications compared to PDS. TRIAL REGISTRATION International Prospective Register of Systematic Reviews (PROSPERO) Identifier: CRD42021282770.
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Affiliation(s)
- Malika Kengsakul
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Panyananthaphikkhu Chonprathan Medical Center, Srinakharinwirot University, Nonthaburi, Thailand.
| | - Gatske M Nieuwenhuyzen-de Boer
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- Department of Obstetrics and Gynecology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Stephen J Kerr
- Biostatistics Excellence Centre, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Christa D Niehot
- Medical Library, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Heleen J van Beekhuizen
- Department of Gynecologic Oncology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
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Multi-Disciplinary Care Planning of Ovarian Cancer in Older Patients: General Statement-A Position Paper from SOFOG-GINECO-FRANCOGYN-SFPO. Cancers (Basel) 2022; 14:cancers14051295. [PMID: 35267603 PMCID: PMC8909025 DOI: 10.3390/cancers14051295] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/25/2022] [Accepted: 02/25/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary This position paper aims to provide practitioners a proposal for multidisciplinary care planning for older patients with ovarian cancer from the time of suspected diagnosis. The first-line treatment of advanced ovarian cancer involves several interdependent sequences: cytoreductive surgery, (neo)adjuvant chemotherapy and maintenance targeted treatments. In older patients, care planning must be adapted to their geriatric parameters and consider the geriatric impact of each treatment sequence to allow treatment completion. Care planning should be centered on patient motivation and imply multidisciplinarity. Each step of treatment plan should be reconsidered in light of a geriatric assessment and follow-up. Studies are needed to prospectively evaluate the impact of geriatric vulnerability parameters at each step of the treatment agenda and the impact of geriatric interventions on patient outcomes. Abstract In this position paper the Société Francophone d’OncoGériatrie (SOFOG; French-speaking oncogeriatric society), the Société Française de Pharmacie Oncologique (SFPO, French society for oncology pharmacy), the Groupe d’Investigateurs Nationaux pour l’Étude des Cancers de l’Ovaire et du sein (GINECO, National Investigators’ Group for Studies in Ovarian and Breast Cancer) and the Groupe Français de chirurgie Oncologique et Gynécologique (FRANCOGYN) propose a multi-disciplinary care planning of ovarian cancer in older patients. The treatment pathway is based on four successive decisional nodes (diagnosis, resectability assessment, operability assessment, adjuvant, and maintenance treatment decision) implying multidisciplinarity and adaptation of the treatment plan according to the patient’s geriatric covariates and her motivation towards treatment. Specific attention must be paid to geriatric intervention, supportive care and pharmaceutical conciliation. Studies are needed to prospectively evaluate the impact of geriatric vulnerability parameters at each step of the treatment agenda and the impact of geriatric interventions on patient outcomes.
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Liang WF, Wang LJ, Li H, Liu CH, Wu MF, Li J. The added value of CA125 normalization before interval debulking surgery to the chemotherapy response score for the prognostication of ovarian cancer patients receiving neoadjuvant chemotherapy for advanced disease. J Cancer 2021; 12:946-953. [PMID: 33403051 PMCID: PMC7778530 DOI: 10.7150/jca.52711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 11/15/2020] [Indexed: 11/11/2022] Open
Abstract
Objective: To investigate whether CA125 normalization following neoadjuvant chemotherapy (NACT) can complement the chemotherapy response system (CRS) in the prognostication of patients with tubo-ovarian high-grade serous carcinoma (HGSC). Methods: In total, 118 HGSC patients who received NACT followed by interval debulking surgery (IDS) for FIGO stage IIIC-IV disease were included, and their clinical data were retrospectively reviewed. The primary endpoint was progression-free survival (PFS). Cox regression analysis was performed to identify predictors of PFS. Results: Following NACT, CRS3 was noted in 35 patients (29.7%), and CA125 normalization (≤ 35 U/ml) was noted in 54 patients (45.8%). Both CRS3 and CA125 normalization were identified as independent prognosticators of PFS. Combining these two factors, we stratified the 106 patients into three groups with different risks of recurrence: low-risk group (CRS3 + post-NACT CA125≤ 35 U/ml; n = 17, 14.4%), intermediate-risk group (CRS3 + post-NACT CA125 > 35 U/ml; n = 19, 16.1%) and high-risk group (CRS1-2; n= 82, 69.5%). The differences in PFS between the three groups were significant (log-rank test, P < 0.0001). In Cox regression analyses, the new stratification method was found to have an independent prognostic effect. Conclusion: Both the CRS system and the normalization of CA125 following NACT could reliably predict the risk of recurrence following primary treatment. The combination of the two factors refined the prognostic stratification of HGSC patients who were treated with NACT and IDS.
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Affiliation(s)
- Wei-feng Liang
- Department of Gynecology and Obstetrics, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, 266035, People's Republic of China
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Li-juan Wang
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Hui Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Chang-hao Liu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Miao-fang Wu
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
| | - Jing Li
- Department of Gynecologic Oncology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, 510120, People's Republic of China
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Advanced ovarian cancer and cytoreductive surgery: Independent validation of a risk-calculator for perioperative adverse events. Gynecol Oncol 2020; 160:438-444. [PMID: 33272645 DOI: 10.1016/j.ygyno.2020.11.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To independently validate a published risk-calculator for adverse perioperative outcomes in patients with epithelial ovarian cancer undergoing debulking surgery at a high-volume surgical center. METHODS Using our institution's curated prospective ovarian cancer database, we identified patients with epithelial ovarian cancer who underwent a debulking procedure from 7/2015 to 5/2019, to be used as the validation cohort. Variables used in the published nomogram were collected. These included American Society of Anesthesiology classification, preoperative albumin, history of bleeding disorder, presence of ascites on preoperative imaging, designation of elective or emergent surgery, age of the patient, and a procedure score. Patients were included if they had information available for all the variables used in the nomogram, and 30-day follow-up within our institution. The primary outcome was Clavien-Dindo Class IV with specific conditions (postoperative sepsis, septic shock, cardiac arrest, myocardial infarction, pulmonary embolism, ventilation >48 h, or unplanned intubation) and 30-day mortality. The combination of these endpoints is called the combined complication rate. RESULTS A total of 700 patients who underwent debulking surgery for epithelial ovarian cancer during the timeframe met inclusion criteria. The combined complication rate was 11.7%; 9.9% of patients were readmitted; 2.7% required reoperation. Sepsis was the most common primary endpoint complication (4.4%), followed by septic shock (1.4%). There was no 30-day mortality in our cohort. The nomogram performed well, with a c index of 0.715 (95% CI 0.66-0.768), which was comparable to the published nomogram. CONCLUSIONS We independently validated a complication nomogram at a high-volume surgical center. This nomogram performs well at predicting a lower likelihood of serious postoperative complications. An enhanced nomogram would help identify patients at higher risk for serious complications.
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O’Dwyer J, O’Cearbhaill RE, Wylie R, O’Mahony S, O’Dwyer M, Duffy GP, Dolan EB. Enhancing delivery of small molecule and cell-based therapies for ovarian cancer using advanced delivery strategies. ADVANCED THERAPEUTICS 2020; 3:2000144. [PMID: 33709016 PMCID: PMC7942751 DOI: 10.1002/adtp.202000144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Indexed: 12/17/2022]
Abstract
Ovarian cancer is the most lethal gynecological malignancy with a global five-year survival rate of 30-50%. First-line treatment involves cytoreductive surgery and administration of platinum-based small molecules and paclitaxel. These therapies were traditionally administered via intravenous infusion, although intraperitoneal delivery has also been investigated. Initial clinical trials of intraperitoneal administration for ovarian cancer indicated significant improvements in overall survival compared to intravenous delivery, but this result is not consistent across all studies performed. Recently cell-based immunotherapy has been of interest for ovarian cancer. Direct intraperitoneal delivery of cell-based immunotherapies might prompt local immunoregulatory mechanisms to act synergistically with the delivered immunotherapy. Based on this theory, pre-clinical in vivo studies have delivered these cell-based immunotherapies via the intraperitoneal route, with promising results. However, successful intraperitoneal delivery of cell-based immunotherapy and clinical adoption of this technique will depend on overcoming challenges of intraperitoneal delivery and finding the optimal combinations of dose, therapeutic and delivery route. We review the potential advantages and disadvantages of intraperitoneal delivery of cell-based immunotherapy for ovarian cancer and the pre-clinical and clinical work performed so far. Potential advanced delivery strategies, which might improve the efficacy and adoption of intraperitoneal delivery of therapy for ovarian cancer, are also outlined.
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Affiliation(s)
- Joanne O’Dwyer
- Department of Biomedical Engineering, School of Engineering, College of Science and Engineering, National University of Ireland Galway, Ireland; Anatomy & Regenerative Medicine Institute, School of Medicine, College of Medicine Nursing and Health Sciences, National University of Ireland Galway, Ireland
| | - Roisin E. O’Cearbhaill
- Anatomy & Regenerative Medicine Institute, School of Medicine, College of Medicine Nursing and Health Sciences, National University of Ireland Galway, Ireland; Department of Medical Oncology, Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Robert Wylie
- Anatomy & Regenerative Medicine Institute, School of Medicine, College of Medicine Nursing and Health Sciences, National University of Ireland Galway, Ireland
| | - Saoirse O’Mahony
- Department of Biomedical Engineering, School of Engineering, College of Science and Engineering, National University of Ireland Galway, Ireland
| | - Michael O’Dwyer
- Apoptosis Research Centre, National University of Ireland Galway, Ireland
| | - Garry P. Duffy
- Anatomy & Regenerative Medicine Institute, School of Medicine, College of Medicine Nursing and Health Sciences, National University of Ireland Galway, Ireland
| | - Eimear B. Dolan
- Department of Biomedical Engineering, School of Engineering, College of Science and Engineering, National University of Ireland Galway, Ireland
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Chandramohan A, Panda S, Thomas A, Chandy R, Joel A, Ram TS, Peedicayil A. Management Driven Structured Reporting in Ovarian Cancer. JOURNAL OF GASTROINTESTINAL AND ABDOMINAL RADIOLOGY 2019. [DOI: 10.1055/s-0039-1698480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
AbstractSince majority (80%) of ovarian cancer patients present at an advanced stage, imaging performed on these patients have numerous findings. The combination of multiple findings on imaging, complexity of anatomical structures which are involved in ovarian cancer, and the need to perceive certain subtle imaging features which would impact management often makes it challenging to systematically review images of these patients. Similarly, it is difficult to effectively communicate these findings in radiology reports. Structured reporting that is geared toward clinical decision-making has been an area of recognized need. An understanding of the review areas, which aid clinical decision-making in a multidisciplinary team setting at our institution led us to the proposed structured reporting template for ovarian cancer. Through this review, the authors would like to share this reporting template with examples.
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Affiliation(s)
| | - Sourav Panda
- Department of Radiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anitha Thomas
- Department of Gynecological Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Rachel Chandy
- Department of Gynecological Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anjana Joel
- Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Thomas Samuel Ram
- Department of Radiation Oncology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Abraham Peedicayil
- Department of Gynecological Oncology, Christian Medical College, Vellore, Tamil Nadu, India
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Ferron G, Narducci F, Pouget N, Touboul C. [Surgery for advanced stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:197-213. [PMID: 30792175 DOI: 10.1016/j.gofs.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Indexed: 01/10/2023]
Abstract
Debulking surgery is the key step of advanced stage ovarian cancer treatment with chemotherapy. The quality of surgical resection is the main prognosis factor, thus a complete resection must be achieved (grade A) in an expert center (grade B). Surgery for stage IV is possible and has a benefit in case of complete peritoneal resection (LoE3). Pelvic and aortic lymphadenectomies are recommended in case of clinical or radiological suspicious lymph nodes (grade B). In absence of clinical or radiological suspicious lymph nodes and in case of complete peritoneal resection during initial debulking surgery, lymphadenectomy can be omitted because it won't change nor medical treatment nor overall survival (grade B). Neoadjuvant chemotherapy can be proposed in case of: impossibility to perform initial complete surgical resection (grade B) ; alteration of general state or co-morbidities or elderly patient (in order to decrease morbidity and increase quality of life) (grade B); stage IV with multiple intra-hepatic or pulmonary metastasis or important ascites with miliary (grade B). In case of stage III or IV ovarian cancer diagnosed on a biopsy during prior laparotomy, a neoadjuvant chemotherapy and interval debulking surgery should be preferred (gradeC). In case of palliative surgery or peroperative impossibility to perform a complete resection, no data regarding the type of surgery to perform influencing survival or quality of life is available. Peritoneal carcinosis description before resection and residual disease at the end of the surgery should be reported (size, location and reason of non-extirpability) (grade B). A score of peritoneal carcinosis such as Peritoneal Carcinosis Index (PCI) should be used in order to objectively evaluate the tumoral burden (gradeC). A standardized operative report is recommended (gradeC).
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Affiliation(s)
- G Ferron
- Inserm CRCT 19, département de chirurgie oncologique, institut Claudius Regaud, institut universitaire du cancer, 31000 Toulouse, France
| | - F Narducci
- Inserm U1192, département de chirurgie oncologique, centre Oscar Lambret, 59000 Lille, France
| | - N Pouget
- Département de chirurgie oncologique, chirurgie gynécologique et mammaire, institut Curie, site Saint-Cloud, 75005 Paris, France
| | - C Touboul
- IMRB, U955 Inserm, service de gynécologie obstétrique et médecine de la reproduction, centre hospitalier intercommunal de Créteil, institut Mondor de recherche biomédicale, 94000 Créteil, France.
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Bendifallah S, Body G, Daraï E, Ouldamer L. [Diagnostic and prognostic value of tumor markers, scores (clinical and biological) algorithms, in front of an ovarian mass suspected of an epithelial ovarian cancer: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:134-154. [PMID: 30733191 DOI: 10.1016/j.gofs.2018.12.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the diagnostic value of serum/urinary biomarkers and the operability diagnosis strategy to make management recommendations. METHODS Bibliographical search in French and English languages by consultation of Pubmed, Cochrane and Embase databases. RESULTS For the diagnosis of a suspicious adnexal mass on imaging: Serum CA125 antigen is recommended (grade A). Serum CAE is not recommended (grade C). The low evidence in literature concerning diagnostic value of CA19.9 does not allow any recommendation concerning its use. Serum Human epididymis protein 4 (HE4) is recommended (grade A). Comparison of data concerning diagnosis value of CA125 and HE4 show similar results for the prediction of malignancy in case of a suspicious adnexal mass on imaging (NP1). Urinary HE4 is not recommended (grade A). The use of circulating tumor DNA is not recommended (grade A). Tumor associated antigen-antibodies (AAbs) is not recommended (grade B). The use of ROMA score (Risk of Ovarian Malignancy Algorithm) is recommended (grade A). The use of Copenhagen index (CPH-I), R-OPS score, OVA500 is not recommended (grade C). For the prediction of resectability of an ovarian cancer with peritoneal carcinomatosis in the context of a primary debulking surgery: It is not recommendend to use serum CA125 (grade A). The low evidence in literature concerning diagnostic value of HE4 does not allow any recommendation concerning its use in this context. No recommendation can be given concerning CA19.9 and CAE. For the prediction of resectability of an ovarian cancer with peritoneal carcinomatosis in the context of surgery after neoadjuvant chemotherapy: the low evidence in literature concerning diagnostic value of serum markers in this context does not allow any recommendation concerning their use in this context. Place of laparoscopy for the prediction of resectability in case of upfront surgery of an ovarian cancer with peritoneal carcinomatosis robust data shows that the use of laparoscopy significantly reduce futile laparotomies (LE1). Laparoscopy is recommended in this context (grade A). Fagotti score is a reproducible tool (LE1) permitting the evaluation of feasibility of an optimal upfront debulking (NP4), its use is recommended (grade C). A Fagotti score≥8 is correlated to a low probability of complete or optimal debulking surgery (LE4) (grade C). There is no sufficient evidence to recommend the use of the modified Fagotti score or any other laparoscopic score (LE4). In case of laparotomy for an ovarian cancer with peritoneal carcinomatosis, the use of Peritoneal Cancer Index (PCI) is recommended (grade C). For the prediction of overall survival, disease free survival and the prediction of postoperative complications, the clinical and statistical of actually available tools do not allow any recommendation.
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Affiliation(s)
- S Bendifallah
- Département de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris (AP-HP), 4, rue de la Chine, 75020 Paris, France; UMR_S938, université de Sorbonne, 75000 Paris, France
| | - G Body
- Département de gynécologie, centre hospitalier universitaire de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Inserm U1069, université François-Rabelais, 37044 Tours, France
| | - E Daraï
- Département de gynécologie-obstétrique, hôpital Tenon, Assistance publique des Hôpitaux de Paris (AP-HP), 4, rue de la Chine, 75020 Paris, France; Inserm UMR S 938, université Pierre-et-Marie-Curie, 75000 Paris, France
| | - L Ouldamer
- Département de gynécologie, centre hospitalier universitaire de Tours, 2, boulevard Tonnellé, 37044 Tours, France; Inserm U1069, université François-Rabelais, 37044 Tours, France.
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[Epithelial ovarian cancer and elderly patients. Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]. ACTA ACUST UNITED AC 2019; 47:238-249. [PMID: 30712964 DOI: 10.1016/j.gofs.2018.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Indexed: 11/24/2022]
Abstract
In ovarian, tubal and primary peritoneal cancers, older adults have an over-mortality due to more aggressive disease (NP4), surgical and chemotherapy under treatment (NP4) and co-morbidities (NP4). Older age is at higher risk for postoperative morbidity and mortality (NP4). Surgery is more often incomplete in this elderly population (NP4). Older age is a risk factor for lower dose intensity in adjuvant chemotherapy (NP4) and incomplete chemotherapy (NP4). Nevertheless, the benefit of a complete surgery remains identical to that of the younger population (NP2). Preoperative functional assessment identifies patients at risk for postoperative complications (NP4). The perioperative risk depends on three variables, the ASA score, the age and the complexity score of the surgery (NP4). It is recommended to perform cytoreduction surgery in an expert centre (grade C) and on the basis of geriatric expertise analysing functional and physical performance (grade C). The benefit/risk balance of surgery should be assessed on a case-by-case basis for the most at-risk (NP4) populations defined by: (i) age≥80 years, especially if albuminemia≤37g/L; (ii) age≥75 years and FIGO stage IV; (iii) age≥75 years, stage FIGO III and≥1 comorbidity. A comprehensive geriatric assessment is recommended prior to the management of an elderly person with primary ovarian, tubal or peritoneal cancer (grade C). The GVS (Geriatric Vulnerability Score) is used to identify vulnerable elderly patients (NP2). In fit elderly patients, it is recommended to perform intravenous chemotherapy identical to that of younger patients (ie platinum-based dual therapy) (grade B). In vulnerable elderly patients, various adapted chemotherapy regimens have been prospectively evaluated in non-comparative trials, and seem feasible considering specific and nonspecific toxicities: carboplatin monotherapy (NP2), carboplatin AUC2+paclitaxel 60mg/m2 3 weeks/4 (NP2), carboplatin AUC 4-5+paclitaxel 135mg/m2/3 weeks (NP2), carboplatin AUC5/3 weeks+paclitaxel 60mg/m2/week (NP3). In the absence of comparative data, no recommendation can be made in this population. Primary chemotherapy decreases the complexity of the surgical procedure and perioperative morbidity and mortality during interval surgery (NP1). It should be considered after 70 years in cases of comorbidities and/or peritoneal carcinomatosis sufficient for complex initial surgery (NP4).
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Torres D, Kumar A, Bakkum-Gamez JN, Weaver AL, McGree ME, Wang C, Langstraat CL, Cliby WA. Mesenchymal molecular subtype is an independent predictor of severe postoperative complications after primary debulking surgery for advanced ovarian cancer. Gynecol Oncol 2019; 152:223-227. [DOI: 10.1016/j.ygyno.2018.11.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 12/18/2022]
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21
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Castro BGR, Dos Reis R, Cintra GF, Sousa MMDA, Vieira MDA, Andrade CEMDC. Predictive Factors for Surgical Morbidities and Adjuvant Chemotherapy Delay for Advanced Ovarian Cancer Patients Treated by Primary Debulking Surgery or Interval Debulking Surgery. Int J Gynecol Cancer 2018; 28:1520-1528. [PMID: 30036229 DOI: 10.1097/igc.0000000000001325] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE Postoperative complications and adjuvant chemotherapy delay (ACD) are the most damaging outcomes after surgical treatment of advanced ovarian cancer. Establishing predictive factors should prevent their occurrence. METHODS We analyzed retrospectively all patients with advanced ovarian cancer who underwent cytoreduction at our institution between December 2010 and May 2016. We evaluated all 30-day complications and considered ACD all cases who did not start adjuvant chemotherapy until 42 days or did not perform it after cytoreductive surgery. These data were analyzed in the general group, and between primary debulking surgery (PDS) and interval debulking surgery (IDS) using χ test and Student t test. Relationship of variables was verified using Multiple Logistic Regression. RESULTS A total of 83 women were included. Of these, 43 (51.8%) were submitted to PDS and 40 (48.2%) to IDS. In the PDS group, 23 (53.5%) of the patients had complications. For the IDS group, 27 (67.5%) complicated (P = 0.192). Regarding the general group, independent predictors for 30-day complications were presence of comorbidities (odds ratio [OR], 5.466, 95% confidence interval [CI], 1.151-25,972; P = 0.033) and estimated blood loss of greater than 300 mL (OR, 14.407; 95% CI, 2.736-75.863; P = 0.002). In multivariate analysis of the general group, independent predictors for ACD were the presence of hypertension as comorbidity (OR, 3.898; 95% CI, 1.119-13.578; P = 0.033), body mass index of greater than 30 kg/m (OR, 5.728; 95% CI, 1.169-28.069; P = 0.031), 30-day reoperation (OR, 21.275; 95% CI, 1.799-251.651; P = 0.015), and fever within 30 days (OR, 11.594; 95% CI, 1.714-78.412; P = 0.012). CONCLUSIONS Comorbidities and intraoperative bleeding are the most relevant findings related to surgical complications. Surgical approach (PDS or IDS) was not related with complications. Surgical complications were significantly related to ACD.
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Affiliation(s)
| | - Ricardo Dos Reis
- Gynecologic Oncology Department, Barretos Cancer Hospital, Barretos, SP, Brazil
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Bommert M, Harter P, Heitz F, du Bois A. When should Surgery be used for Recurrent Ovarian Carcinoma? Clin Oncol (R Coll Radiol) 2018; 30:493-497. [PMID: 29743148 DOI: 10.1016/j.clon.2018.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 04/05/2018] [Indexed: 12/31/2022]
Abstract
Cytoreductive surgery is an important column in the treatment of primary ovarian cancer. Surgical outcome is one of the most important prognostic factors and one of the few prognostic variables that can be influenced by therapists. Retrospective studies suggested that only complete cytoreduction was associated with a benefit. Therefore, definition of predictors of complete resection is of the utmost importance to avoid surgical burden in patients with both limited benefit of the procedure and limited overall life expectancy. Two prospective multicentre randomised surgical trials in platinum-sensitive recurrent ovarian cancer (DESKTOP III [NCT #01166737] and GOG 213 [NSC #704865]) comparing secondary cytoreductive surgery followed by platinum-based chemotherapy versus chemotherapy alone have been conducted. The results of the DESKTOP III were recently presented at the American Society of Clinical Oncology meeting in Chicago. It showed a benefit of secondary cytoreductive surgery exclusively in patients with complete resection with a progression-free survival of 5.6 months (P < 0.001). This overview aims to support this task and concentrates on the currently available data regarding surgery in recurrent ovarian cancer.
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Affiliation(s)
- M Bommert
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte, Essen, Germany.
| | - P Harter
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - F Heitz
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - A du Bois
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte, Essen, Germany
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Shim SH, Lee SJ, Dong M, Suh JH, Kim SY, Lee JH, Kim SN, Kang SB, Kim J. Prediction model for 30-day morbidity after gynecological malignancy surgery. PLoS One 2017; 12:e0178610. [PMID: 28570652 PMCID: PMC5453555 DOI: 10.1371/journal.pone.0178610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 05/16/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE The potential risk of postoperative morbidity is important for gynecologic cancer patients because it leads to delays in adjunctive therapy and additional costs. We aimed to develop a preoperative nomogram to predict 30-day morbidity after gynecological cancer surgery. METHODS Between 2005 and 2015, 533 consecutive patients with elective gynecological cancer surgery in our center were reviewed. Of those patients, 373 and 160 patients were assigned to the model development or validation cohort, respectively. To investigate independent predictors of 30-day morbidity, a multivariate Cox regression model with backward stepwise elimination was utilized. A nomogram based on this Cox model was developed and externally validated. Its performance was assessed using the concordance index and a calibration curve. RESULTS Ninety-seven (18.2%) patients had at least one postoperative complication within 30 days after surgery. After bootstrap resampling, the final model indicated age, operating time, and serum albumin level as statistically significant predictors of postoperative morbidity. The bootstrap-corrected concordance index of the nomogram incorporating these three predictors was 0.656 (95% CI, 0.608-0.723). In the validation cohort, the nomogram showed fair discrimination [concordance index: 0.674 (95% CI = 0.619-0.732] and good calibration (P = 0.614; Hosmer-Lemeshow test). CONCLUSION The 30-day morbidity after gynecologic cancer surgery could be predicted according to age, operation time, and serum albumin level. After further validation using an independent dataset, the constructed nomogram could be valuable for predicting operative risk in individual patients.
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Affiliation(s)
- Seung-Hyuk Shim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Sun Joo Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
- * E-mail:
| | - Meari Dong
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Jung Hwa Suh
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Seo Yeon Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Ji Hye Lee
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Soo-Nyung Kim
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Soon-Beom Kang
- Department of Obstetrics and Gynecology, Konkuk University School of Medicine, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
| | - Jayoun Kim
- Research Coordinating Center, Konkuk University Medical Center, 120 Neungdong-ro, Gwangjin-gu, Seoul, Korea
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Di Donato V, Kontopantelis E, Aletti G, Casorelli A, Piacenti I, Bogani G, Lecce F, Benedetti Panici P. Trends in Mortality After Primary Cytoreductive Surgery for Ovarian Cancer: A Systematic Review and Metaregression of Randomized Clinical Trials and Observational Studies. Ann Surg Oncol 2017; 24:1688-1697. [DOI: 10.1245/s10434-016-5680-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Smith CG. A Resident's Perspective of Ovarian Cancer. Diagnostics (Basel) 2017; 7:E24. [PMID: 28448435 PMCID: PMC5489944 DOI: 10.3390/diagnostics7020024] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/12/2017] [Accepted: 04/20/2017] [Indexed: 12/20/2022] Open
Abstract
Identifying, understanding, and curing disease is a lifelong endeavor for any medical practitioner. Equally as important is to be cognizant of the impact a disease has on the individual suffering from it, as well as on their family. Ovarian cancer is the leading cause of death from gynecologic malignancies. Symptoms are vague, and the disease is generally at an advanced stage at diagnosis. Efforts have been made to develop methods to identify ovarian cancer at earlier stages, thus improving overall mortality. Transvaginal ultrasound (TVUS), with and without laboratory tests, can be used to screen for ovarian cancer. For over thirty years, the University of Kentucky Markey Cancer Center Ovarian Cancer Screening Program has been studying the efficacy of TVUS for detecting early stage ovarian cancer. After 285,000+ TVUS examinations provided to over 45,000 women, the program has demonstrated that regular TVUS examinations can detect ovarian cancer at early stages, and that survival is increased in those women whose ovarian cancer was detected with screening and who undergo standard treatment. These results demonstrate the utility of TVUS as an efficacious method of ovarian cancer screening.
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Affiliation(s)
- Christopher G Smith
- Department of Obstetrics & Gynecology, University of Kentucky Medical Center, 800 Rose Street, Lexington, KY 40536-0293, USA.
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26
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Rutten MJ, van Meurs HS, van de Vrie R, Gaarenstroom KN, Naaktgeboren CA, van Gorp T, Ter Brugge HG, Hofhuis W, Schreuder HWR, Arts HJG, Zusterzeel PLM, Pijnenborg JMA, van Haaften M, Fons G, Engelen MJA, Boss EA, Vos MC, Gerestein KG, Schutter EMJ, Opmeer BC, Spijkerboer AM, Bossuyt PMM, Mol BW, Kenter GG, Buist MR. Laparoscopy to Predict the Result of Primary Cytoreductive Surgery in Patients With Advanced Ovarian Cancer: A Randomized Controlled Trial. J Clin Oncol 2016; 35:613-621. [PMID: 28029317 DOI: 10.1200/jco.2016.69.2962] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Purpose To investigate whether initial diagnostic laparoscopy can prevent futile primary cytoreductive surgery (PCS) by identifying patients with advanced-stage ovarian cancer in whom > 1 cm of residual disease will be left after PCS. Patients and Methods This multicenter, randomized controlled trial was undertaken within eight gynecologic cancer centers in the Netherlands. Patients with suspected advanced-stage ovarian cancer who qualified for PCS were eligible. Participating patients were randomly assigned to either laparoscopy or PCS. Laparoscopy was used to guide selection of primary treatment: either primary surgery or neoadjuvant chemotherapy followed by interval surgery. The primary outcome was futile laparotomy, defined as a PCS with residual disease of > 1 cm. Primary analyses were performed according to the intention-to-treat principle. Results Between May 2011 and February 2015, 201 participants were included, of whom 102 were assigned to diagnostic laparoscopy and 99 to primary surgery. In the laparoscopy group, 63 (62%) of 102 patients underwent PCS versus 93 (94%) of 99 patients in the primary surgery group. Futile laparotomy occurred in 10 (10%) of 102 patients in the laparoscopy group versus 39 (39%) of 99 patients in the primary surgery group (relative risk, 0.25; 95% CI, 0.13 to 0.47; P < .001). In the laparoscopy group, three (3%) of 102 patients underwent both primary and interval surgery compared with 28 (28%) of 99 patients in the primary surgery group ( P < .001). Conclusion Diagnostic laparoscopy reduced the number of futile laparotomies in patients with suspected advanced-stage ovarian cancer. In women with a plan for PCS, these data suggest that performance of diagnostic laparoscopy first is reasonable and that if cytoreduction to < 1 cm of residual disease seems feasible, to proceed with PCS.
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Affiliation(s)
- Marianne J Rutten
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Hannah S van Meurs
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Roelien van de Vrie
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Katja N Gaarenstroom
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Christiana A Naaktgeboren
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Toon van Gorp
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Henk G Ter Brugge
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Ward Hofhuis
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Henk W R Schreuder
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Henriette J G Arts
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Petra L M Zusterzeel
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Johanna M A Pijnenborg
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Maarten van Haaften
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Guus Fons
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Mirjam J A Engelen
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Erik A Boss
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - M Caroline Vos
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Kees G Gerestein
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Eltjo M J Schutter
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Brent C Opmeer
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Anje M Spijkerboer
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Patrick M M Bossuyt
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Ben Willem Mol
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Gemma G Kenter
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Marrije R Buist
- Marianne J. Rutten, Hannah S. van Meurs, Roelien van de Vrie, Christiana A. Naaktgeboren, Guus Fons, Brent C. Opmeer, Anje M. Spijkerboer, Patrick M.M. Bossuyt, Gemma G. Kenter, and Marrije R. Buist, Academic Medical Center, Amsterdam; Katja N. Gaarenstroom, Leiden University Medical Center, Leiden; Toon van Gorp, Maastricht University Medical Center, Maastricht; Henk G. Ter Brugge, Isala Hospital, Zwolle; Ward Hofhuis, Sint Franciscus Gasthuis, Rotterdam; Henk W.R. Schreuder, University Medical Center Utrecht; Maarten van Haaften, Diakonessenhuis, Utrecht; Henriette J.G. Arts, University Medical Center Groningen, Groningen; Petra L.M. Zusterzeel, Radboud University Medical Center, Nijmegen; Johanna M.A. Pijnenborg and M. Caroline Vos, Elisabeth-Tweesteden Hospital, Tilburg; Mirjam J.A. Engelen, Atrium Medical Center, Heerlen; Erik A. Boss, Máxima Medical Center, Veldhoven; Kees G. Gerestein, Meander Medical Center, Amersfoort; Eltjo M.J. Schutter, Medical Spectrum Twente, Enschede, the Netherlands; and Ben Willem Mol, The Robinson Research Institute, University of Adelaide; The South Australian Health and Medical Research Institute, Adelaide, Australia
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A laparoscopic risk-adjusted model to predict major complications after primary debulking surgery in ovarian cancer: A single-institution assessment. Gynecol Oncol 2016; 142:19-24. [DOI: 10.1016/j.ygyno.2016.04.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 04/14/2016] [Accepted: 04/16/2016] [Indexed: 11/18/2022]
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The Frequency of Unplanned Rehospitalization and Associated Factors in Gyneoncology Patients: A Retrospective Study. Int J Gynecol Cancer 2016; 27:183-188. [DOI: 10.1097/igc.0000000000000852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
ObjectiveIn this study, we aim to analyze rate and associated factors with unplanned rehospitalization in gynecological cancer patients.Materials and MethodsThe electronic database query (2007 to 2014) was used to evaluate rehospitalization rates within 90 days of index admission in patients with gynecological cancer. Multivariable logistic regression was used to identify factors associated with rehospitalization.ResultsMean patient age was 59.05 ± 11.96 years (minimum, 32 years; maximum, 85 years). A total of 152 patients’ data were evaluated. Seventy-three patients (48.0%) were rehospitalized within 90 days of discharge. The median length of index hospital stay (from 3 to 34 days) was 8.90 ± 6.03 days. The most common rehospitalization causes includes pain (24.6%), recurrence (21.9%), ascites (13.7%), surgical site infection (12.3%), acute reoperation (9.6%), thromboembolism (8.2%), renal failure (5.5%), ileus/obstruction (2.7%), and lymphedema (1.4%). In multivariable logistic regression model, difference was found between history of operation, receive chemotherapy, development of the complication during hospitalization comorbidities as well as multiparity variables, and rehospitalization (P < 0.05).ConclusionsUnplanned rehospitalization after discharge for gynecological cancer is common with significant associated risk factors and patient outcomes. Integrated multidisciplinary health care strategies, such as safe transition, communication, patient and family education, accurate medication reconciliation, and short-interval outpatient follow-up may help to prevent rehospitalization after discharge and improve patient outcomes.
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Lin JJ, Egorova N, Franco R, Prasad-Hayes M, Bickell NA. Ovarian Cancer Treatment and Survival Trends Among Women Older Than 65 Years of Age in the United States, 1995-2008. Obstet Gynecol 2016; 127:81-89. [PMID: 26646132 PMCID: PMC4689627 DOI: 10.1097/aog.0000000000001196] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate whether overall survival is improving among women in the United States with advanced ovarian cancer. METHODS This retrospective cohort study evaluated trends in treatment and overall survival for women older than 65 years diagnosed with stage III and IV epithelial ovarian cancer between 1995 and 2008 using Surveillance, Epidemiology, and End Results-Medicare data. Parametric and semiparametric multivariate survival analyses were used to assess comparative treatment survival rates and factors affecting survival and recurrence. RESULTS Of 7,938 women who met study criteria, 2.9% received no treatment, 15.4% underwent surgery only, 24.8% received chemotherapy only, 41.8% underwent primary debulking surgery and chemotherapy in an optimal timeframe, and 15.1% had primary debulking surgery and chemotherapy, but the timing was not optimal or patients did not complete all six cycles of chemotherapy. Those who underwent surgery only had similar survival as those who received no treatment (2.2 compared with 1.7 months), whereas those who received chemotherapy only had a better overall survival (14.4 months). Optimal treatment was associated with the longest survival time (P<.001, median overall survival 39.0 months). Additionally, survival time associated with optimal treatment increased over the past decade. However, the proportion of women who received optimal treatment has decreased over the past decade. CONCLUSION Elderly women with advanced ovarian cancer have the best survival with optimal therapy. When this is not offered or possible, chemotherapy alone offers better survival than surgery alone.
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MESH Headings
- Aged
- Aged, 80 and over
- Antineoplastic Agents/therapeutic use
- Chemotherapy, Adjuvant
- Cytoreduction Surgical Procedures
- Female
- Humans
- Neoadjuvant Therapy
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/mortality
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/therapy
- Ovarian Neoplasms/mortality
- Ovarian Neoplasms/pathology
- Ovarian Neoplasms/therapy
- Retrospective Studies
- SEER Program
- Survival Rate
- United States/epidemiology
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Affiliation(s)
- Jenny J. Lin
- Division of General Internal Medicine, Icahn School of Medicine at
Mount Sinai, NY, NY
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of
Medicine at Mount Sinai, NY, NY
| | - Rebeca Franco
- Department of Population Health Science and Policy, Icahn School of
Medicine at Mount Sinai, NY, NY
| | - Monica Prasad-Hayes
- Division of Gynecologic Oncology, Icahn School of Medicine at Mount
Sinai, NY, NY
| | - Nina A. Bickell
- Department of Population Health Science and Policy, Icahn School of
Medicine at Mount Sinai, NY, NY
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Kumar A, Janco JM, Mariani A, Bakkum-Gamez JN, Langstraat CL, Weaver AL, McGree ME, Cliby WA. Risk-prediction model of severe postoperative complications after primary debulking surgery for advanced ovarian cancer. Gynecol Oncol 2016; 140:15-21. [DOI: 10.1016/j.ygyno.2015.10.025] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/28/2015] [Accepted: 10/31/2015] [Indexed: 01/31/2023]
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Coccolini F, Catena F, Manfredi R, Montori G, Manegold JE, Ansaloni L. Value of neoadjuvant chemotherapy in advanced ovarian cancer. World J Obstet Gynecol 2015; 4:64-67. [DOI: 10.5317/wjog.v4.i3.64] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/20/2015] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
Data regarding the role of neoadjuvant chemotherapy (NACT) are not definitive. Several randomized trials and meta-analyses demonstrate that this chemotherapy regimen decreases the morbidity and mortality rates and increases complete cytoreduction rates. If combined with hyperthermic intraperitoneal chemotherapy (HIPEC), NACT could potentially further improve upon these already promising results. Moreover the use of NACT could help in evaluating the chemo-sensitivity of the cancer, thus preventing unnecessary HIPEC procedures in chemo-resistant patients. NACT should definitely be considered as a preferred regimen in the management of advanced ovarian cancer, especially in association with cytoreductive surgery + HIPEC procedure in the context of a multidisciplinary team management in an experienced cancer centre.
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Complications après exentération pelvienne postérieure modifiée selon Hudson dans le cadre de tumeurs malignes ovariennes. ACTA ACUST UNITED AC 2015; 43:342-7. [DOI: 10.1016/j.gyobfe.2015.03.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2014] [Accepted: 03/06/2015] [Indexed: 11/18/2022]
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Horowitz NS, Miller A, Rungruang B, Richard SD, Rodriguez N, Bookman MA, Hamilton CA, Krivak TC, Maxwell GL. Does aggressive surgery improve outcomes? Interaction between preoperative disease burden and complex surgery in patients with advanced-stage ovarian cancer: an analysis of GOG 182. J Clin Oncol 2015; 33:937-43. [PMID: 25667285 PMCID: PMC4348639 DOI: 10.1200/jco.2014.56.3106] [Citation(s) in RCA: 198] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To examine the effects of disease burden, complex surgery, and residual disease (RD) status on progression-free (PFS) and overall survival (OS) in patients with advanced epithelial ovarian cancer (EOC) or primary peritoneal cancer (PPC) and complete surgical resection (R0) or < 1 cm of RD (MR) after surgical cytoreduction. PATIENTS AND METHODS Demographic, pathologic, surgical, and outcome data were collected from 2,655 patients with EOC or PPC enrolled onto the Gynecologic Oncology Group 182 study. The effects of disease distribution (disease score [DS]) and complexity of surgery (complexity score [CS]) on PFS and OS were assessed using the Kaplan-Meier method and multivariable regression analysis. RESULTS Consistent with existing literature, patients with MR had worse prognosis than R0 patients (PFS, 15 v 29 months; P < .01; OS, 41 v 77 months; P < .01). Patients with the highest preoperative disease burden (DS high) had shorter PFS (15 v 23 or 34 months; P < .01) and OS (40 v 71 or 86 months; P < .01) compared with those with DS moderate or low, respectively. This relationship was maintained in the subset of R0 patients with PFS (18.3 v 33.2 months; DS moderate or low: P < .001) and OS (50.1 v 82.8 months; DS moderate or low: P < .001). After controlling for DS, RD, an interaction term for DS/CS, performance status, age, and cell type, CS was not an independent predictor of either PFS or OS. CONCLUSION In this large multi-institutional sample, initial disease burden remained a significant prognostic indicator despite R0. Complex surgery does not seem to affect survival when accounting for other confounding influences, particularly RD.
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Affiliation(s)
- Neil S Horowitz
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Austin Miller
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Bunja Rungruang
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Scott D Richard
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Noah Rodriguez
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Michael A Bookman
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Chad A Hamilton
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - Thomas C Krivak
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA
| | - G Larry Maxwell
- Neil S. Horowitz, Brigham and Women's Hospital, Boston, MA; Austin Miller, Roswell Park Cancer Institute, Buffalo, NY; Bunja Rungruang, Georgia Regents University, Augusta, GA; Scott D. Richard, Hahnemann University Hospital, Philadelphia; Thomas C. Krivak, Western Pennsylvania Hospital, Pittsburgh, PA; Noah Rodriguez, Kaiser Permanente Irvine Medical Center, Irvine, CA; Michael A. Bookman, University of Arizona Cancer Center, Tucson, AZ; Chad A. Hamilton, Walter Reed National Military Medical Center, Bethesda, MD; and G. Larry Maxwell, Inova Fairfax Women's Hospital, Falls Church, VA.
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Comparative effectiveness research in gynecologic oncology. Cancer Treat Res 2015; 164:237-59. [PMID: 25677027 PMCID: PMC4484275 DOI: 10.1007/978-3-319-12553-4_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
The field of gynecologic oncology is faced with a number of challenges including how to incorporate new drugs and procedures into practice, how to balance therapeutic efficacy and toxicity of treatment, how to individualize therapy to particular patients or groups of patients, and how to contain the rapidly rising costs associated with oncologic care. In this chapter we examine three common and highly debated clinical scenarios in gynecologic oncology: the initial management of ovarian cancer, the role of lymphadenectomy in the treatment of endometrial cancer, and the choice of adjuvant therapy for ovarian cancer.
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Robotic-assisted surgery in gynecologic oncology. Fertil Steril 2014; 102:922-32. [DOI: 10.1016/j.fertnstert.2014.08.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 08/12/2014] [Accepted: 08/12/2014] [Indexed: 12/17/2022]
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van Meurs HS, Schuit E, Horlings HM, van der Velden J, van Driel WJ, Mol BWJ, Kenter GG, Buist MR. Development and internal validation of a prognostic model to predict recurrence free survival in patients with adult granulosa cell tumors of the ovary. Gynecol Oncol 2014; 134:498-504. [PMID: 24983647 DOI: 10.1016/j.ygyno.2014.06.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/18/2014] [Accepted: 06/23/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Models to predict the probability of recurrence free survival exist for various types of malignancies, but a model for recurrence free survival in individuals with an adult granulosa cell tumor (GCT) of the ovary is lacking. We aimed to develop and internally validate such a prognostic model. METHODS We performed a multicenter retrospective cohort study of patients with a GCT. Demographic, clinical and pathological information were considered as potential predictors. Univariable and multivariable analyses were performed using a Cox proportional hazards model. Using backward stepwise selection we identified the combination of predictors that best predicted recurrence free survival. Discrimination (c-statistic) and calibration were used to assess model performance. The model was internally validated using bootstrapping techniques to correct for overfitting. To increase clinical applicability of the model we developed a nomogram to allow individual prediction of recurrence free survival. RESULTS We identified 127 patients with a GCT (median follow-up time was 131 months (IQR 70-215)). Recurrence of GCT occurred in 81 out of 127 patients (64%). The following four variables jointly best predicted recurrence free survival; clinical stage, Body Mass Index (BMI), tumor diameter and mitotic index. The model had a c-statistic of 0.73 (95% CI 0.66-0.80) and showed accurate calibration. CONCLUSIONS Recurrence free survival in patients with an adult GCT of the ovary can be accurately predicted by a combination of BMI, clinical stage, tumor diameter and mitotic index. The introduced nomogram could facilitate in counseling patients and may help to guide patients and caregivers in joint decisions on post-treatment surveillance.
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Affiliation(s)
- Hannah S van Meurs
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Ewoud Schuit
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Universiteitsweg 100, 3584 CG Utrecht, The Netherlands.
| | - Hugo M Horlings
- Department of Pathology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Jacobus van der Velden
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Willemien J van Driel
- Department of Gynecology, Center for Gynecologic Oncology Amsterdam, Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
| | - Ben Willem J Mol
- The Robinson Institute, School of Pediatrics and Reproductive Health, University of Adelaide, Level 3 Medical School South Building, Frome Road, SA 5005 Adelaide, Australia.
| | - Gemma G Kenter
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
| | - Marrije R Buist
- Department of Obstetrics and Gynecology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands.
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Wong AK, Joanna Nguyen T, Peric M, Shahabi A, Vidar EN, Hwang BH, Niknam Leilabadi S, Chan LS, Urata MM. Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 2014; 35:6-12. [PMID: 24431159 DOI: 10.1002/micr.22223] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Revised: 12/20/2013] [Accepted: 12/26/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND There are numerous factors that may contribute to microvascular free flap failure. Although technical issues are dominant factors, patient and clinical characteristics are also contributory. The aim of this study was to investigate non-technical variables associated with microsurgical free flap failure using a multi-institutional dataset. METHODS Utilizing the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database, we identified all patients who underwent microvascular free tissue transfer from 2005 through 2009. Univariate analysis was performed to determine the association of flap failure with the following factors: age, gender, ethnicity, body mass index, intraoperative transfusion, diabetes, smoking, alcohol, American Society of Anesthesiologists classification, year of operation, operative time, number of flaps, and type of reconstruction. Factors with a significance of P < 0.2 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. RESULTS A total of 639 patients underwent microsurgical free flap reconstruction with 778 flaps over the 4-year study period; 139 patients had two free flaps during the same operation. The overall incidence of flap failure was 4.4% (34/778) (95% confidence interval [CI]: 3.0%, 6.2%). Operative time was identified as an independent risk factor for free flap failure. After adjusting for other factors, those whose operative time was equal to or greater than the 75th percentile (625.5 min) were twice as likely to experience flap failure (AOR 2.09; 95% CI: 1.01-4.31; P = 0.045). None of the other risk factors studied were significant contributors. CONCLUSIONS In this series, the overall flap loss rate of was 4.4%. Operative time was a significant independent risk factor for flap failure.
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Affiliation(s)
- Alex K Wong
- Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, CA
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Lotti M, Busci LM, Campanati L, Catena F, Coccolini F, Bakrin N, Iaco PD, Ercolani G, Grosso G, Pisano M, Poiasina E, Rossetti D, Rossi M, Zamagni C, Bertoli P, Pinna AD, Frigerio L, Ansaloni L. Cytoreductive surgery and HIPEC after neoadjuvant chemotherapy for advanced epithelial ovarian cancer. World J Obstet Gynecol 2013; 2:167-175. [DOI: 10.5317/wjog.v2.i4.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Revised: 04/23/2013] [Accepted: 07/11/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To reduce postoperative complications and to make possible an optimal cytoreduction, neoadjuvant chemotherapy (NACT) followed by interval debulking surgery has been applied with encouraging results.
METHODS: Between December 2009 and February 2012, patients with stage IIIC-IV epithelial ovarian cancer (EOC) underwent diagnostic laparoscopy, to assess the feasibility of optimal debulking surgery. The modified Fagotti score was applied to assess the feasibility of resection with zero residual tumor. Patients who were not candidate for upfront debulking surgery were submitted to NACT, then reassessed according to the RECIST 1.1 criteria and submitted to cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) if they showed clinical response or stable disease. The remaining cycles of adjuvant systemic chemotherapy (ASCT) were administered postoperatively, to complete 6 cycles of systemic chemotherapy.
RESULTS: Nine patients were included. Clinical response to NACT was complete in 3 patients and partial in 5 patients; one patient had stable disease. All patients underwent CRS resulting in CC0 disease prior to HIPEC. Average operative time was 510 min. Average intensive care unit stay was 2 d. Average postoperative hospital stay was 25 d. No postoperative mortality was observed. One patient experienced pelvic abscess. One patient refused ASCT. The remaining 8 patients started ASCT. Average time to chemotherapy was 36 d. All patients are alive, with an average follow up of 11 mo. Eight patients are disease-free at follow up.
CONCLUSION: HIPEC after CRS for advanced EOC is feasible with acceptable morbidity and mortality. NACT may increase the chance for achieving complete cytoreduction. Phase 3 studies are needed to determine the effects of HIPEC on survival.
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Walters CL, Schneider KE, Whitworth JM, Fauci JM, Smith HJ, Barnes MN, Straughn JM. Perioperative morbidity and mortality in octogenarians with ovarian cancer. Int J Gynecol Cancer 2013; 23:1006-9. [PMID: 23714708 DOI: 10.1097/igc.0b013e3182980fac] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The decision to choose surgical cytoreduction in patients with newly diagnosed ovarian cancer may be influenced by their age. We compared perioperative morbidity and mortality of octogenarians compared with younger patients undergoing surgical cytoreduction. METHODS A retrospective chart review identified patients who underwent primary surgical cytoreduction for ovarian cancer between January 2005 and December 2009. Patients were divided into 2 cohorts: younger than 80 years and 80 years or older (octogenarian). Patient demographics, surgical procedures, 30-day readmission, length of stay, 30-day mortality rates, and chemotherapy administration were examined. Student t test and χ test were used to evaluate statistical significance. RESULTS Three hundred eighty-four patients who underwent surgical cytoreduction for ovarian cancer were identified. Three hundred fifty-two patients (91.7%) were younger than 80 years, whereas 32 patients (8.3%) were 80 years or older. Two hundred thirty-six women (67.0%) in the younger cohort had optimal cytoreduction (<1 cm) compared with 17 women (53.1%) in the older cohort (P = 0.12). Thirty-day readmission rates and postoperative complications were similar. More patients in the older cohort required preoperative admission for medical clearance (P < 0.01). Mean length of stay was significantly longer in the older cohort (10.0 vs 7.5; P = 0.02). The number of patients who received adjuvant chemotherapy was significantly lower in the older cohort (71.9% vs 93.8%; P < 0.01). The 30-day mortality rate was significantly higher in the older cohort (18.8% vs 4.0%; P < 0.01). CONCLUSIONS Although octogenarians with ovarian cancer have similar surgical complication rates as their younger counterparts, they require more medical clearance and have a longer hospital stay. Older patients are less likely to undergo chemotherapy and have a higher 30-day mortality rate than are younger patients.
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MESH Headings
- Adenocarcinoma, Clear Cell/mortality
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/surgery
- Adenocarcinoma, Mucinous/mortality
- Adenocarcinoma, Mucinous/pathology
- Adenocarcinoma, Mucinous/surgery
- Adult
- Aged
- Aged, 80 and over
- Carcinoma, Papillary/mortality
- Carcinoma, Papillary/pathology
- Carcinoma, Papillary/surgery
- Cystadenocarcinoma, Serous/mortality
- Cystadenocarcinoma, Serous/pathology
- Cystadenocarcinoma, Serous/surgery
- Endometrial Neoplasms/mortality
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/surgery
- Female
- Follow-Up Studies
- Humans
- Middle Aged
- Morbidity
- Neoplasm Staging
- Ovarian Neoplasms/mortality
- Ovarian Neoplasms/pathology
- Ovarian Neoplasms/surgery
- Patient Readmission
- Perioperative Period
- Postoperative Complications
- Prognosis
- Retrospective Studies
- Survival Rate
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Affiliation(s)
- Christen L Walters
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, AL 35233, USA.
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Coccolini F, Catena F, Manfredi R, Lotti M, Frigerio L, Ansaloni L. Advanced ovarian cancer: Neoadjuvant chemotherapy plus surgery and HIPEC as up-front treatment. World J Obstet Gynecol 2012; 1:55-59. [DOI: 10.5317/wjog.v1.i4.55] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Epithelial ovarian cancer (EOC) is one of the most common malignancies and one of the principal causes of death in gynecological neoplasms. The majority of EOC patients present with an advanced International Federation of Gynecology and Obstetrics stage disease. The current standard treatment for these patients consists of complete cytoreduction and combined systemic chemotherapy of a platinum agent and paclitaxel. Even if the majority of patients with EOC respond to first-line platinum based chemotherapy, almost 20% of them are resistant or refractory. According to these data, the main risk is for a certain number of patients to have undergone cytoreductive surgery (CRS) and subsequent hyperthermic intraoperative peritoneal chemotherapy (HIPEC) in a useful way. Radical surgery, especially in advanced cases, is associated with a high incidence of postoperative morbidity and mortality, which could be increased by the HIPEC. Every effort should be made for previously selected patients to improve outcome and optimize resources. Over the last decade, new options have been introduced to prolong survival. Improved long-term results can be achieved using CRS in combination with intraoperative HIPEC. This combination has also been used in an up-front setting. Controversial outcomes have been reported for neoadjuvant platinum-based chemotherapy. Different papers have been published reporting discordant results. Further studies are needed.
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Wright JD, Herzog TJ, Siddiq Z, Arend R, Neugut AI, Burke WM, Lewin SN, Ananth CV, Hershman DL. Failure to Rescue As a Source of Variation in Hospital Mortality for Ovarian Cancer. J Clin Oncol 2012; 30:3976-82. [DOI: 10.1200/jco.2012.43.2906] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Although the association between high surgical volume and improved outcomes from procedures is well described, the mechanisms that underlie this association are uncertain. There is growing recognition that high-volume hospitals may not necessarily have lower complication rates but rather may be better at rescuing patients with complications. We examined the role of complications, failure to rescue from complications, and mortality based on hospital volume for ovarian cancer. Patients and Methods The Nationwide Inpatient Sample was used to identify women who underwent surgery for ovarian cancer from 1988 to 2009. Hospitals were ranked on the basis of their procedure volume. We determined the risk-adjusted mortality, major complication rate, and “failure to rescue” rate (mortality in patients with a major complication) for each tertile. Univariate and multivariate associations were then compared. Results We identified 36,624 patients. The mortality rate for the cohort was 1.6%. The major complication rate was 20.4% at low-volume, 23.4% at intermediate-volume, and 24.6% at high-volume hospitals (P < .001). However, the rate of failure to rescue (death after a complication) was markedly higher at low-volume (8.0%) compared with high-volume hospitals (4.9%; P < .001). After accounting for patient and hospital characteristics, women treated at low-volume hospitals who experienced a complication were 48% more likely (odds ratio [OR], 1.48; 95% CI, 1.11 to 1.99) to die than patients with a complication at a high-volume hospital. Conclusion Mortality is lower for patients with ovarian cancer treated at high-volume hospitals. The reduction in mortality does not appear to be the result of lower complications rates but rather a result of the ability of high-volume hospitals to rescue patients with complications.
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Affiliation(s)
- Jason D. Wright
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Thomas J. Herzog
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Zainab Siddiq
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Rebecca Arend
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Alfred I. Neugut
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - William M. Burke
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Sharyn N. Lewin
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Cande V. Ananth
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
| | - Dawn L. Hershman
- Jason D. Wright, Thomas J. Herzog, Zainab Siddiq, Rebecca Arend, Alfred I. Neugut, William M. Burke, Sharyn N. Lewin, Cande V. Ananth, and Dawn L. Hershman, Columbia University College of Physicians and Surgeons; Alfred I. Neugut and Dawn L. Hershman, Mailman School of Public Health; and Jason D. Wright, Thomas J. Herzog, Alfred I. Neugut, Sharyn N. Lewin, and Dawn L. Hershman, Herbert Irving Comprehensive Cancer Center, New York, NY
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Diagnosis and management of peritoneal metastases from ovarian cancer. Gastroenterol Res Pract 2012; 2012:541842. [PMID: 22888339 PMCID: PMC3408715 DOI: 10.1155/2012/541842] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2012] [Accepted: 05/12/2012] [Indexed: 02/08/2023] Open
Abstract
The management and the outcome of peritoneal metastases or recurrence from epithelial ovarian cancer are presented. The biology and the diagnostic tools of EOC peritoneal metastasis with a comprehensive approach and the most recent literatures data are discussed. The definition and the role of surgery and chemotherapy are presented in order to focuse on the controversial points. Finally, the paper discusses the new data about the introduction of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced epithelial ovarian cancer.
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Cliby W, Aletti G, Chi D, Bristow R. RE: Defining the limits of radical cytoreductive surgery in ovarian cancer. Gynecol Oncol 2012; 125:509-10; author reply 508-9. [DOI: 10.1016/j.ygyno.2012.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Accepted: 01/11/2012] [Indexed: 11/26/2022]
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Rutten MJ, Gaarenstroom KN, Van Gorp T, van Meurs HS, Arts HJ, Bossuyt PM, Ter Brugge HG, Hermans RH, Opmeer BC, Pijnenborg JM, Schreuder HW, Schutter EM, Spijkerboer AM, Wensveen CW, Zusterzeel P, Mol BWJ, Kenter GG, Buist MR. Laparoscopy to predict the result of primary cytoreductive surgery in advanced ovarian cancer patients (LapOvCa-trial): a multicentre randomized controlled study. BMC Cancer 2012; 12:31. [PMID: 22264278 PMCID: PMC3292486 DOI: 10.1186/1471-2407-12-31] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Accepted: 01/20/2012] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Standard treatment of advanced ovarian cancer is surgery and chemotherapy. The goal of surgery is to remove all macroscopic tumour, as the amount of residual tumour is the most important prognostic factor for survival. When removal off all tumour is considered not feasible, neoadjuvant chemotherapy (NACT) in combination with interval debulking surgery (IDS) is performed. Current methods of staging are not always accurate in predicting surgical outcome, since approximately 40% of patients will have more than 1 cm residual tumour after primary debulking surgery (PDS). In this study we aim to assess whether adding laparoscopy to the diagnostic work-up of patients suspected of advanced ovarian carcinoma may prevent unsuccessful primary debulking surgery for ovarian cancer. METHODS Multicentre randomized controlled trial, including all gynaecologic oncologic centres in the Netherlands and their affiliated hospitals. Patients are eligible when they are planned for PDS after conventional staging. Participants are randomized between direct PDS or additional diagnostic laparoscopy. Depending on the result of laparoscopy patients are treated by PDS within three weeks, followed by six courses of platinum based chemotherapy or with NACT and IDS 3-4 weeks after three courses of chemotherapy, followed by another three courses of chemotherapy. Primary outcome measure is the proportion of PDS's leaving more than one centimetre tumour residual in each arm. In total 200 patients will be randomized. Data will be analysed according to intention to treat. DISCUSSION Patients who have disease considered to be resectable to less than one centimetre should undergo PDS to improve prognosis. However, there is a need for better diagnostic procedures because the current number of debulking surgeries leaving more than one centimetre residual tumour is still high. Laparoscopy before starting treatment for ovarian cancer can be an additional diagnostic tool to predict the outcome of PDS. Despite the absence of strong evidence and despite the possible complications, laparoscopy is already implemented in many countries. We propose a randomized multicentre trial to provide evidence on the effectiveness of laparoscopy before primary surgery for advanced stage ovarian cancer patients. TRIAL REGISTRATION Netherlands Trial Register number NTR2644.
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Affiliation(s)
- Marianne J Rutten
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, The Netherlands.
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Ansaloni L, De Iaco P, Frigerio L. Re: "cytoreductive surgery and hyperthermic intraperitoneal chemotherapy as upfront therapy for advanced epithelial ovarian cancer: multi-institutional phase II trial." - Proposal of a clinical trial of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in advanced ovarian cancer, the CHORINE study. Gynecol Oncol 2012; 125:279-81. [PMID: 22233688 DOI: 10.1016/j.ygyno.2012.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2011] [Accepted: 01/03/2012] [Indexed: 02/06/2023]
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Heitz F, du Bois A, Kurzeder C, Pfisterer J, Barinoff J, Grabowski J, Hilpert F, Mahner S, Harter P. Surgery for Recurrent Ovarian Cancer. WOMENS HEALTH 2011; 7:529-35. [DOI: 10.2217/whe.11.52] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Cytoreductive surgery is accepted as a major treatment of primary ovarian cancer. The role in recurrent ovarian cancer remains a field of discussion and controversy, mainly owing to missing data from prospective randomized trials and lack of universal definitions. Retrospective data indicate that complete resection of recurrent tumor formations should be aimed for, since survival prolongation is mainly seen for patients with no residual disease. Thus, it is most important to find predictors of complete resection, on the one hand to offer the best therapeutic chances to patients, but on the other hand to protect patients with limited life expectancy from additional surgical burden. The first prospective surgical trial in recurrent ovarian cancer, AGO-DESKTOP II validated a score (‘AGO score’) for complete resection. It was shown that patients with a good general condition (ECOG 0), no residual disease after surgery for primary ovarian cancer and absence of ascites in presurgical diagnostics have a 76% likelihood of undergoing complete resection. In this article, further recent data regarding surgery for recurrent ovarian cancer are going to be discussed and the advantages of incorporating these patients into randomized trials are highlighted.
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Affiliation(s)
- Florian Heitz
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte; Huyssen-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Andreas du Bois
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte; Huyssen-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Christian Kurzeder
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte; Huyssen-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Jacobus Pfisterer
- Department of Gynecology & Obstetrics, Städtisches Klinikum Solingen gGmbH, Solingen, Germany
| | - Jana Barinoff
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte; Huyssen-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Jacek Grabowski
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte; Huyssen-Stiftung/Knappschaft GmbH, Essen, Germany
| | - Felix Hilpert
- Department of Gynecology & Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Sven Mahner
- Department of Gynecology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Philipp Harter
- Department of Gynecology & Gynecological Oncology, Kliniken Essen-Mitte; Huyssen-Stiftung/Knappschaft GmbH, Essen, Germany
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Fauci JM, Schneider KE, Frederick PJ, Wilding G, Consiglio J, Sutton AL, Kilgore LC, Barnes MN. Assessment of risk factors for 30-day hospital readmission after surgical cytoreduction in epithelial ovarian carcinoma. Int J Gynecol Cancer 2011; 21:806-10. [PMID: 21412162 DOI: 10.1097/igc.0b013e3182157a19] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To evaluate factors that place epithelial ovarian cancer (EOC) patients at increased risk for hospital readmission. METHODS A retrospective review of patients diagnosed with EOC undergoing surgical cytoreduction at the University of Alabama at Birmingham from 2001 to 2008 was performed. Patients who required readmission were identified. Demographic data, comorbidities, surgical data including bowel resections, and hospital length of stay were evaluated. RESULTS A total of 207 patients were identified. The mean age at diagnosis was 64 years (range, 32-89 years), 58% had optimal debulking (n=120), and the mean number of comorbidities was 1.3 (range, 0-6). Readmission within 30 days of discharge occurred in 33 (16%) of 207 patients. The readmission group had a statistically higher number of comorbidities (1.75 vs 1.01, P=0.025). The most common reasons for readmission were small bowel obstruction/ileus, wound complications, and thromboembolic events. CONCLUSIONS The most common reason for readmission after cytoreductive surgery for EOC is small bowel obstruction/ileus. Studies assessing postoperative disease management programs including nursing telephone follow-up, administration of outpatient intravenous fluids, and continuation of antithrombotic agents may offer opportunities to reduce readmissions.
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Affiliation(s)
- Janelle M Fauci
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, AL 35249, USA.
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