Interval Cytoreductive Surgery in Stage III Epithelial Ovarian Carcinoma Following Neoadjuvant Chemotherapy A Prospective, Non Randomized, Case-Control Study

Background: Primary optimal cytoreductive surgery followed by combination chemotherapy of Paclitaxel and Platinum is currently the standard treatment for advanced stage epithelial ovarian carcinoma. The aim of primary surgery is to achieve optimal cytoreduction because the amount of residual disease is one of the most important prognostic factors for survival. Primary neoadjuvant chemotherapy followed by optimal cytoreductive surgery is an alternative approach to the treatment of the subgroup of patients who present with advanced disease that is unlikely to be initially optimally cytoreduced and provided that the patient responded to chemotherapy and optimal cytoreduction could then be achieved.Objectives: This is a prospective, non-randomized, case- control study evaluating the feasibility of interval cytoreductive surgery following primary neoadjuvant chemotherapy for a subgroup of patients with advanced, stage III epithelial ovarian cancer who were initially deemed inappropriate candidates for primary optimal cytoreductive surgery either because of the disease extent or because of the patient s medical condition that precludes initial surgical intervention. Results will be expressed in terms of median progression free survival and median overall survival.Patients and Methods: Forty three patients with stage III epithelial ovarian carcinoma were enrolled in the current study. The control group consisted of 25 patients who under¬went primary cytoreductive surgery followed by adjuvant chemotherapy. Eighteen cases underwent primary neoadjuvant chemotherapy followed by interval cytoreductive surgery. Patients were stratified for treatment according to clinical, and radiologic criteria and CA 125 level. Optimal cytoreduction was defined as a residual disease 1 cm. cytoreductive surgery included total abdominal hysterectomy, bilateral salpin- gooophorectomy and omentectomy, in addition to the necessary surgical procedures to achieve optimal cytoreduction. Com-bination chemotherapy regimen consisted of Paclitaxel (175 mg/m2, 3 hours infusion) and Carboplatin (AUC = 5 mg/ml/ min).Results: The rate of optimal cytoreduction was higher among patients submitted to primary cytoreductive surgery as compared to interval cytoreductive surgery (76% Vs. 72% respectively), although this was not statistically significant (p= 1.0). The median progression free survival for the control group was 23 and 16 months (optimal Vs. suboptimal cytore¬duction) while The median overall survival was 38 and 22 months (optimal Vs suboptimal cytoreduction). The median progression free survival following interval cytoreduction was 26 and 13 (optimal Vs. suboptimal cytoreduction) and the median overall survival was 34 and 18 months (optimal Vs. suboptimal cytoreduction).Conclusion: Until the results of the randomized controlled trials addressing the question whether neoadjuvant chemo-therapy before surgery could replace the primary surgery followed by adjuvant chemotherapy in terms of survival are available, the standard treatment for advanced stage epithelial ovarian carcinoma remains primary optimal cytoreduction followed by adjuvant chemotherapy. Neoadjuvant chemotherapy followed by interval cytoreductive surgery is an alternative approach that is currently reserved for the subgroup of patients in whom initial optimal cytoreduction is unlikely and those whose medical condition needs to be stabilized prior to surgery.