Predictors of Optimal Cytoreduction

Predicting which patients can be optimally debulked remains difficult. Chi and associates28 and subsequently Brockbank and associates29 demonstrated in their small series that optimal cytoreduction, defined as residual disease of 1 cm or less, was achieved in 73% and 83% of patients with a preoperative CA-125 level of less than 500 U/mL, whereas optimal tumor cytoreduction could be accomplished in only 22% and 18% of patients with CA-125 level above 500 U/mL, respectively. Scoring systems that are based on imaging studies are complex and difficult to apply clinically and have not been validated in large series.30-32 Axtell and colleagues,33 in their review of a cohort of patients at one institution, were able to identify the three strongest CT predictors of optimal cytoreduction with an accuracy of 80%. However, when this

Years from randomization

Patients at risk:

No lymphad. 211 177 136 104 78 56

Lymphad. 216 195 153 110 84 64

Years from randomization

Patients at risk:

No lymphad. 211 177 136 104 78 56

Lymphad. 216 195 153 110 84 64

Events

Totals

No lymphad. Lymphad.

99 103

211 X2 (log-rank): 0.0869 (P = .768)

Figure 7-18. Overall survival (OS) for patients with optimally debulked advanced ovarian carcinoma undergoing systematic aortic and pelvic lymphadenectomy (Lymphad.) versus resection of bulky nodes only (No lymphad.). Median OS times were 62.1 months (interquartile range = 30.9 months to still not reached) in the systematic lymphadenectomy arm and 56.3 months (interquartile range = 31.3 to 123.6 months) in the no-lymphadenectomy arm. (From Panici PB, Maggioni A, Hacker N, et al: Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial. J Natl Cancer Inst 97:560-566, 2005, Figure 3.)

model was applied to two previously published patient cohorts, the accuracy rates dropped to 27% and 60%, respectively. Reciprocally, when the CT models derived from the latter two studies were applied to the initial group of patients, the rates of accuracy fell from 93% and 79% to 65% and 69%, respectively. Some authors have used laparoscopy to establish the diagnosis and assess the resectability in patients with advanced epithelial ovarian cancer. Using diagnostic open laparoscopy, Angioli and colleagues34 were able to identify 53 patients who were deemed operable among 87 patients with advanced epithelial ovarian cancer. Optimal debulking, which was defined as complete absence of disease after cytoreduction, was achieved in 96% of these patients.

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