Kushnir, Spirtos
Radiological predictors of cytoreductive outcomes in women with advanced ovarian cancer CL Kushnir, NM Spirtos The Women’s Cancer Center of Nevada, Division of Gynecologic Oncology, University of Nevada School of Medicine, Las Vegas, NV, USA Linked article: This is a mini commentary on J Borley et al., pp. 843–9 in this issue. To view this article visit http:// dx.doi.org/10.1111/1471-0528.12992. Published Online 20 October 2014. Use of radiological predictive tools is not universally accepted as a standard means to stratify patients to undergo either primary cytoreductive surgery or neoadjuvant chemotherapy. The accuracy of predicting a suboptimal surgical outcome (71– 93%) has not been reproducible (Axtell AE et al. J Clin Oncol 2007;25:384–9; Gemer O et al. Eur J Surg Oncol 2005;31:1006–10). In the two studies in which cross-validation was attempted, a significant decline in accuracy was noted when the method was applied to a new cohort of patients, raising serious misgivings regarding the applicability of such predictive models. Similar shortcomings are noted in this study by Borley et al. (BJOG 2014;Doi 10.1111/1471-0528.12992.). In the test set, 25% (12/48) of patients had a high-risk score, associated with suboptimal residual disease and 39% (11/27) of patients in the validation set had a high-risk score but still achieved optimal cytoreduction. The authors mistakenly conclude that a patient with a high-risk score should receive neoadjuvant chemotherapy followed by interval debulking without compromising overall survival. This conclusion can only be reached if the results published by Vergote et al. (N Engl J
850
Med 2010;363:943–53), were unquestionably accurate and reflective of the best surgical strategies available in the twenty-first century. The EORTC results have been widely debated and challenged with criticisms centring on the relatively poor survival in both arms of that study (median approximating 29– 30 months). These results pale in comparison to GOG #172 results, wherein patients were treated with either intravenous or intraperitoneal chemotherapy following optimal cytoreductive surgery and had median survivals of 50–66 months, respectively. (Armstrong DK et al. N Engl J Med 2006;354:34–43) Regardless of intent and the extent of the surgical effort, one unquestionable truth remains, those patient rendered disease free at the time of primary surgery, live significantly longer than those left with residual disease. One particular concern in this study is the 25% of the patient population deemed unresectable because of the presence of disease in the infra-renal lymph nodes. It is most unusual that disease present in this area cannot be removed in its entirety. Moreover, using this model, 39% of patients with resectable disease would probably have their survival compromised because they
would undergo neoadjuvant chemotherapy and be denied the opportunity to have their disease removed completely. Admirably, there was significant improvement in achieving optimal cytoreductive status (46.8–75.7%), and complete gross resection (30.45– 54.3%) noted by the authors. Subset analysis was performed to assess if this model could predict the amount of residual disease versus complete gross resection. The model performed worse, but to what extent, we do not know. What we do know is, as with previous validation studies, accuracy of predicting suboptimal cytoreduction remains unacceptably low; a maximal surgical effort to render patients disease-free, followed by intraperitoneal platinum-based chemotherapy, should be, after three randomised trials reported over the last 25 years demonstrating superior overall survival, the standard of care worldwide; and preoperative predictor models must be more accurate before, in good conscience, their use could be recommended on a routine basis.
Disclosure of interests The authors have nothing to disclose. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Radiological predictors of cytoreductive outcomes in women with advanced ovarian cancer CL Kushnir, NM Spirtos The Women’s Cancer Center of Nevada, Division of Gynecologic Oncology, University of Nevada School of Medicine, Las Vegas, NV, USA Linked article: This is a mini commentary on J Borley et al., pp. 843–9 in this issue. To view this article visit http:// dx.doi.org/10.1111/1471-0528.12992. Published Online 20 October 2014. Use of radiological predictive tools is not universally accepted as a standard means to stratify patients to undergo either primary cytoreductive surgery or neoadjuvant chemotherapy. The accuracy of predicting a suboptimal surgical outcome (71– 93%) has not been reproducible (Axtell AE et al. J Clin Oncol 2007;25:384–9; Gemer O et al. Eur J Surg Oncol 2005;31:1006–10). In the two studies in which cross-validation was attempted, a significant decline in accuracy was noted when the method was applied to a new cohort of patients, raising serious misgivings regarding the applicability of such predictive models. Similar shortcomings are noted in this study by Borley et al. (BJOG 2014;Doi 10.1111/1471-0528.12992.). In the test set, 25% (12/48) of patients had a high-risk score, associated with suboptimal residual disease and 39% (11/27) of patients in the validation set had a high-risk score but still achieved optimal cytoreduction. The authors mistakenly conclude that a patient with a high-risk score should receive neoadjuvant chemotherapy followed by interval debulking without compromising overall survival. This conclusion can only be reached if the results published by Vergote et al. (N Engl J
850
Med 2010;363:943–53), were unquestionably accurate and reflective of the best surgical strategies available in the twenty-first century. The EORTC results have been widely debated and challenged with criticisms centring on the relatively poor survival in both arms of that study (median approximating 29– 30 months). These results pale in comparison to GOG #172 results, wherein patients were treated with either intravenous or intraperitoneal chemotherapy following optimal cytoreductive surgery and had median survivals of 50–66 months, respectively. (Armstrong DK et al. N Engl J Med 2006;354:34–43) Regardless of intent and the extent of the surgical effort, one unquestionable truth remains, those patient rendered disease free at the time of primary surgery, live significantly longer than those left with residual disease. One particular concern in this study is the 25% of the patient population deemed unresectable because of the presence of disease in the infra-renal lymph nodes. It is most unusual that disease present in this area cannot be removed in its entirety. Moreover, using this model, 39% of patients with resectable disease would probably have their survival compromised because they
would undergo neoadjuvant chemotherapy and be denied the opportunity to have their disease removed completely. Admirably, there was significant improvement in achieving optimal cytoreductive status (46.8–75.7%), and complete gross resection (30.45– 54.3%) noted by the authors. Subset analysis was performed to assess if this model could predict the amount of residual disease versus complete gross resection. The model performed worse, but to what extent, we do not know. What we do know is, as with previous validation studies, accuracy of predicting suboptimal cytoreduction remains unacceptably low; a maximal surgical effort to render patients disease-free, followed by intraperitoneal platinum-based chemotherapy, should be, after three randomised trials reported over the last 25 years demonstrating superior overall survival, the standard of care worldwide; and preoperative predictor models must be more accurate before, in good conscience, their use could be recommended on a routine basis.
Disclosure of interests The authors have nothing to disclose. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
