ASO Author Reflections: Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer
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ASO AUTHOR REFLECTIONS
ASO Author Reflections: Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer Claudia Marchetti, MD, PhD1, Anna Fagotti, MD, PhD1,2, Giovanni Scambia, FP, PhD1,2, and Francesca De Felice, MD, PhD3 1
Department of Woman and Child Sciences, Fondazione Policlinico Universitario Agostino Gemelli, IRCCS, Rome, Italy; Catholic University of the Sacred Heart, Rome, Italy; 3Department of Radiotherapy, Policlinico Umberto I, ’’Sapienza’’ University of Rome, Rome, Italy
2
PAST Treatment of platinum-sensitive recurrences in ovarian cancer is evolving. While medical management has been well-defined with platinum-based doublets, often followed by maintenance therapy, the role of secondary cytoreductive surgery has been unclear and controversial for years. Only recently, three randomized clinical trials have been completed to establish whether the addition of secondary cytoreductive surgery to systemic therapy improves survival outcomes of platinum-sensitive recurrent ovarian cancer.1–3 PRESENT Our meta-analysis, including the three randomized trials and, overall, 1250 patients, compared secondary cytoreductive surgery followed by chemotherapy with chemotherapy alone.4 In the overall population, despite similar overall survival (OS; hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.78–1.10, p = 0.37), a higher progression-free survival (PFS) rate was noted among patients treated with surgery before medical treatment (HR 0.69, 95% CI 0.61–0.78, p \ 0.001). In patients receiving surgical complete
Ó Society of Surgical Oncology 2020 First Received: 30 September 2020 Accepted: 4 October 2020 F. De Felice, MD, PhD e-mail: [email protected]
resection, with no residual disease, we found an absolute PFS and OS benefit (HR 0.56, 95% CI 0.48–0.66; and HR 0.73, 95% CI 0.59–0.91, respectively). FUTURE Based on the results of this meta-analysis, the role of complete surgical approach in platinum-sensitive recurrent ovarian cancer is established, as for the primary setting. Conversely, no value is shown for secondary surgery with any residual disease. To achieve this goal, preoperative assessment of the feasibility of complete tumor removal is of utmost importance and should be further improved with additional research on this topic. Indeed, only 50% of the platinum-sensitive recurrent ovarian cancers have a positive AGO score and only 75% can be completely resected. Moreover, if we assume that the lower the tumor burden, the higher the chances of removing all the visible disease, the current guidelines of follow-up in ovarian cancer should probably be revisited as they do not routinely recommend radiological investigation for ovarian cancer surveillance.5 Indeed, early detection of ovarian cancer recurrence might reduce the risk of finding a disseminated and probably unresectable disease. Lastly, most of the available data about secondary cytoreductive surgery come from the era before the advent of maintenance therapies, either with bevacizumab or poly(ADP)-ribose polymerase (PARP) inhibitors. The
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