Guaglio Marcello

Multisocietal Consensus on the Use of Cytoreductive Surgery and HIPEC for the Treatment of Epithelial Ovarian Cancer: A GRADE Approach for Evidence Evaluation and Recommendation

ABSTRACTIntroductionThe locoregional treatment of high grade serous ovarian cancer (HGSOC) comprises of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Recent evidence form randomized trials, has led to controversy related to the use of HIPEC in addition to interval CRS (iCRS) and the role of secondary CRS (sCRS) in patients with the first platinum‐sensitive recurrence from high‐grade serous ovarian cancer (HGSOC). This multi‐society consensus, coordinated by the Peritoneal Surface Oncology Group International (PSOGI) with inputs from ISSPP, SSO, ESSO, and IGCS, evaluated the role of these interventions using the GRADE ADOLOPMENT methodology.Patients and MethodsAn international expert panel reviewed evidence for the use of HIPEC in addition to iCRS in stage 3 high grade serous ovarian cancer (HGSOC) and the role of sCRS for patients with platinum‐sensitive recurrent HGSOC. A systematic review assessed randomized controlled trials (RCTs) for recurrence‐free survival (RFS), overall survival (OS), safety, and quality of life (QoL). Recommendations were formulated using the GRADE Evidence‐to‐Decision framework.ResultsHIPEC in addition to iCRS was strongly recommended based on the results of the OVHIPEC‐1 trial, which showed significant benefit in RFS (3.5 months) and OS (12 months) without increasing the grade 3–4 morbidity. For the first platinum‐sensitive recurrence, a conditional recommendation was made either for sCRS with systemic therapy or systemic therapy alone, reflecting variability in trial outcomes due to heterogeneity in the patient population in the trials and lack of surgical standardization.ConclusionThis consensus highlights the benefits of HIPEC in addition of iCRS and key factors that limit its wide‐spread use. It underlines the need for individualized decision‐making while selecting patients for sCRS. Future research integrating advanced systemic therapies is essential to refine these recommendations and provide equitable access to these complex locoregional treatments.

Impact of Previous Gynecologic Surgical Procedures on Outcomes of Non-Gynecologic Peritoneal Malignancies Mimicking Ovarian Cancer: Less Is More?

Non-gynecologic rare peritoneal surface malignancies (PSMs) often are misdiagnosed as disseminated ovarian cancer and initially treated by gynecologic surgeons. This study aimed to assess whether these previous maneuvers (i.e., full surgical staging and/or cytoreductive attempts) affect outcomes after the definitive surgery performed in a tertiary center. The study reviewed 298 women affected by non-gynecologic PSM who underwent cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) after previous gynecologic surgery. Prior surgery was categorized as limited surgery (pLS: abdominal exploration with biopsy plus adnexectomy and/or appendectomy) or extended surgery (pES: full surgical staging or cytoreductive attempts including hysterectomy with bilateral salpingo-oophorectomy). Of the 298 patients, 143 had pLS and 153 had pES. Morbidity was similar between the groups (P = 0.143), but the pES group had more severe urinary tract injuries (19 vs. 3; P < 0.001), longer operating time (585.9 vs. 506.7; P = 0.027), and more patients needing more than two anastomoses (41 vs. 26; P = 0.033). Age older than 55 years (odds ratio [OR] 2.42; P = 0.009) and number of anastomoses (OR 3.17; P = 0.002) correlated with severe morbidity; pES correlated with urinary tract grades 3 and 4 injuries (OR 7.9; P = 0.001). The 5-year cumulative incidence of locoregional relapse was significantly higher in the pES group (0.41 vs. 0.27; P = 0.012; median follow-up period, 69 months). The multivariate analysis identified a Peritoneal Carcinomatosis Index (PCI) higher than 20 and pES as independent risk factors. For women undergoing CRS±HIPEC for non-gynecologic PSM, the risk for locoregional relapse and severe postsurgical urinary tract complications is increased by pES. Therefore, prior full surgical staging or cytoreductive attempts without definitive gynecologic histology should be avoided. Prophylactic ureteral stenting and stricter oncologic follow-up assessment must be considered in this scenario.

ASO Author Reflections: Preoperative Staging for Nongynecological Peritoneal Malignancies Mimicking Ovarian Cancer—Making the Omelet without Breaking the Eggs