Survival impact of low anterior resection in patients with epithelial ovarian cancer grossly confined to the pelvic cavity: a Korean multicenter study

Miseon Kim; Dong Hoon Suh; Jeong-Yeol Park; E Sun Paik; Seungmee Lee; Kyung Jin Eoh; Joo-Hyun Nam; Yoo-Young Lee; Jae-Weon Kim; Sunghoon Kim

doi:10.3802/jgo.2018.29.e60

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Kim, Suh, Park, Paik, Lee, Eoh, Nam, Lee, Kim, and Kim: Survival impact of low anterior resection in patients with epithelial ovarian cancer grossly confined to the pelvic cavity: a Korean multicenter study

Original Article

J Gynecol Oncol 2018;29(4):e60.

Published online: 4 July 2018

DOI: https://doi.org/10.3802/jgo.2018.29.e60

Survival impact of low anterior resection in patients with epithelial ovarian cancer grossly confined to the pelvic cavity: a Korean multicenter study

Miseon Kim¹, Dong Hoon Suh¹, Jeong-Yeol Park^2,, E Sun Paik³, Seungmee Lee⁴, Kyung Jin Eoh⁵, Joo-Hyun Nam², Yoo-Young Lee³, Jae-Weon Kim⁴, Sunghoon Kim⁵

¹Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea

²Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

³Department of Obstetrics and Gynecology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

⁴Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea

⁵Department of Obstetrics and Gynecology, Yonsei University College of Medicine, Seoul, Korea

Correspondence to Jeong-Yeol Park Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea. E-mail: catgut1-0@hanmail.net

Received 2 November 2017 Revised 23 February 2018 Accepted 29 March 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Objective

To evaluate survival impact of low anterior resection (LAR) in patients with epithelial ovarian cancer (EOC) grossly confined to the pelvis.

Methods

We retrospectively reviewed 397 patients who underwent primary staging surgery for treatment of 2014 International Federation of Gynecology and Obstetrics (FIGO) stage II–IIIA EOC: 116 (29.2%) IIA, 212 (53.4%) IIB, and 69 (17.4%) IIIA. Patients with grossly enlarged retroperitoneal lymph nodes positive for metastatic carcinoma were excluded. Of 92 patients (23.2%) with gross tumors at the rectosigmoid colon, 68 (73.9%) underwent tumorectomy and 24 (26.1%), LAR for rectosigmoid lesions. Survival outcomes between patients who underwent tumorectomy and LAR were compared using Kaplan-Meier curves.

Results

During the median follow-up of 55 months (range, 1–260), 141 (35.5%) recurrences and 81 (20.4%) deaths occurred. Age (52.8 vs. 54.5 years, p=0.552), optimal debulking (98.5% vs. 95.0%, p=0.405), histologic type (serous, 52.9% vs. 50.0%, p=0.804), FIGO stage (p=0.057), and platinum-based adjuvant chemotherapy ≥6 cycles (85.3% vs. 79.2%, p=0.485) were not different between groups. No significant difference in 5-year progression-free survival (PFS; 57.9% vs. 62.5%, p=0.767) and overall survival (OS; 84.7% vs. 63.8%, p=0.087), respectively, was noted between groups. Postoperative ileus was more frequent in patients subjected to LAR than those who were not (4/24 [16.7%] vs. 11/373 [2.9%], p=0.001). The 5-year PFS (60.3% vs. 57.9%, p=0.523) and OS (81.8% vs. 87.7%, p=0.912) between patients who underwent tumorectomy and those who did not were also similar.

Conclusion

Survival benefit of LAR did not appear to be significant in EOC patients with grossly pelvis-confined tumors.

Keywords: Colectomy, Epithelial Ovarian Cancer, Progression-Free Survival

References

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Fig. 1.

(A) The 5-year PFS (64.9%, 60.8%, and 47.0%; p=0.136) and (B) 5-year OS (84.3%, 80.3%, and 80.6%; p=0.423) in the whole study population (n=397) (solid line: FIGO stage IIA; dotted line: FIGO stage IIB; and dot-and-dash line: FIGO stage IIIA). FIGO, International Federation of Gynecology and Obstetrics; OS, overall survival; PFS, progression-free survival.

Fig. 2.

(A) The 5-year PFS (57.9% vs. 62.5%, p=0.767) and (B) 5-year OS (84.7% vs. 63.8%, p=0.087) in patients who had rectosigmoid lesions (solid line: tumorectomy group [n=68]; dotted line: LAR group [n=24]). (C) The 5-year PFS (60.3% vs. 57.9%, p=0.523) and (B) 5-year OS (81.8% vs. 87.7%, p=0.912) in patients who did not receive LAR (solid line: no bowel surgery group [n=305]; dotted line: tumorectomy group [n=68]). LAR, low anterior resection; OS, overall survival; PFS, progression-free survival.

Table 1.

Patient characteristics (n=397)

Characteristics	Value
Age (yr)	51 (17–88)
Follow-up period (mo)	55 (1–260)
Preoperative CA-125 (U/mL)	161.0 (3.1–31,600.0)
Preoperative colonoscopy
No	197 (49.6)
Yes	200 (50.4)
Rectosigmoid lesions
Absent	305 (76.8)
Present	92 (23.2)
Rectum	51
Sigmoid colon	13
Unknown^*	28
Bowel surgery
No	305 (76.8)
Tumorectomy	68 (17.1)
LAR	24 (6.1)
Optimal debulking
No	10 (2.5)
Yes	335 (84.4)
Unknown^*	52 (13.1)
Histologic type
Serous	209 (52.6)
Non-serous	188 (47.4)
FIGO stage
IIA	116 (29.2)
IIB	212 (53.4)
IIIA	69 (17.4)
Adjuvant chemotherapy (cycles)	6 (0–20)
Adjuvant chemotherapy ≥6 cycles
No	62 (15.6)
Yes	335 (84.4)
Recurrence
No	256 (64.5)
Yes	141 (35.5)
Death
No	316 (79.6)
Yes	81 (20.4)

Values are presented as number (%) or median (range). CA-125, cancer antigen-125; FIGO, International Federation of Gynecology and Obstetrics; LAR, Low anterior resection.

^* Without descriptions on operation records.

Table 2.

Univariate and multivariate analysis for independent risk factors of survival outcomes (n=397)

Characteristics	Univariate		Multivariate
	HR (95% CI)	p	HR (95% CI)	p
PFS
Age ≥51 yr	0.973 (0.645–1.468)	0.898
Presence of rectosigmoid lesion	1.085 (0.668–1.761)	0.742
Invasion depth of rectosigmoid lesion > subserosa	1.846 (0.525–6.487)	0.339
Bowel surgery (tumorectomy vs. LAR)	1.238 (0.465–3.297)	0.669
Residual tumor ≥0.5 cm	1.828 (1.029–3.249)	0.040	1.716 (0.960–3.066)	0.068
Residual tumor ≥1.0 cm	1.226 (0.339–4.431)	0.756
Histology of non-serous	1.259 (0.834–1.901)	0.272
FIGO stage ≥ IIB	1.402 (0.881–2.230)	0.154	1.664 (0.995–2.784)	0.052
FIGO stage ≥ IIIA	1.299 (0.763–2.211)	0.334
OS
Age ≥51 yr	1.206 (0.739–1.966)	0.454
Presence of rectosigmoid lesion	1.111 (0.629–1.963)	0.717
Invasion depth of rectosigmoid lesion > subserosa	2.684 (0.739–9.746)	0.133	3.261 (0.838–12.692)	0.088
Bowel surgery (tumorectomy vs. LAR)	1.286 (0.430–3.844)	0.653
Residual tumor ≥0.5 cm	2.145 (1.136–4.048)	0.019	2.129 (1.124–4.033)	0.020
Residual tumor ≥1.0 cm	1.000 (0.208–4.818)	>0.999
Histology of non-serous	1.334 (0.818–2.177)	0.248
FIGO stage ≥ IIB	1.331 (0.761–2.328)	0.316
FIGO stage ≥ IIIA	1.103 (0.586–2.076)	0.762

CI, confidence interval; FIGO, International Federation of Gynecology and Obstetrics; HR, hazard ratio; LAR, low anterior resection; OS, overall survival; PFS, progression-free survival.

Table 3.

Comparisons of clinicopathologic factors (n=397)

Characteristics	No bowel surgery (n=305)	Tumorectomy (n=68)		LAR (n=24)		p^‡
Characteristics	No bowel surgery (n=305)	Value	p^*	Value	p^†	p^‡
Age (yr)	52.0±11.5	52.8±11.4	0.618	54.5±12.7	0.552	0.567
Preoperative CA-125 (U/mL)	671.3±1,607.7	702.9±1,042.2	0.885	2,120.4±6,552.6	0.302	0.008
Location of rectosigmoid lesions^¶	–		–		0.759	–
Rectum		33 (78.6)		18 (81.8)
Sigmoid colon		9 (21.4)		4 (18.2)
Optimal debulking^¶			0.463		0.405	0.942
No	8 (3.1)	1 (1.5)		1 (5.0)
Yes	249 (96.9)	67 (98.5)		19 (95.0)
Histologic type			0.982		0.804	0.851
Serous	161 (52.8)	36 (52.9)		12 (50.0)
Non-serous	144 (47.2)	32 (47.1)		12 (50.0)
FIGO stage			<0.001		0.057	<0.001
IIA	113 (37.0)	3 (4.4)		0
IIB	145 (47.5)	53 (77.9)		14 (58.3)
IIIA	47 (15.4)	12 (17.7)		10 (41.7)
Adjuvant chemotherapy (cycles)	5.8±1.8	5.9±1.6	0.760	5.5±2.5	0.568	0.774
Adjuvant chemotherapy ≥6 cycles			0.884		0.485	0.650
No	47 (15.4)	10 (14.7)		5 (20.8)
Yes	258 (84.6)	58 (85.3)		19 (79.2)
Recurrence			0.623		0.669	0.883
No	198 (64.9)	42 (61.8)		16 (66.7)
Yes	107 (35.1)	26 (38.2)		8 (33.3)
Death			0.913		0.652	0.612
No	244 (80.0)	54 (79.4)		18 (75.0)
Yes	61 (20.0)	14 (20.6)		6 (25.0)

Values are presented as number (%) or mean±standard deviations. CA-125, Cancer antigen-125; FIGO, International Federation of Gynecology and Obstetrics; LAR, Low anterior resection.

^* No bowel surgery vs. tumorectomy;

^† Tumorectomy vs. LAR;

^‡ Among 3 groups;

^¶ In patients with available data.

Table 4.

Operation-related outcomes and morbidity (n=397)

Characteristics	No LAR (n=373)	LAR (n=24)	p
Operation time (min)	232.7±80.6	390.4±142.8	<0.001
Estimated blood loss (mL)	570.2±539.0	856.3±753.3	0.015
Ileus			0.001
No	362 (97.1)	20 (83.3)
Yes	11 (2.9)	4 (16.7)
Bowel leakage			>0.999
No	372 (99.7)	24 (100.0)
Yes	1 (0.3)	0
Fever >3 days			0.519
No	365 (97.9)	23 (95.8)
Yes	8 (2.1)	1 (4.2)
Wound dehiscence			0.271
No	355 (95.2)	24 (100.0)
Yes	18 (4.8)	0

LAR, low anterior resection.

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