A score system for complete cytoreduction in selected recurrent ovarian cancer patients undergoing secondary cytoreductive surgery: predictors- and nomogram-based analyses

Giorgio Bogani; Elena Tagliabue; Mauro Signorelli; Antonino Ditto; Fabio Martinelli; Valentina Chiappa; Lavinia Mosca; Ilaria Sabatucci; Umberto Leone; Roberti Maggiore; Domenica Lorusso; Francesco Raspagliesi

doi:10.3802/jgo.2018.29.e40

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Bogani, Tagliabue, Signorelli, Ditto, Martinelli, Chiappa, Mosca, Sabatucci, Leone, Maggiore, Lorusso, and Raspagliesi: A score system for complete cytoreduction in selected recurrent ovarian cancer patients undergoing secondary cytoreductive surgery: predictors- and nomogram-based analyses

Original Article

J Gynecol Oncol 2018;29(3):e40.

Published online: 4 May 2018

DOI: https://doi.org/10.3802/jgo.2018.29.e40

A score system for complete cytoreduction in selected recurrent ovarian cancer patients undergoing secondary cytoreductive surgery: predictors- and nomogram-based analyses

Giorgio Bogani, Elena Tagliabue, Mauro Signorelli, Antonino Ditto, Fabio Martinelli, Valentina Chiappa, Lavinia Mosca, Ilaria Sabatucci, Umberto Leone, Roberti Maggiore, Domenica Lorusso, Francesco Raspagliesi

Department of Gynecologic Oncology, IRCCS National Cancer Institute, Milan, Italy

Correspondence to Lavinia Mosca Department of Gynecologic Oncology, IRCCS National Cancer Institute, Via Venezian 1, 20133 Milan, Italy. E-mail: laviniamosca@aol.it lavinia.mosca@istitutotumori.mi.it

Received 5 December 2017 Revised 11 January 2018 Accepted 31 January 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 test the applicability of the Arbeitsgemeinschaft Gynäkologische Onkologie (AGO) and Memorial Sloan Kettering (MSK) criteria in predicting complete cytoreduction (CC) in patients undergoing secondary cytoreductive surgery (SCS) for recurrent ovarian cancer (ROC).

Methods

Data of consecutive patients undergoing SCS were reviewed. The Arbeitsgemeinschaft Gynäkologische Onkologie OVARian cancer study group (AGO-OVAR) and MSK criteria were retrospectively applied. Nomograms, based on AGO criteria, MSK criteria and both AGO and MSK criteria were built in order to assess the probability to achieve CC at SCS.

Results

Overall, 194 patients met the inclusion criteria. CC was achieved in 161 (82.9%) patients. According to the AGO-OVAR criteria, we observed that CC was achieved in 87.0% of patients with positive AGO score. However, 45 out of 71 (63.4%) patients who did not fulfilled the AGO score had CC. Similarly, CC was achieved in 87.1%, 61.9% and 66.7% of patients for whom SCS was recommended, had to be considered and was not recommended, respectively. In order to evaluate the predictive value of the AGO-OVAR and MSK criteria we built 2 separate nomograms (c-index: 0.5900 and 0.5989, respectively) to test the probability to achieve CC at SCS. Additionally, we built a nomogram using both the aforementioned criteria (c-index: 0.5857).

Conclusion

The AGO and MSK criteria help identifying patients deserving SCS. However, these criteria might be strict, thus prohibiting a beneficial treatment in patients who do not met these criteria. Further studies are needed to clarify factors predicting CC at SCS.

Keywords: Ovarian Neoplasms, Recurrence, Cytoreduction Surgical Procedures

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Fig. 1.

OS according to CC at SCS. CC, complete cytoreduction; OS, overall survival; SCS, secondary cytoreductive surgery.

Fig. 2.

Nomogram displaying the probability of CC according to the variables included in the AGO-OVAR score.

AGO-OVAR, Arbeitsgemeinschaft Gynäkologische Onkologie OVARian cancer study group; CC, complete cytoreduction; ECOG, Eastern Cooperative Oncology Group; RD, residual disease.

Fig. 3.

Nomogram displaying the probability of CC according to the variables included in the modified MSK criteria. CC, complete cytoreduction; DFI, disease-free interval; MSK, Memorial Sloan Kettering.

Fig. 4.

Nomogram displaying the probability of CC according to the variables included in the AGO-OVAR score and MSK modified criteria. AGO-OVAR, Arbeitsgemeinschaft Gynäkologische Onkologie OVARian cancer study group; CC, complete cytoreduction; DFI, disease-free interval; ECOG, Eastern Cooperative Oncology Group; MSK, Memorial Sloan Kettering; RD, residual disease.

Table 1.

Main characteristics of the study population

Characteristics	Value
Age (yr)
Mean (SD)	61.6 (±12.5)
Median (quartiles^*)	63.0 (53, 71)
BMI (kg/m²)
Mean (SD)	24.7 (±4.2)
Median (quartiles^*)	25.4 (20, 36)
ECOG performance status
0	151 (77.8)
1	43 (22.2)
CA125 at first diagnosis (UI/L)
Mean (SD)	328.5 (±682.2)
Median (quartiles^*)	103 (42, 234.3)
Type of ovarian cancer
High-grade serous	140 (72.5)
Low-grade serous	4 (2.0)
Endometrioid	19 (9.8)
Clear cells	9 (4.6)
Undifferentiated	20 (10.3)
Mucinous	2 (1.0)
FIGO stage
I	5 (2.6)
II	9 (4.6)
III	139 (72.7)
IV	21 (10.8)
Unknown	20 (10.3)
RD
No macroscopic tumor at the end of	146 (75.2)
surgery (RD=0)
Macroscopic tumor at the end of surgery	42 (21.6)
(RD>0)
Unknown	6 (3.1)
Site of recurrent disease
Retroperitoneal	39 (20.1)
Single peritoneal	62 (31.9)
Multiple peritoneal	77 (39.7)
Carcinomatosis	16 (8.3)
Ascites
Yes	23 (11.9)
No	124 (63.9)
Unknown	47 (24.2)
DFI, (mo)
Mean (SD)	43.9 (±38.5)
Median (quartiles^*)	32.5 (18, 59.5)
Follow-up (mo)
Mean (SD)	32.2 (±20.9)
Median (quartiles^*)	26 (17, 43.7)

Values are presented as number (%). BMI, body mass index; CA125, cancer antigen 125; DFI, disease-free interval; ECOG, Eastern Cooperative Oncology Group; FIGO, International Federation of Gynecology and Obstetrics; RD, residual disease; SD, standard deviation.

^* Quartiles indicates the 25 and 75 percentiles.

Table 2.

Factors predicting complete cytoreduction at the time of secondary cytoreductive surgery

Characteristic	Univariate analysis		Multivariate analysis
Characteristic	OR (95% CI)	p-value	OR (95% CI)	p-value
Age (years)^*	1.01 (0.80–1.46)	0.616	–	–
BMI (kg/m²)^*	0.93 (0.84–1.17)	0.544	–	–
ECOG		0.22		–
ECOG 0	Reference		–
ECOG 1	0.59 (0.25–1.36)		–
Histotype		0.019		0.14
High-grade serous	Reference	–	Reference	–
Low grade serous & mucinous	0.31 (0.05–1.83)	0.198	0.45 (0.04–4.85)	0.508
Endometrioid	2.83 (0.36–22.42)	0.325	2.02 (0.23–17.77)	0.525
Clear cells	0.31 (0.07–1.36)	0.122	0.20 (0.03–1.23)	0.083
Undifferentiated	0.24 (0.09–0.65)	0.005	0.29 (0.09–1.00)	0.05
CA125 levels	0.99 (0.99–1.001)	0.266	–	–
Stage at presentation		N.E.		–
I–II	Reference		–
III–IV	N.E.		–
RD at primary cytoreductive surgery		0.037		0.239
RD0	Reference		Reference
RD>0	0.42 (0.19–0.95)		0.55 (0.20–1.49)
Site of recurrent disease		0.137
Peritoneal multiple site	Reference		–	–
Retroperitoneal	1.78 (0.54–5.87)	0.345	–	–
Peritoneal single site	1.06 (0.43–2.60)	0.905	–	–
Carcinomatosis	0.34 (0.11–1.10)	0.071
Ascites		0.086		0.138
No	Reference		Reference
Yes	0.43 (0.16–1.13)		0.44 (0.15–1.31)
Disease-free interval		0.019		0.43
<12 months	Reference		Reference
≥12 months	3.16 (1.21–8.26)		1.62 (0.49–5.36)

BMI, body mass index; CA125, cancer antigen 125; CI, confidence interval; ECOG, Eastern Cooperative Oncology Group; N.E., no estimate; OR, odds ratio; RD, residual disease.

^* OR per 10-year increase in age and one-unit increase in BMI.

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