SURGERY OF RECURRENCIES

Transcription

1 La chirurgia Bergamo, delle 6 th May recidive 2011 SURGERY OF RECURRENCIES Pierluigi Benedetti Panici Calcagno Marco, Gasparri Maria Luisa, Domenici Lavinia, Bellati Filippo

2 CANCRO EPITELIALE DELL OVAIO: Ovarian Cancer: Epidemiology INCIDENZA Europe: 5% female tumors Estimated New Cases Ovary 22,430 3% Estimated Deaths Ovary 15,280 6% Estimated New Cases Ovary 8,550 Estimated Deaths Ovary 2,800 Estimated Recurrences 2000 Linee Guida AIOM % Age y Jemal A, Cancer Statistics 2009 Heintz AP Int J Gyn Obstet 2006 Boyle P, J Epidemiol Biostat 1998

3 Survival (mo) PROGRESS IN OVARIAN CANCER Progress in ovarian cancer Median Survival Increase in AOC patients over the past two decades YEAR Spriggs D CHT in Gyn Neopl 2005

4 Markman M., Gynecol Oncol, 2007 End Points of Second Line Treatment When patients recur, the goal of therapy changes from curative to palliative. Recurrent ovarian cancer invariably is FATAL Ozols RF. JCO 2002 Recurrent/Resistant ovarian cancer, in many individuals, can be reasonably considered a very serious CHRONIC DISEASE PROCESS Prolong Survival Markman M. Int J Gynecol Cancer 2009 Delay Time to Progression Control Disease-Related Symptoms Minimize Symptoms Maintain or Improve Quality of Life

5 RECURRENT OVARIAN CANCER (roc) Modi THERAPEUTIC per trattare OPTIONS la recidiva

6 Role Of Secondary Cytoreductive Surgery No patients: 106 DFI RT >36 mo 6-12 mo P= mo P= RT > 0 RT = 0 DFI (months) > Median Survival (months) RT RT > RT = Median Survival (months) Eisenkop SM et al. Cancer 2000

7 157 Platinum-Sensitive Recurrent OC pts Guidelines and Selection Criteria for Secondary Cytoreduction The DFI and the number of recurrence sites should be used as selection criteria to offer secondary cytoreduction DFI 6-12 mo mo 39 mo.005 >30 mo Median OS 30 mo 51 mo P INDIPENDENT PROGNOSTIC FACTORS N site recurr. Single Multiple 42 mo <.001 Carcinom Median OS 60 mo 28 mo P DFI Single site Multiple Sites No carcinomatosis 6-12 mth Offer SC Consider SC No SC Carcinomatosis mth Offer SC Offer SC Consider SC >30 mth Offer SC Offer SC Offer SC Chi DS, Cancer 2006

8 Cytoreductive surgery for recurrent ovarian cancer: a meta-analysis RT=0 Complete cytoreductive surgery is indepentently associated with overall post recurrence survival time Each 10% increase in the proportion of patients left with optimal residual disease was associated with 2,69 months increase in median survival time. Bristow R. Gyn Oncol 2009

9 DESKTOP I Trial: Comparison of pts with and without PERITONEAL CARCINOSIS and complete debulking Feasibility of optimal cytoreduction 92 pts 33 pts NPC : 92/125 pts 74% PC: 33/125 pts 26% Tot. Pts 250 NPC=Non Peritoneal carcinosis PC=Peritoneal carcinosis Harter P, Ann Surg Oncol 2009

10 DESKTOP III Study A randomized trial evaluating cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer Strata: Platinum-free interval 6-12 mo vs 12 mo 1 line platinum-based CT: yes/no R A N D O M Cytoreductive surgery No surgery platinum-based chemotherapy* recommended * Recommended platinum-based chemotherapy regimens: - carboplatin/paclitaxel - carboplatin/gemcitabine - carboplatin/pegliposomal doxorubicin - or other platinum combinations in prospective trials Primary Objective: OS Secondary Objectives: PFS, QoL, CRR, Surgical Complications

11 FOLLOW-UP: PET- TC vs TC influenced management in 58.9% of cases detected many more lesions within and outside the abdomen than abdominal and pelvic CT was superior to abdominal and pelvic CT in the detection of nodal, peritoneal and subcapsular liver disease (90,1 % vs 79,6%) Sunit Sebastian et al., Abdom Imaging 2008 Fulham M.J.et al., Gynec Oncol 2009

12 ROLE OF LAPAROSCOPY IN PREDICTING OPTIMAL CYTOREDUCTION IN SCS LPS : 58 pts CT: 11 pts not avaible for surgery Surgery : 47 pts RT>2 2 pts (4%) 1<RT<2 4 pts (8,5%) RT<1 4 pts (8,5%) Accurancy of LPS: 87,5% RT= 0 37 pts (79%) Benedetti Panici P. Ann. Surg. Onc. 2007

13 2007: Our Experience on Secondary Cytoreduction OS 49 mo 47 Platinum-Sensitive Recurrent OC pts P=0.02 RT=0 RT>0 CA125<35 Variables not SIGNIF. influencing survival: DFI NACT N sites of recurrence Site of recurrence Histology Tumour grade RT at first surgery P=0.04 CA125>35 Benedetti Panici P, Ann Surg Oncol 2007

14 Tertiary Cytoreduction 135 roc pts Surgical Results (3 Cytor.) RT>2 45 pts (33.3%) RT pts (6%) RT 1 28 pts (20.7%) RT =0 53 pts (39.3%) Median OS: 19.1 mo nths Fotopoulou C, Sehouli J, Ann Surg Oncol 2010

15 Tertiary Cytoreduction: Our Experience 14 pts 3 cytoreduction 22 roc pts LPS Type of surgery at TCR Benedetti Panici P. submitted 8 pts 3 line ChT Large Bowel Resection 6 Peritoneal stripping 1 Liver resection 2 Lymphadenectomy 4 Splenectomy 2 N pts Surgical Results RT >2 4 pts (28.6%) RT = pts (28.6%) RT = 0 6 pts (42.8%) Mean Operative Time Mean Blood Loss Median Intraop and Postop transfusions OPERATIVE DATAS 196 min ( min) 692 ml( ml) 0 (0-2) Median Hospital Stay 8 days (3-31) Intraoperative Complications 3 (21,4%) 1 cava vein lesion 1 small bowel perforation 1 bladder lesion Postoperative Complications 2 (14,2%) 1 wound dehiscence 1 deep vein thrombosis

16 Tertiary Cytoreduction: Our Experience 3 Cytored P= line CT RT=0 Median Survival: Surg: 23 mo nths CT: 12 months RT>0 P= Benedetti Panici P, submitted

17 Shih KK, Chi DS, Gynecol Oncol 2010 Beyond Tertiary Cytoreduction roc pts, all optimally (RT 0.5 cm) debulked at 3 th cytoreduction RT 1 cm RT > 1 cm Single (n=8) Multiple (n=7) P=0.008 P=0.01

18 Beyond Tertiary Cytoreduction...Our Experience N pts 12 roc pts, previously debulked at 3 th cytoreduction RT=0 Median DFI Median OS Current status mo 18.6 mo 3 DOD 9 ED N (%) Pts with complications 5 (42%) Total n of complications 8 (66%) Wound Dehiscence/Cellulitis 3 (25%) Abdominal Abscess 2 (16%) Pancreatic leak 1 (8%) Symptomatic lymphocele 1 (8%) Pleural effusion 1 (8%) Treatment-related COMPLICATIONS Benedetti Panici P, submitted

19 Complications Rate Complications rate and OS trend based on number of cytoreductive surgeries 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 6% 6% 19% Median OS: 49mo 27% 21% Median OS: 23mo 47% 42% Median OS: 19mo 1st Cytored 2nd Cytored 3rd Cytored 4th Cytored Our Experience

20 Sites of Recurrence: Splenic Recurrence Our experience N of pts 24 Spleen Recurrent Site Solitary (9 pts) Intraparen. 6 - Hylar. 3 9 Superficial - 6 Multiple (15 pts) Median Operative Time: 155 min Median Postop Hospital Stay: 6 days Benedetti Panici P, Bellati F, et al. Ann Surg Oncol 2006

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22 UPPER CENTRAL ABDOMEN DEBULKING

23 SPLENECTOMY: our experience ASSOCIATED SURGICAL PROCEDURES AT CYTOREDUCTION 16/25 Pts PROCEDURES* (67%) DISTAL PANCREATECTOMY 8 (34%) PARTIAL GASTRECTOMY 1 (4%) PARTIAL HEPATECTOMY 2(8%) DIAPHRAGMATIC RESECTION 11 (46%) LARGE BOWEL RESECTION 5 (21%) SMALL BOWEL RESECTION 2(8%) LYMPHADENECTOMY 2 (8%)

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25 Liver resection for recurrent ovarian cancer: our experience N of pts 18 Type of liver resection wedge 12 segmentectomy 5 lobe 1 Median blood loss 600 ml (range ) Major complications 2 Median survival (ys) 2.9 Benedetti Panici and Berloco 2010

26 HEPATIC METASTASECTOMY

27 HEPATIC METASTASECTOMY

28 RIGHT UPPER ABDOMEN DEBULKING

29 DIAPHRAGMATIC SURGERY

30 DIAPHRAGMATIC SURGERY

31 DIAPHRAGMATIC SURGERY TRANS-DIAPHRAGMATIC DECOMPRESSION OF PNEUMOTHORAX DURING CYTOREDUCTIVE SURGERY FOR OVARIAN CANCER

32 Lymph Node Recurrence: Bulky lymph node resection Inclusion criteria: DFI > 6 months Bulky lymph node recurrence Pts s consent to adjuvant CT 49 pts 20 pts: Not Cytoriducible 29 pts: Cytoriducible 17 pts: system lymphadenect 12 pts: system lymphadenect + resection of macroscopic disease Benedetti Panici, Perniola Int J Gynecol Cancer 2007

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35 Conclusions Patients Selection is very important when adressing to recurrence surgery PET-scan is important for early diagnosis LPS maybe has a role in selection of patients Optimal residual tumor at surgery is associated with a good overall survival. Cytoreductive surgery for recurrent disease should be performed in Refferal Centres (lower complications rate) Secondary but also tertiary, quaternary cytoreduction is possible.

36 Università di Roma Sapienza