Neo-adjuvant chemotherapy does not reduce surgical complexity nor the accuracy of intra-operative visual assessment of disease in advanced ovarian cancer

Aim: Compare the surgical complexity and histological accuracy of visual inspection of disease in patients un-dergoing primary debulking (PDS) versus delayed debulking surgery (DDS) following neo-adjuvant chemo-therapy (NACT) for advanced ovarian cancer (AOC).Materials and methods: All patients undergoing PDS or DDS for stage III / IV AOC at a UK cancer centre between January 2014-October 2021 were included. Retrospective data was collected accessing an electronic gynaeco-logical oncology database, operation and histology records. Comparative frequencies of surgical procedures performed were calculated for primary versus delayed cohorts; and correlation between intra-operative suspicion of disease and specimen histology at PDS and DDS compared.Results: N=232. PDS was performed in 45.3% and DDS in 54.7% of patients; achieving complete cytoreduction in 77.2%. Appendicectomy, pelvic and para-aortic nodal dissection were undertaken significantly more often at primary surgery; whilst right diaphragm stripping, pelvic peritonectomy, splenectomy and cholecystectomy were more likely following NACT. We found no variation in bowel resection rates between cohorts. For the majority of specimens, there was no difference in correlation between intra-operative suspicion of disease and final histo-pathology - with a significantly lower positive predictive value for visual assessment demonstrated only for liver capsule and pelvic peritoneum at DDS.Conclusion: NACT does not appear to reduce the complexity of surgery, including rates of bowel resection; nor accuracy of intra-operative visual assessment of disease. We therefore caution against both deferring to NACT to facilitate less radical delayed debulking; and any presumption that macroscopically abnormal tissue at DDS may represent inert post-NACT 'burn-out', mitigating indication for excision. We instead suggest reservation of the neo-adjuvant pathway for patients with poor PS and radiologically-confirmed surgical stopping points; and advocate equivalent and maximal cytoreductive effort to remove all visibly abnormal tissue in both the upfront and delayed surgical settings.

Automated summary

This study compares the surgical complexity and histological accuracy of primary debulking surgery (PDS) versus delayed debulking surgery (DDS) in patients with advanced ovarian cancer (AOC) after neo-adjuvant chemotherapy (NACT). The results show that NACT does not reduce the complexity of surgery or improve the accuracy of intra-operative visual assessment of disease. The study cautions against deferring to NACT for less radical delayed debulking and suggests that macroscopically abnormal tissue at DDS may not represent inert post-NACT tissue.