Download PDF
TumorDiagnostik & Therapie 2021; 42(01): 53-61
DOI: 10.1055/a-1334-2575
Thieme Onkologie aktuell

Stellenwert der präoperativen Computertomografie für die Prädiktion einer optimalen Zytoreduktion beim fortgeschrittenen Ovarialkarzinom

The Significance of Preoperative Computed Tomography for Predicting Optimal Cytoreduction in Advanced Ovarian Cancer
Angrit Stachs
1   Gynäkologische Radiologie, University of Rostock, Rostock, Germany
,
Karen Engel
2   University of Rostock, Rostock, Germany
,
Johannes Stubert
3   Universitätsfrauenklinik, University of Rostock, Rostock, Germany
,
Toralf Reimer
3   Universitätsfrauenklinik, University of Rostock, Rostock, Germany
,
Bernd Gerber
3   Universitätsfrauenklinik, University of Rostock, Rostock, Germany
,
Max Dieterich
3   Universitätsfrauenklinik, University of Rostock, Rostock, Germany
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Zusammenfassung

Einleitung Eine optimale Zytoreduktion ist der wichtigste Prognosefaktor beim fortgeschrittenen Ovarialkarzinom. Obwohl Stadieneinteilung und Einschätzung der Operabilität durch Explorativ-Operation erfolgen, gilt die präoperative Computertomografie (CT) des Abdomens als Standard. Ziel dieser Studie ist die Überprüfung verschiedener CT-Parameter hinsichtlich der Prädiktion einer optimalen Zytoreduktion.

Patienten und Methoden In die retrospektive Studie wurden 131 Patientinnen mit zwischen 2010 bis 2014 neu diagnostiziertem Ovarialkarzinom aufgenommen. Davon wurden n = 36 im FIGO-Stadium I bis IIB aus der Studie ausgeschlossen. Von den 95 Patientinnen mit FIGO-Stadium IIC bis IV lagen bei n = 75 präoperative CT-Abdomen vor. Die CT-Scans wurden einem verblindeten Review unterzogen. Die evaluierten 11 CT-Parameter wurden mittels χ2-Test und logistischer Regressionsanalyse hinsichtlich der Endpunkte makroskopischer Tumorrest sowie Tumorrest > 1 cm überprüft. Überlebensanalysen erfolgten mittels Kaplan-Meier-Methode und Log-Rank-Test.

Ergebnisse Von 75 Patientinnen hatten 28 (37,3 %) eine vollständige Tumorresektion und 26 (34,7 %) Tumorreste ≤ 1 cm. Tumorreste > 1 cm fanden sich bei 21 Patientinnen (28 %), davon waren 5 nicht resektabel. Das Gesamtüberleben bei Tumorrest > 1 cm unterschied sich signifikant von der Gruppe mit makroskopischer Tumorfreiheit (p = 0,003) bzw. Tumorrest ≤ 1 cm (p = 0,04). Die CT-Parameter Tumorherde am Diaphragma, Mesokolon, Omentum majus, Peritoneum sowie Aszites korrelierten mit makroskopischem Tumorrest. In der multivariaten logistischen Regressionsanalyse war lediglich hinsichtlich der Prädiktion einer suboptimalen Tumorresektion (> 1 cm) der CT-Parameter intraparenchymatöse Lebermetastase statistisch signifikant (OR 8,04; 95 %-KI 1,57–42,4; p = 0,0134). Sensitivität, Spezifität, PPV und NPV betragen 37,5, 89,7, 66,7 und 72,2 %.

Schlussfolgerung Obwohl mittels CT Abdomen Risikoparameter für suboptimale Tumorreduktion identifizierbar sind, ist wegen der geringen diagnostischen Genauigkeit die chirurgische Exploration mit histologischer Diagnosesicherung unverzichtbar.

Abstract

Introduction Optimal cytoreduction is the most important prognostic factor in advanced ovarian cancer. Although staging and assessment of operability are made by exploratory surgery, preoperative computed tomography (CT) of the abdomen is regarded as standard. The aim of this study was to examine various CT parameters with regard to prediction of optimal cytoreduction.

Patients and Methods The retrospective study included 131 patients with ovarian cancer newly diagnosed between 2010 and 2014. Of these, n = 36 with FIGO stage I to IIB were excluded from the study. A preoperative abdominal CT was available for n = 75 of the 95 patients with FIGO stage IIC to IV. The CT scans underwent blinded review. The 11 evaluated CT parameters were examined by means of χ2 test and logistic regression analysis with regard to the endpoints of macroscopic residual tumour and residual tumour > 1 cm. Survival analyses used the Kaplan-Meier method and log rank test.

Results Of 75 patients, 28 (37.3 %) had complete tumour resection and 26 (34.7 %) had residual tumour ≤ 1 cm. Residual tumours > 1 cm were found in 21 (28 %) patients, five of which were not resectable. Overall survival with residual tumour > 1 cm differed significantly from the group with no macroscopic residual tumour (p = 0.003) and with residual tumour ≤ 1 cm (p = 0.04). The CT parameters tumour foci in the diaphragm, mesocolon, greater omentum and peritoneum as well as ascites correlated with macroscopic residual tumour. In the multivariate logistic regression analysis only the CT parameter intraparenchymal liver metastasis was statistically significant with regard to prediction of suboptimal tumour resection (> 1 cm) (OR 8.04; 95 % CI 1.57–42.4; p = 0.0134). The sensitivity, specificity, PPV and NPV were 37.5, 89.7, 66.7 and 72.2 %.

Conclusion Although risk parameters for suboptimal tumour reduction can be identified by CT of the abdomen, surgical exploration with histological confirmation of the diagnosis is essential because of the poor diagnostic accuracy.

Schlüsselwörter

Ovarialkarzinom - Computertomografie - R0-Resektion - Debulking-Operation

Key words

ovarian cancer - computed tomography - R0 resection - debulking surgery


Publication History

Article published online:
28 January 2021

© 2020. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Robert Koch-Institut. Krebs in Deutschland für 2015/2016. Berlin: Robert Koch-Institut; 2019
    PubMedGoogle Scholar
  • 2 du Bois A, Reuss A, Pujade-Lauraine E. et al. Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe dʼInvestigateurs Nationaux Pour les Etudes des Cancers de lʼOvaire (GINECO). Cancer 2009; 115: 1234-1244
    CrossrefPubMedGoogle Scholar
  • 3 Vergote I, Tropé CG, Amant F. et al. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med 2010; 363: 943-953
    CrossrefPubMedGoogle Scholar
  • 4 Tangjitgamol S, Manusirivithaya S, Laopaiboon M. et al. Interval debulking surgery for advanced epithelial ovarian cancer. Cochrane Database Syst Rev 2013; 4: CD006014
    PubMedGoogle Scholar
  • 5 Kehoe S, Hook J, Nankivell M. et al. Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet 2015; 386: 249-257
    CrossrefPubMedGoogle Scholar
  • 6 Onda T, Satoh T, Ogawa G. et al. Comparison of survival between primary debulking surgery and neoadjuvant chemotherapy for stage III/IV ovarian, tubal and peritoneal cancers in phase III randomised trial. Eur J Cancer 2020; 130: 114-125
    CrossrefPubMedGoogle Scholar
  • 7 Fagotti A, Ferrandina G, Vizzielli G. et al. Phase III randomised clinical trial comparing primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load (SCORPION trial): Final analysis of peri-operative outcome. Eur J Cancer 2016; 59: 22-33
    CrossrefPubMedGoogle Scholar
  • 8 Leitlinienprogramm-Onkologie. Leitlinien/Ovarialkarzinom. 01/2019. ed: AWMF. 2019. Online (last access: 31.03.2020): https://www.awmf.org/uploads/tx_szleitlinien/032-035OLl_S3_Ovarialkarzinom_2020-04.pdf
    PubMedGoogle Scholar
  • 9 Du Bois AJS, Vergote I, Ferron G. et al. Randomized phase III study to evaluate the impact of secondary cytoreductive surgery in recurrent ovarian cancer: Final analysis of AGO DESKTOP III/ENGOT-ov20. J Clin Oncol 2020; 38 (Suppl.) Abstr. 6000 DOI: 10.1200/JCO.2020.38.15_suppl.6000.
    CrossrefPubMedGoogle Scholar
  • 10 Nam EJ, Yun MJ, Oh YT. et al. Diagnosis and staging of primary ovarian cancer: correlation between PET/CT, Doppler US, and CT or MRI. Gynecol Oncol 2010; 116: 389-394
    CrossrefPubMedGoogle Scholar
  • 11 Yuan Y, Gu ZX, Tao XF. et al. Computer tomography, magnetic resonance imaging, and positron emission tomography or positron emission tomography/computer tomography for detection of metastatic lymph nodes in patients with ovarian cancer: a meta-analysis. Eur J Radiol 2012; 81: 1002-1006
    CrossrefPubMedGoogle Scholar
  • 12 Byrom J, Widjaja E, Redman CW. et al. Can pre-operative computed tomography predict resectability of ovarian carcinoma at primary laparotomy?. BJOG 2002; 109: 369-375
    CrossrefPubMedGoogle Scholar
  • 13 Bristow RE, Duska LR, Lambrou NC. et al. A model for predicting surgical outcome in patients with advanced ovarian carcinoma using computed tomography. Cancer 2000; 89: 1532-1540
    CrossrefPubMedGoogle Scholar
  • 14 Nelson BE, Rosenfield AT, Schwartz PE. Preoperative abdominopelvic computed tomographic prediction of optimal cytoreduction in epithelial ovarian carcinoma. J Clin Oncol 1993; 11: 166-172
    CrossrefPubMedGoogle Scholar
  • 15 Dowdy SC, Mullany SA, Brandt KR. et al. The utility of computed tomography scans in predicting suboptimal cytoreductive surgery in women with advanced ovarian carcinoma. Cancer 2004; 101: 346-352
    CrossrefPubMedGoogle Scholar
  • 16 Jung DC, Kang S, Kim MJ. et al. Multidetector CT predictors of incomplete resection in primary cytoreduction of patients with advanced ovarian cancer. Eur Radiol 2010; 20: 100-107
    CrossrefPubMedGoogle Scholar
  • 17 Gemer O, Gdalevich M, Ravid M. et al. A multicenter validation of computerized tomography models as predictors of non-optimal primary cytoreduction of advanced epithelial ovarian cancer. Eur J Surg Oncol 2009; 35: 1109-1112
    CrossrefPubMedGoogle Scholar
  • 18 Axtell AE, Lee MH, Bristow RE. et al. Multi-institutional reciprocal validation study of computed tomography predictors of suboptimal primary cytoreduction in patients with advanced ovarian cancer. J Clin Oncol 2007; 25: 384-389
    CrossrefPubMedGoogle Scholar
  • 19 Harter P, Sehouli J, Lorusso D. et al. A Randomized Trial of Lymphadenectomy in Patients with Advanced Ovarian Neoplasms. N Engl J Med 2019; 380: 822-832
    CrossrefPubMedGoogle Scholar
  • 20 Winter WE, Maxwell GL, Tian C. et al. Prognostic factors for stage III epithelial ovarian cancer: a Gynecologic Oncology Group Study. J Clin Oncol 2007; 25: 3621-3627
    CrossrefPubMedGoogle Scholar
  • 21 Elattar A, Bryant A, Winter-Roach BA. et al Optimal primary surgical treatment for advanced epithelial ovarian cancer. Cochrane Database Syst Rev 2011; (08) CD007565
    PubMedGoogle Scholar
  • 22 Harter P, Muallem ZM, Buhrmann C. et al. Impact of a structured quality management program on surgical outcome in primary advanced ovarian cancer. Gynecol Oncol 2011; 121: 615-619
    CrossrefPubMedGoogle Scholar
  • 23 Horowitz NS, Miller A, Rungruang B. et al. Does aggressive surgery improve outcomes? Interaction between preoperative disease burden and complex surgery in patients with advanced-stage ovarian cancer: an analysis of GOG 182. J Clin Oncol 2015; 33: 937-943
    CrossrefPubMedGoogle Scholar
  • 24 Wright AA, Bohlke K, Armstrong DK. et al. Neoadjuvant Chemotherapy for Newly Diagnosed, Advanced Ovarian Cancer: Society of Gynecologic Oncology and American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol 2016; 34: 3460-3473
    CrossrefPubMedGoogle Scholar
  • 25 Meyer JI, Kennedy AW, Friedman R. et al. Ovarian carcinoma: value of CT in predicting success of debulking surgery. Am J Roentgenol 1995; 165: 875-878
    CrossrefPubMedGoogle Scholar
  • 26 Qayyum A, Coakley FV, Westphalen AC. et al. Role of CT and MR imaging in predicting optimal cytoreduction of newly diagnosed primary epithelial ovarian cancer. Gynecol Oncol 2005; 96: 301-306
    CrossrefPubMedGoogle Scholar
  • 27 Kebapci M, Akca AK, Yalcin OT. et al. Prediction of suboptimal cytoreduction of epithelial ovarian carcinoma by preoperative computed tomography. Eur J Gynaecol Oncol 2010; 31: 44-49
    PubMedGoogle Scholar
  • 28 Chesnais M, Lecuru F, Mimouni M. et al. A pre-operative predictive score to evaluate the feasibility of complete cytoreductive surgery in patients with epithelial ovarian cancer. PLoS One 2017; 12: e0187245
    CrossrefPubMedGoogle Scholar
  • 29 Ferrandina G, Sallustio G, Fagotti A. et al. Role of CT scan-based and clinical evaluation in the preoperative prediction of optimal cytoreduction in advanced ovarian cancer: a prospective trial. Br J Cancer 2009; 101: 1066-1073
    CrossrefPubMedGoogle Scholar
  • 30 Borley J, Wilhelm-Benartzi C, Yazbek J. et al. Radiological predictors of cytoreductive outcomes in patients with advanced ovarian cancer. BJOG 2015; 122: 843-849
    CrossrefPubMedGoogle Scholar
  • 31 Chang SJ, Hodeib M, Chang J. et al. Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. Gynecol Oncol 2013; 130: 493-498
    CrossrefPubMedGoogle Scholar
  • 32 Ricciardi E, Baert T, Ataseven B. et al. Low-grade Serous Ovarian Carcinoma. Geburtshilfe Frauenheilkd 2018; 78: 972-976
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 Gómez-Hidalgo NR, Martinez-Cannon BA, Nick AM. et al. Predictors of optimal cytoreduction in patients with newly diagnosed advanced-stage epithelial ovarian cancer: Time to incorporate laparoscopic assessment into the standard of care. Gynecol Oncol 2015; 137: 553-558
    CrossrefPubMedGoogle Scholar
  • 34 Fagotti A, Fanfani F, Ludovisi M. et al. Role of laparoscopy to assess the chance of optimal cytoreductive surgery in advanced ovarian cancer: a pilot study. Gynecol Oncol 2005; 96: 729-735
    CrossrefPubMedGoogle Scholar
  • 35 Fagotti A, Ferrandina G, Fanfani F. et al. Prospective validation of a laparoscopic predictive model for optimal cytoreduction in advanced ovarian carcinoma. Am J Obstet Gynecol 2008; 199: 642.e1-642.e6
    CrossrefPubMedGoogle Scholar
  • 36 Fagotti A, Vizzielli G, De Iaco P. et al. A multicentric trial (Olympia-MITO 13) on the accuracy of laparoscopy to assess peritoneal spread in ovarian cancer. Am J Obstet Gynecol 2013; 209: 462.e1-462.e11
    CrossrefPubMedGoogle Scholar
  • 37 van de Vrie R, Rutten MJ, Asseler JD. et al Laparoscopy for diagnosing resectability of disease in women with advanced ovarian cancer. Cochrane Database Syst Rev 2019; (03) CD009786
    PubMedGoogle Scholar
  • 38 Widschwendter P, Blersch A, Friedl TWP. et al. CT Scan in the Prediction of Lymph Node Involvement in Ovarian Cancer – a Retrospective Analysis of a Tertiary Gyneco-Oncological Unit. Geburtshilfe Frauenheilkd 2020; 80: 518-525
    Article in Thieme ConnectPubMedGoogle Scholar