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A minimally invasive approach to interval debulking surgery in advanced ovarian cancer was associated with similar oncologic outcomes and favorable surgical outcomes compared to laparotomy in a retrospective cohort study.

In over 400 patients treated with neoadjuvant chemotherapy at three centers, those who underwent minimally invasive surgery (MIS) saw improved rates of complete resection (66% vs 46% with open surgery, P<0.001) and optimal cytoreduction (93% vs 84%, P=0.02), reported Alice Barr, MD, of Carolinas Medical Center in Charlotte, North Carolina.

Median progression-free survival reached 18.1 months in the MIS group compared with 15.1 months in the open surgery group (P=0.051), with a 2-year rate of 40% versus 30%, respectively, according to the findings presented at the virtual Society of Gynecologic Oncology (SGO) meeting.

Median overall survival was 40.9 months in the MIS group and 36.7 months in the open surgery group, a non-significant difference.

Barr cautioned, however, that patients with a better prognosis tended to be chosen for MIS, as evidenced by the fact that they had less-complex surgeries (Aletti score >3) compared to the open surgery group (19% vs 36%, P<0.001).

"For decades, the standard of care for advanced epithelial ovarian cancer has been upfront surgery followed by platinum-based chemotherapy," Barr said. "Now however, we are seeing increasing treatment with neoadjuvant chemotherapy followed by interval debulking surgery. While this interval debulking surgery has traditionally been performed using open technique, minimally invasive surgery offers multiple advantages."

In the multicenter analysis, patients who underwent MIS had a lower 30-day post-operative complication rate, at 20% versus 43% with open surgery (P<0.001), and spent less time in the hospital, at an average 2.2 versus 5.9 days (P<0.001). Time in surgery was not significantly different (196.3 vs 191.1 minutes, respectively).

Patients in the MIS group had significantly less blood loss, so fewer needed transfusions compared to the open surgery group:

• Blood loss: 181.5 vs 326.2 mL (P<0.001)
• Transfusion rate: 4% vs 25% (P<0.001)

MIS "may be considered a feasible and potentially effective mode of interval debulking surgery after neoadjuvant chemotherapy in patients with advanced epithelial ovarian cancer," said Barr, adding that MIS should be compared with open surgery in a randomized trial.

Speaking in favor of the approach during a "pro-con" debate, Anna Fagotti, MD, PhD, of Fondazione Policlinico A. Gemelli Catholic University of the Sacred Heart in Rome, said the ideal candidate would be a patient with no ascites and a normalization of CA-125 serum levels following neoadjuvant chemotherapy who is not indicated for bowel resection, has no carcinomatosis in the supra-mesocolic region, and where there is correspondence between findings on imaging and during MIS.

She also highlighted some common concerns with MIS for interval debulking, most notably the risk for leaving behind residual or occult disease, and the lack of high-level evidence.

On the con side, Jill Tseng, MD, of University of California Davis, said "laparotomy is still the answer" in patients with large tumor burden, in cases requiring high surgical complexity, and when complete gross resection is the goal.

Tseng reminded the audience of the phase III Laparoscopic Approach to Cervical Cancer (LACC) trial, where patients on the MIS arm saw poorer outcomes compared to the open surgery arm.

The will potentially answer the question in advanced ovarian cancer.

The current study examined outcomes in 415 consecutive women with ovarian, fallopian tube, or primary peritoneal cancers treated at three centers from 2008 to 2019 with either laparotomy (n=293) or MIS (n=122). Robotic assistance was used in 64% of MIS cases, while conventional laparoscopy was used in the remaining.

Patients were eligible if they had received three to six cycles of neoadjuvant chemotherapy followed by interval debulking surgery. Average follow-up time was 36 months for the MIS group and 33 months for open surgery group.

Baseline characteristics were similar between groups, with an average age of 65 and 63 for the the MIS and open surgery groups, respectively. Mean BMI was significantly lower in the MIS group, at 27 versus 29 in the open surgery group (P=0.009), as was average cycles of adjuvant therapy, at 3.0 versus 3.4, respectively (P=0.01). CA-125 level at diagnosis was similar between arms.

Barr noted several limitations to the research, including the study's retrospective nature, variable surgery expertise with MIS, and that most robotic cases were performed at a single center.

"While the data could imply that patients with a better prognosis were chosen for the minimally invasive surgery group, this is not necessarily a limitation," she said. "Our study reflects real-world parameters, where patients who are likely to have the best outcomes are selected for minimally invasive surgery."

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