Postoperative mortality after primary cytoreductive surgery for advanced stage epithelial ovarian cancer: A systematic review

doi:10.1016/j.ygyno.2009.03.011

Gynecologic Oncology

Volume 114, Issue 3, September 2009, Pages 523-527

https://doi.org/10.1016/j.ygyno.2009.03.011 Get rights and content

Abstract

Objective

Accurate estimation of the risk of postoperative mortality (POM) is essential for the decision whether or not to perform cytoreductive surgery in a patient with advanced stage ovarian cancer. To ascertain modern reference figures, a systematic review of studies reporting POM after primary cytoreductive surgery for advanced stage epithelial ovarian cancer (EOC) was performed.

Materials and methods

A Medline search was performed to retrieve papers on primary cytoreductive surgery for advanced stage EOC. Twenty-three papers met the inclusion criteria and were reviewed.

Results

According to population-based studies, POM after primary cytoreductive surgery for EOC is 3.7% on average. Single centre studies report an average rate of 2.5%. The overall mean POM is 2.8%. POM is more frequent for elderly women and after extensive procedures. Accurate information on age-specific and procedure-specific rates could not be obtained.

Conclusion

POM rates after surgery for EOC are satisfactorily low. There is a clear need for reliable reference figures for mortality after debulking surgery in the elderly.

Introduction

Epithelial ovarian cancer (EOC) continues to be the leading cause of death from gynaecological cancer [1]. Cure rates are low because most patients are diagnosed with advanced disease. Treatment is based on cytoreductive surgery and platinum-based chemotherapy. Individual prognosis depends on FIGO (International Federation of Gynaecology and Obstetrics) stage [2] and the ability to perform optimal cytoreductive surgery [3], [4], [5]. To achieve a minimal residual tumour load, surgery may need to be quite extensive and can be accompanied by postoperative complications.

Postoperative morbidity and mortality depend upon the extent of surgery, age, performance status and co-morbidity [6], [7], [8], [9]. Cytoreductive surgery clearly improves survival but may be withheld if the operative risk is deemed too high. The role of upfront cytoreductive surgery in patients with unresectable disease is under debate. Several studies suggest that neo-adjuvant chemotherapy followed by interval surgery will lead to similar survival with less operative morbidity [10], [11], [12].

POM is generally defined as death from any cause within 30 days of operation and has been suggested as a performance indicator for other types of cancer. For ovarian cancer, POM is considered to be low but may yet be useful as an objective parameter of surgical care. To obtain reference standards for POM, we performed a systematic review on published POM rates after primary cytoreductive surgery for advanced stage EOC.

Section snippets

Search methods

We performed a Medline search of English-language articles published between January 1, 1981, and March 1, 2008. The keywords used were: “ovarian carcinoma”, “ovarian cancer”, “ovarian neoplasma” and “cytoreductive surgery”, “surgical outcome”, “30-day mortality”, “in-hospital mortality”, “postoperative death”, “postoperative mortality” and “postoperative complications”. Additionally, the Cochrane Library and Embase were searched for any relevant reports.

Inclusion criteria

POM was defined as death from any cause

Description of studies

We identified 23 eligible reports on primary cytoreductive surgery for advanced stage EOC. Twenty reports described retrospectively collected data; three studies reported results of a prospective study.

Population-based studies

Three population-based case series on cytoreductive surgery for advanced stage EOC were found, with a mean POM rate of 3.7% (range 2.5–4.8%) (Table 1).

Single centre studies

Twenty single centre reports, on primary cytoreductive surgery for advanced stage EOC, reported data on postoperative mortality. POM ranged from 0

Discussion

Population-based reports on POM after primary cytoreductive surgery for advanced stage EOC vary with rates ranging from 2.5% to 4.8%, with a mean of 3.7%. Reports from single centres present slightly better results, with a mean POM of 2.5%. The overall POM is 2.8% on average. Published results may, however, be biased due to reporting and publication bias.

The low operative risk corroborates the current treatment strategy of primary cytoreductive surgery followed by platinum-based chemotherapy in