Cyto-redux.

Top Line: Does secondary cytoreductive surgery improve survival in women with recurrent ovarian cancer?

The Study: Three randomized trials have asked this question: GOG-0213, SOC-1, and DESKTOP III. GOG-0231 found no difference in progression free survival (PFS) or overall survival (OS) with surgery, but the GOG trial had no formal resectability criteria (surgeon discretion) and the complete resection rate was 67%. Also, the majority of patients in GOG-0231 (84%) received maintenance bevacizumab. SOC-1, which had formal resectability criteria and a 77% complete resection rate, found a significant improvement in median PFS (OS results of SOC-1 are immature). Here we have published results from the DESKTOP III trial. As an historical side note, DESKTOP I found that complete resection (not just cytoreduction) was associated with improved survival and that three factors were predictive of complete resection (called the AGO criteria): a complete resection at original primary surgery, ECOG performance status 0, and ≤ 500 cc ascites. DESKTOP II then showed that GTR was achievable in 76% of patients meeting the AGO criteria. So, DESKTOP III was designed to determine if secondary cytoreduction for recurrent disease in patients likely to have complete resection could improve overall survival. Over 400 women with recurrence > 6 months after initial platinum-based chemo who met the AGO criteria and who had a normal CA-125 were randomized to platinum-based chemo with or without up-front surgery. Most (75%) had a platinum-free interval > 12 months. Among those randomized to surgery, 93.2% actually had surgery and 76% of those had a complete resection. Only 2% were deemed unresectable after enrollment but prior to surgery. Median OS was significantly longer with surgery and chemo than with only chemo (53.7 v 46 months) and so was median progression-free survival (18.4 v 14 months). All subgroups of patients benefited from cytoreductive surgery–except those who did not have complete resection. Median OS after incomplete resection was less than half that following complete resection (27 v 61.9 months). Bevacizumab maintenance was given in 23%.

TBL: Secondary cytoreductive surgery that is able to achieve complete resection prior to chemotherapy improves progression-free and overall survival in women with recurrent ovarian cancer. Objective criteria are necessary to select resection candidates as incomplete resection provides no benefit. | Harter, N Engl J Med 2021