Quaternary cytoreductive surgery in ovarian cancer: does surgical effort still matter?

Background: To evaluate surgical outcome and survival benefit after quaternary cytoreduction (QC) in epithelial ovarian cancer (EOC) relapse. Methods: We systematically evaluated all consecutive patients undergoing QC in our institution over a 12-year period (October 2000-January 2012). All relevant surgical and clinical outcome parameters were systematically assessed. Results: Forty-nine EOC patients (median age: 57; range: 28-76) underwent QC; in a median of 16 months (range: 2-142) after previous chemotherapy. The majority of the patients had an initial FIGO stage III (67.3%), peritoneal carcinomatosis (77.6%) and no ascites (67.3%). At QC, patients presented following tumour pattern: lower abdomen 85.7%; middle abdomen 79.6% and upper abdomen 42.9%. Median duration of surgery was 292 min (range: a total macroscopic tumour clearance could be achieved. Rates of major operative morbidity and 30-day mortality were 28.6% and 2%, respectively. Mean follow-up from QC was 18.41 months (95% confidence interval (CI): 12.64-24.18) and mean overall survival (OS) 23.05 months (95% CI: 15.5-30.6). Mean OS for patients without vs any tumour residuals was 43 months (95% CI: 26.4-59.5) vs 13.4 months (95% CI: 7.42-19.4); P = 0.001. Mean OS for patients who received postoperative chemotherapy (n = 18; 36.7%) vs those who did not was 40.5 months (95% CI: 27.4-53.6) vs 12.03 months (95% CI: 5.9-18.18); P<0.001. Multivariate analysis indentified multifocal tumour dissemination to be of predictive significance for incomplete tumour resection, higher operative morbidity and lower survival, while systemic chemotherapy subsequent to QC had a protective significant impact on OS. No prognostic impact had ascites, platinum resistance, high grading and advanced age. Conclusion: Even in this highly advanced setting of the third EOC relapse, maximal therapeutic effort combining optimal surgery and chemotherapy appear to significantly prolong survival in a selected patients 'group'.