M D Ray*, TSHV Surya and Premanand N
Background: Neoadjuvant chemotherapy is used in the patients of advanced ovarian cancer, not amenable for upfront surgery. Desmoplastic response to chemotherapy poses difficulty to complete surgical resection apart from anesthetic implications secondary to chemotherapy. Interval cytoreductive surgery requires expertise and intensive perioperative care to minimize the complications and better surgical outcomes. Present study describes the technique, as practiced by the author emphasizing the importance of surgical skill and technique in interval setting and the author raised the question ‘Does NACT really ease the burden?’. Author explained it with his expences in a tertiary oncological referral centre.
Methods: An audit of a prospectively maintained computerized ovarian cancer database in the department of surgical oncology was done. Intraoperative and immediate post-operative outcomes were analysed along with our surgical technique performed in 106 CRS after NACT and 95 upfront cases. We also compared between upfront and interval groups in terms of both perioperative and survival outcomes.
Results: In 516 cases of ovarian cancer operated from January 2014 to November 2020, but in this study,we included 201 patients who fulfilled the inclusion criteria. Post NACT cytoreduction was performed in 106 patients and upfront cytoreduction was performed in 95 cases. Nerve-sparing Hysterectomy and Nerve-sparing Retroperitoneal lymph node dissection were performed in 29.24% (31/106) cases. Nerve sparing surgery is less in interval group compare to upfront group 69.47% (66/95). Perioperative outcomes, in terms of less extensive surgical procedure, bowel resection rates, blood transfusions, readmission rate within 30 days of surgery, are better in post NACT group compared to upfront cytoreduction.However it is not statistically significant. Because the completeness of surgery is an issue and development of resistant clone to chemotherapy causing more relapse thereby compromised survival which is reflected in our study in the interval group. (median DFS 44 months versus 38 months)
Conclusion: Interval cytoreductive surgery seems easy but it is truly a surgical challenge with almost always an issue for optimal CRS. In true sense, it does not ease the burden as our results reflected it in terms of DFS. Thereby, NACT should not be used as an armamentarium to compensate for poor or inexperienced surgical skill.
