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Advanced Ovarian Cancer Survival Rates Longer After Primary Cytoreductive Surgery Compared With Neoadjuvant Chemotherapy

Advanced Ovarian Cancer Survival Rates Longer After Primary Cytoreductive Surgery Compared With Neoadjuvant Chemotherapy

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Median 5-year overall survival for patients with HGSC was 3.89 after PCS and 2.48 after NACT.
Median 5-year overall survival for patients with HGSC was 3.89 after PCS and 2.48 after NACT.

Primary cytoreductive surgery (PCS) is associated with a longer survival rate compared with neoadjuvant chemotherapy (NACT) in patients with stage IIIC and IV high-grade serous ovarian carcinoma (HGSC), according to a study published in the International Journal of Gynecological Cancer.

Taymaa May, MD, MSc, FRCSC, from the Department of Obstetrics and Gynecology at the University of Toronto, and colleagues, conducted a retrospective cohort analysis to examine patterns of clinical practice in the management of women with advanced HGSC. A total of 852 women between ages 18 and 80 years with International Federation of Gynecology and Obstetrics stage IIIC or IV high-grade serous ovarian, fallopian tube, or primary peritoneal carcinoma from 4 Canadian cancer centers were included.


Patients were categorized into 2 groups: those who underwent PCS followed by adjuvant chemotherapy (PCS group) and those who were treated with NACT and interval cytoreductive surgery (NACT group). The extent of residual disease was based on the diameter of the single largest lesion and categorized as microscopic (0 mm), 1 to 9 mm, and 10 mm or more. 

The study was conducted from January 2007 to December 2013, with the primary end point at 5-year and 7-year overall survival (OS). Survival end point was defined as the date of first treatment for the NACT group or the date of surgery for the PCS group to the date of death from ovarian cancer, death from other cause, lost to follow-up, or last follow-up date.

Of the 852 patients, 357 (42%) received care at Princess Margaret Cancer Center, Toronto; 225 (26%) at Tom Baker Cancer Center, Calgary; 205 (24%) at London Health Science Center, London, ON; and 65 (8%) at Cancer Care Manitoba, Winnipeg. Overall, 449 patients (53%) had primary debulking surgery, and 403 patients (47%) had NACT. Mean age of study patients was 62.1 years. Patients were followed for a mean of 4.1 years.

A total of 72 (8%) of 852 patients had intraoperative complications. Among patients who experienced complications, 28 patients (39% of complications, 3.2% of study patients) had surgery that was considered aggressive. The 30- and 90-day postoperative mortality rates in the PCS cohort were 0.2% and 0.7%, respectively. The 30- and 90-day postoperative mortality rates in the NACT cohort were 0% and 1.2%, respectively.

The median 5-year overall survival was 3.89 for the PCS group and 2.48 in the NACT group. Patients with 0-mm residual had OS of 4.66, compared with 1- to 9-mm residual (OS = 2.80) and 10-mm residual or longer (OS = 2.50). The survival advantage with the extent of surgical cytoreduction was more pronounced with PCS compared with NACT. Patients who had PCS and 1- to 9-mm residual disease had an increased OS when compared with patients who underwent NACT and had 1- to 9-mm residual disease (42.4 vs 23.88 months, respectively).


“In conclusion, our work indicates superior survival in patients who undergo PCS for stage IIIC and IV HGSC,” the authors concluded. “All patients who present with advanced ovarian neoplasms should be referred to a gynecologic oncologist for surgical consultation and not automatically triaged to NACT. When judged feasible, PCS should be the favorable treatment modality.”


May T, Altman A, McGee J, et al. Examining Survival Outcomes of 852 Women With Advanced Ovarian Cancer: A Multi-institutional Cohort Study. Int J Gynecol Cancer. [Published online ahead of print]. 2018 Apr 4. doi: 10.1097/IGC.0000000000001244





Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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All of the following statements regarding the risk of ovarian cancer are true EXCEPT:

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The correct answer is E.

The answer is E.  A variety of genetic syndromes substantially increase a woman’s risk of developing ovarian cancer. Approximately 10% of women with ovarian cancer have a germline mutation in one of two DNA repair genes: BRCA1 (chromosome 17q12-21) or BRCA2 (chromosome 13q12-13). Individuals inheriting a single copy of a mutant allele have a very high incidence of breast and ovarian cancer. Most of these women have a family history that is notable for multiple cases of breast and/or ovarian cancer, although inheritance through male members of the family can camouflage this genotype through several generations. The most common malignancy in these women is breast carcinoma, although women harboring germline BRCA1 mutations have a marked increased risk of developing ovarian malignancies in their 40s and 50s with a 30%–50% lifetime risk of developing ovarian cancer. Women harboring a mutation in BRCA2 have a lower penetrance of ovarian cancer with perhaps a 20%–40% chance of developing this malignancy, with onset typically in their 50s or 60s. Women with a BRCA2 mutation also are at slightly increased risk of pancreatic cancer. Likewise, women with mutations in the DNA mismatch repair genes associated with Lynch syndrome type 2 (MSH2MLH1MLH6PMS1PMS2) may have a risk of ovarian cancer as high as 1% per year in their 40s and 50s. Finally, a small group of women with familial ovarian cancer may have mutations in other BRCA-associated genes such as RAD51CHK2, and others. Screening studies in this select population suggest that current screening techniques, including serial evaluation of the CA-125 tumor marker and ultrasound, are insufficient at detecting early-stage and curable disease, so women with these germline mutations are advised to undergo prophylactic removal of ovaries and fallopian tubes typically after completing childbearing and ideally before age 35–40 years. Early prophylactic oophorectomy also protects these women from subsequent breast cancer, with a reduction of breast cancer risk of approximately 50%.


A 75-year-old triathlete complains of gradually worsening vision over the past year. It seems to be involving near and far vision. The patient has never required corrective lenses and has no significant medical history other than diet-controlled hypertension. He takes no regular medications. Physical examination is normal except for bilateral visual acuity of 20/100. There are no focal visual field defects and no redness of the eyes or eyelids. Which of the following is the most likely diagnosis?

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The correct answer is A. You answered A.

Age-related macular degeneration is a major cause of painless, gradual bilateral central visual loss. It occurs as nonexudative (dry) or exudative (wet) forms. Recent genetic data have shown an association with the alternative complement pathway gene for complement factor H. The mechanism link for that association is unknown. The nonexudative form is associated with retinal drusen that leads to retinal atrophy. Treatment with vitamin C, vitamin E, beta-carotene, and zinc may retard the visual loss. Exudative macular degeneration, which is less common, is caused by neovascular proliferation and leakage of choroidal blood vessels. Acute visual loss may occur because of bleeding. Exudative macular degeneration may be treated with intraocular injection of a vascular endothelial growth factor antagonist (bevacizumab or ranibizumab). Blepharitis is inflammation of the eyelids usually related to acne rosacea, seborrheic dermatitis, or staphylococcal infection. Diabetic retinopathy, now a leading cause of blindness in the United States, causes gradual bilateral visual loss in patients with long-standing diabetes. Retinal detachment is usually unilateral and causes visual loss and an afferent pupillary defect.


Mr. Jenson is a 40-year-old man with a congenital bicuspid aortic valve who you have been seeing for more than a decade. You obtain an echocardiogram every other year to follow the progression of his disease knowing that bicuspid valves often develop stenosis or regurgitation requiring replacement in middle age. Given his specific congenital abnormality, what other anatomic structure is important to follow on his biannual echocardiograms?

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The correct answer is A. You answered A.

The answer is A. (Chap. 282) Bicuspid aortic valve is among the most common of congenital heart cardiac abnormalities. Valvular function is often normal in early life and thus may escape detection. Due to abnormal flow dynamics through the bicuspid aortic valve, the valve leaflets can become rigid and fibrosed, leading to either stenosis or regurgitation. However, pathology in patients with bicuspid aortic valve is not limited to the valve alone. The ascending aorta is often dilated, misnamed “poststenotic” dilatation; this is due to histologic abnormalities of the aortic media and may result in aortic dissection. It is important to screen specifically for aortopathy because dissection is a common cause of sudden death in these patients.



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