Giovanni Scambia
Polo Scienze della Salute della Donna e del Bambino
Il parere dell’esperto
• Ovarian cancer in the Era of Personalized Medicine
• Tailored Surgery for Ovarian Cancer
• Cervical cancer
Menagin Ovarian Cancer in the Era of
Personalized Oncology
OC is not one disease
Outcome depends on histotype
PARP inhibitors in ovarian cancer:
current status and future promise
OLAPARIB (Lynparza ®)
FDA approved: mantainance therapy in platinum sensitive relapse high grade ovarian cancer + Deleterious BRCA mutation associated with advanced ovarian cancer EMA approved: mantainance therapy in BRCA + platinum sensitive relapse high grade ovarian cancer
NIRAPARIB (Zejula®)
FDA + EMA approved:
mantainance therapy in platinum sensitive relapse high grade ovarian cancer
RUCAPARIB (Rubraca®) FDA approved:
Deleterious BRCA
mutation associated with advanced ovarian cancer
VELIPARIB
TALAZOPARIB
Quality of Life?
NACT RATIONALE in ONCOLOGY
NACT in ADVANCED OVARIAN CANCER
Clinical evidences supporting NACT
Potential risks of NACT
Catholic University management
NACT PERSPECTIVES
“Tailored” treatment
ITEMS
Neoadjuvant ChemoTherapy: PRINCIPLES
New strategy to increase resectability (“to downstage” the patient) on head and neck cancer
1982
To shrink the tumor in patients who were not candidates for primary surgery, and to allow
organ preservation
reduction of mortality rate
1990s-2010s
PROSTATE CANCER
BREAST CANCER
COLO-RECTAL CANCER
LUNG CANCER
Cancer statistics, 2017
A.Fagotti et al. (EJC - 2016) RESIDUAL DISEASE
EARLY (<30days) COMPLICATIONS LATE 1-6 months from surgery) COMPLICATIONS
NACT vs PDS: RCTs
Single institution Phase III Randomised clinical trial
110 eligible women, 55 assigned to arm A (PDS) and 55 to arm B (NACT+IDS)
AEOC supposed resectable women with PI > 8 or < 12 (considered as HTL) were included
2 arms: A) PDS followed by systemic adjuvant chemotherapy ; B) NACT followed by IDS
2 Co-primary outcomes: post-operative complications
& PFS
- NACT /IDS is better than PDS in patients with HTL (PI >8 and
< 12) in abdomen, as assessed by s-LPS, in terms of
perioperative morbidity
- No differences in QoL measurements at the end of
treatment between the 2 arms.
PATIENTS’ SELECTION
SURGICAL EFFORT
High and uniform SCS
Procedures endowed with high SCS (score =2-3) were required in 100% versus 48.1%, in PDSarm versus
NACT/IDS arm , respectively (p = 0.0001)
Gynecologic Oncology - 2015
Level of evidence: IIB
MIS approaches may be useful when evaluating
whether maximum cytoreduction can be achieved in
newly diagnosed and recurrent OC 109,122,123,135,136
Variation in NACT at high volume hospitals
Gynecologic Oncology - 2017
11.574 pts with FIGO stage IIIC – IV of OC.
78.4% received PDS, while 21.6%
treated with NACT/IDS.
All woman treated at 55 high volume hospitals (>20 cases/year), classified in:
• Low utilization of NACT (14)
• Average utilization of NACT (31)
• High utilization of NACT (10)
Utilization of NACT to treat stage IIIC and IV OC varies widely among high volume hospitals.
Receipt of care at a hospital with an average or high NACT use rate was associated with a decreased rate of death compared to care at a low utilization hospitals.
It is plausible that low utilization of NACT is associated
with increased suboptimal primary cytoreductive
surgery rates and increased major postoperative
complications with adjuvant treatment delays, both
leading to decresed survival. Further research is needed.
NACT+IDS pts showed more frequently
carcinomatosis, and platinum-resistant disease at recurrence compared with PDS
Patients treated with NACT+IDS showed a shorter Post-Relapse survival compared with PDS (3-yrs PRS, PDS=58% vs NACT-IDS=18% )
NACT-IDS negatively influences the pattern and timing of recurrence, probably favoring the selection
of chemoresistant clones
Potential risks of NACT
Annals of Surgical Oncology, 2013
Potential risks of NACT
2015
Incorporation of Bevacizumab into upfront regimens prolongs PFI in AOC patients, but is associated with a more aggressive behaviour of recurrent disease:
1) Wider presentation of relapse ( p 0.035)
2) Lower percentage of patients suitable for SCS ( p 0.016)
3) Shorter TTP to second line chemotherapy in women with platinum-sensitive disease (p-value ( p-value 0.041)
2016
Gynecologic Oncology
CATHOLIC UNIVERSITY MANAGEMENT OF AOC
·OVARIAN CANCER SURGERY - GUIDELINES·
1
OV ARI AN CANCER SURGERY GUI DEL I NES
- Complete r epor t -
·OVARIAN CANCER SURGERY - GUIDELINES· 1
OVARIAN CANCER SURGERY GUIDELINES
- ASSESSMENT FORM -
SURNAME:
FIRST NAME(S):
COUNTRY:
PLEASE PROVIDE YOUR DISCIPLINE(S) OR SPECIALITY(IES):
·OVARIAN CANCER SURGERY - GUIDELINES·
3
ALGORITHM FOR EPITHELIAL OVARIAN CANCER SURGERY (2)
Strongly disagree Indecision Strongly agree
ò ò ò
1 2 3 4 5 6 7 8 9
Do you feel that this algorithm is clinically relevant?
Do you feel that this algorithm is usable in your practice?
·
Open commentary - Elements supporting your position (e.g. clinical arguments, bibliographic data, etc.)
·
MANDATORY if at least one score is < 7 (optional in other situations)
S-LPS
Vizzielli score
S-LPS
Vizzielli score
31
MINIMALLY INVASIVE SURGERY after NACT
Am J Obstet Gynecol 2016
Minimally Invasive-IDS in patients with clinically complete response to NACT seems to be feasible
and safe in terms of perioperative outcomes, psycho-oncological impact, and survival rate.
A high level of satisfaction was informally recorded for our patients, in line with the fact that a scarless surgery may help to avoid an unnecessary mark of a difficult history,
and reduce postoperative pain.
Multicentric phase II Clinical Trial
Of 184 advanced EOC patients
considered eligible for IDS, finally
30 woman received the planned
treatment of MI-IDS.
Minimally invasive approach could represent an advantageousalternative surgical way to perform interval debulking surgery in this specific subset of patients.
MIS is superior to standard laparotomy in terms of EBL, discharge time and TTC.
MI approach determines a higher percentage of women with positive well-being compared to pts treated with the conventional approach.Women treated with
MI-IDS showed a 6 months longer
PFS compared to Controls
MINIMALLY INVASIVE SURGERY after NACT
Gyn Oncology - 2016
• Retrospective cohort study
• 3.071 pts with AOC, who underwent NACT and IDS
• 47.5% LPS vs 52.5% LPT
No difference in survival between women who underwent laparoscopic IDS and those underwent laparotomy.
Short postoperative hospitalization after laparoscopic surgery and no difference in risk of unplanned readmission or perioperative death.
In well-selected pts, such as those who have a complete response to NACT, laparoscopic IDS may be a safe and effective alternative to laparotomy.
• Relatively short FU (3 ys)
• Lack of random allocation
• Inability to verify registry data
• Retrospective case-control study
• 30 AEOC pts treated with MI- IDS; 65 submitted to LPT-IDS
• Small sample size
• Short duration of median FU
AOC pts with BRCAmut are highly responsive to P-based
chemotherapy, with also prolonged PFS after NACT , compared with BRCA naïve.
Gorodnova TV, et al. Cancer Letter, 2015;
Mahdi H, et al. Gynecol Oncol 2015
MOLECULAR CHARACTERIZATION FOR NACT
PDS
NACT
Submitted
Progression-free survival (%)
PDS
NACT
p=0.05
p=ns BRCAwt
PDS NACT Median PFS
26 months 18 months
BRCAmut
PDS NACT Median PFS
28 months
24 months
Neoadjuvant ChemoTherapy: PRINCIPLES
New strategy to increase resectability (“to downstage” the patient) on head and neck cancer
1982
To shrink the tumor in patients who were not candidates for primary surgery, and to allow
organ preservation
reduction of mortality rate
1990s-2010s
PROSTATE CANCER
BREAST CANCER
COLO-RECTAL CANCER
LUNG CANCER
Cancer statistics, 2017
To test the activity of a therapeutic
approach or the potential importance of biological factors in
determining disease outcome 2017
Achiving a complete pathologic response seems to correlate to the best prognosis ever achieved
2010s
J Clin Oncol 30:1796-1804, 2012
Ann Surg Oncol (2012 ) BREAST CANCER
COLO-RECTAL CANCER LUNG CANCER
AJOG (2014)
OS PFS
PATHOLOGICAL RESPONSE TO NACT
• cPR : cases with no residual neoplastic cells in all the surgical specimens, including the adnexa
• microPR : microscopic foci (maximum diameter ≤ 3 mm)
• macroPR : persistent macroscopic site of disease after NACT
• cPR is an uncommon event in AOC patients receiving NACT and is associated with a longer PFS and OS compared with women showing no cPR
• cPR, rather than only an
estimation of disease extension after NACT, clearly emerges as a marker of extreme sensitivity to platinum-based
chemotherapy.
Neoadjuvant ChemoTherapy: PERSPECTIVES
Neoadjuvant ChemoTherapy: PERSPECTIVES
BRCA1=27%
Olaparib with weekly JM8 and TAX as NACT in BRCA mut advanced HGSOC women: a PHASE II multicentric study
PRIMARY AIM: Pathological complete response after 3 cycles of NACT including OLAPARIB and weekly JM8-TAX in BRCAmut advanced HGSOC
SECONDARY AIMS: Complete cytoreduction rate at IDS, response rate (RECIST
criteria), surgical assessment of response with a laparoscopic standardized score
(Fagotti score), toxicity Profile, PFS,OS.
Suspicious AEOC : GYO + imaging + S-LPS
TISSUE ACQUISITION
Histology & molecular analysis
TUMOUR LOAD
& peri-op risk
LTL/ITL<8
Low peri-op risk PDS
HTL 8-12
High peri-op risk
CHEMORESISTANT (LGSOC; mucinous;
BRCA wt)
CHEMOSENSITIVE
(High grade; BRCA mut;
TGF-beta pathway)
Discuss with the pt PDS or NACT
Offer exp. treatment NACT with target treatment
Unresectable
NACT
75%
<5%
20-25%
Catholic University Integrated Algorithm for
Personalized Treatment in HGSOC
CONCLUSIONS...
We are moving from generalized guidelines, where PDS is still against NACT, to tailored approaches where PDS and NACT are both first-line available treatments that we need to
carefully choose for EACH patient
DON’T MAKE IT LOOK GOOD ON YOU BUT
MAKE IT GOOD FOR YOU
KEY POINTS
•
• CARATTERIZZAZIONE MOLECOLARE
• CHIRURGIA TRATTAMENTO MEDICO
•
where are
we going ?
Unanswered questions
Early stage and fertility sparing tratments
Sentinel node
Adjuvant treatment
Local Adavenced disease (Prognostic groups)
Neoadjuvant chemotherapy
Metastatic cervical cancer
Target Therapy
What is the appropriate endpoint?
Should we do phase II or phase III studies?
Proposed primary endpoints included overall survival (OS), progression free survival (PFS), and response rates (ORR). Secondary endpoints included PFS, quality of life (QOL), patient reported outcomes (PRO), and safety
News in cervical cancer ?
Int J Gynecol Cancer. 2016 Jan;26(1):199-207
Feb-1999: NCI issues clinical announcement on cervical cancer
1.reduction in risk of death (HR 0.69, 95% CI 0.61-0.77)
2.reduction in risk of local recurrence (OR 0.59, 95% CI 0.50-0.69) 3.trend in reduction of distant metastasis (OR 0.81, 95% CI 0.65-1.01)
I.V. CISPLATIN CHEMOTHERAPY Cisplatin 40mg/m2 (Max dose 70mg)
IV q wk during RT (6wks) EXTERNAL BEAM
pelvic
radiation(40 to 60 Gy)
BRACHYTHERAPY (8,000 to 8,500 cGy
to Point A)
CTRT: CONSIDERED THE WORLD
STANDARD TREATMENT for LACC
OTHER OPTIONS
• Chemo/radiation
• Chemo/radiation followed by surgery
• Neoadjuvant chemotherapy
• followed by surgery
• followed by chemo/radiation
• Trial closed for poor accrual
• No difference OS between
surgery vs no surgery after CTRT
• This study failed to
demonstrate that RH after
EBRT-CT is superior to
standard BCT
Accrual: 103 pts
Eligibility
Cervix carcinoma stage IB2-IVA
Age<80y
Adequate bone marrow function
Adequate renal function Normal liver function
T
Clinical Response
-CR 36 pt(34.9%) -PR 63 pt(61.2%) -SD 2 pt(1.9%) -PD 2 pt(1.9%)
RT
39.6 GY(PELVIC LYMPH NODE DRAINAGE, BULKY TUMOR,PARAMETRIA) + 10.8 GY(PRIMARY
TUMOR,PARAMETRIA)
CT
CISPLATIN 20 MG/M2 P1Q25+CAPECITABINE 1300 MG/M2 DAILY
DFS 73%
OS 86.1%
TOXICITY
-Leukopenia 19.4% G1 19.4% G2 -Gastrointestinal 32% G1
9.7% G2 -Genitourinary 11.6% G1 2.9% G2
RELAPSE 25 pt(24.3%) DEATH 10 pt(9.7%)
Ferrandina et al. Int J Radiat Oncol Biol Phys 2014 RADICAL HYSYTER
ECTOMY
3 years
OTHER OPTIONS
• Chemo/radiation
• Chemo/radiation followed by surgery
• Neoadjuvant chemotherapy
• followed by surgery
• followed by chemo/radiation
NACT: AIMS
DEBULKING EFFECT AND TUMOR SIZE REDUCTION
IMPROVING SURGICAL OUTCOMES
BETTER ACTIVITY AGAINST MICROMETASTASIS
PERMIT CONSERVATIVE SURGERY
LESS TOXICITY
EASIER MANAGEMENT OF SALVAGE THERAPY
OTHER OPTIONS
• Chemo/radiation
• Chemo/radiation followed by surgery
• Chemo/radiation-chemotherapy
• Neoadjuvant chemotherapy
• followed by surgery
• followed by chemo/radiation
IB2 to III stages
Tierney et al. Eur J Cancer 2003
• 5 randomized trials
• 872 pts (97% of total)
• Stage:
IB 35%
II 38%
III 26%
NACT & RS vs RT
EORTC 55994 (started 1999 !!!)
INCLUSION CRITERIA
•FIGO IB2, IIA, IIB
•PS 0-2
•Age 18-75
•Squamous
•Adenocarcinoma
•Adenosquamous
STRATIFICATION
• FIGO
• Institution
• Age 18-50 vs 50-75
• Histology:
Squamous vs
Adenocarcinoma vs
Adenosquamous
ENDPOINTS
• Primary: OS
• Secondary:
PFS
Toxicity
QoL
R A N D O M
Cisplatin based chemotherapy:
Min. total dose of 225 mg/mq
25 mg/mq per week
Final dose no later than 8°week
Radical hysterectomy
Chemo-radiotherapy
• CDDP 40 mg/mq (6 week) + EBRT 45-50 Gy
OTHER OPTIONS
• Chemo/radiation
• Chemo/radiation followed by surgery
• Chemo/radiation-chemotherapy
• Neoadjuvant chemotherapy
• followed by surgery
• followed by chemo/radiation
TREATMENTS IN LACC
• Chemo/radiation
• Chemo/radiation followed by surgery
• Neoadjuvant chemotherapy followed by chemo/radiation
• Neoadjuvant chemotherapy followed by surgery
CHEMOTHERAPY IS MANDATORY!
But how can we choose???
KEY QUESTIONS
Carboplatin or cisplatin?
WHICH Platinum doublet?
Which role for TARGET THERAPY in CC?
+2,2 m
+3,5 m
CECILIA (MO29594): trial design
• AUC, area under the concentration curve; q3w, every 3 weeks
*Minimum of 6 cycles, unless toxicity necessitates discontinuation of one or both chemotherapy agents, in which case non-implicated drug(s) and Bevacizumab can be continued alone
Metastatic, recurrent or persistent cervical
cancer patients not amenable to curative
treatment with surgery and/or radiation therapy
n=150
Until disease progression, unacceptable
toxicity or withdrawal of consent Paclitaxel 175mg/m
2q3w*
Carboplatin AUC5 q3w*
Bevacizumab 15mg/kg q3w
A MULTICENTRE OPEN-LABEL SINGLE-ARM PHASE II STUDY EVALUATING THE SAFETY AND EFFICACY OF Bevacizumab IN COMBINATION WITH CARBOPLATIN AND PACLITAXEL IN PATIENTS WITH METASTATIC, RECURRENT OR PERSISTENT CERVICAL CANCER
MO29594– Adapted from
https://clinicaltrials.gov/ct2/show/NCT02467907?term=bevacizumab+cervical&rank=5
Randomize
Carboplatin AUC5 + Paclitaxel 175mg/m
2+ Nintenanib 200 mg Bid
Weeks 1-6
Nintenanib until progression
Primary End-point: PFS
Secondary End-point: OS, Toxicity, Patient Health status
Ongoing Trial: Phase II, randomized, double bind and placebo controlled trial
Carboplatin AUC5 + Paclitaxel 175mg/m
2+
Placebo Bid
Weeks 1-6
Placebo until progression
Figo IVB/recurent disease
NINTENANIB
Advanced cervical carcinoma (FIGO stage IIB-IIIB or IB- IIA with pelvic node
metastasis and/or tumour size ≥ 5 cm
n=57
RT/BRT 45 Gy (over
5 ws in 25 once daily fractions)
Bevacizumab 10 mg/kg Iv q2 weeks (days 1, 15 and
29, total 3 doses) during chemoradiation, before cisplatin and on the same
day as cisplatin
Phase II, single arm trial
Primary endpoints: treatment-related serious adverse events rates and adverse events rates within the first 90 days
Secondary endpoints: treatment-related serious adverse events rates and adverse events rates at any time, DFS, OS, angiogenic markers
Schefter et al IJR Oncol Biol Phys. 2012,2014
The Catholic University GYO Network
Dpt. Ob/GYN
Gemelli Hospital, Rome
Dpt. Oncology
Centre for Research, Campobasso
Campobasso Chieti
Acquaviva delle Fonti Palermo
Novara Abano
Terme
Gyn Onc Unit University of Palermo Gyn Onc Unit
University of Chieti
Gyn Onc Unit
University of Piemonte Orientale
Gyn Onc Unit Miulli Hospital, Acquaviva delle Fonti
SITE Essen criteria Leuven criteria Abdominal
metastases
Multiple parenchymatous liver metastases
Infiltration of large parts of the pancreas (not only tail) and/or the duodenum
Infiltration of the porta hepatis or truncus coeliacus
Deep infiltration of the radix mesenterii
Diffuse and confluent carcinomatosis of the stomach and/or small bowel
Involvement of the SMA
Intraephatic metastases
Infiltration of the duodenum and/or pancreas and/or the large vessels of the porta hepatis or truncus coeliacus
Extra-abdominal metastases
Not completely resectable metastases All, excluding: resectable
inguinal lymph nodes, solitary retrocrual or paracardial nodes, Pleural fluid cytologically
malignant cells without presence of pleural tumors
Pts characteristics Poor PS-ECOG
Vergote I and Du Bois A, 2012
Criteria for suboptimal debulking surgery in AOC
Borley J, BJOG, 2014
Predictive performances of CT scan in AEOC
findings confirm previously reported results (Bristow et al, 2000;
Chi et al, 2000; Cooper et al, 2002; Saygili et al, 2002; Memarzadeh et al, 2003), and definitively recognise the extent of the impact played by ECOG-PS in the preoperative prediction of ovarian cancer primary resectability (Aletti et al, 2007). The models based on diagnostic performance and on results from multivariate
analysis showed the same accuracy in predicting the chance of optimal cytoreduction, although they included slightly different CT-based features; in particular, involvement of bowel mesentery, omentum, liver, and diaphragm were shown to fulfil all the required criteria (Bristow et al, 2000) in Approach A, whereas in multivariate analysis the involvement of peritoneum and suprar- enal aortic lymph nodes, besides bowel/mesentery and diaphragm disease, were independently associated with suboptimal cyto- reduction. The divergence between the two approaches remains difficult to explain, although the strict and, to a certain extent, unpredictable associations among the variables might more likely have an impact on multivariate analysis. In any case, our findings support the relevance of the assessment of the status of bowel mesentery and diaphragm involvement, recognised among the most important features determining the feasibility of ovarian T able 4 Prediction of optimal cytoreduction: univariate and multivariate analysis by logistic regression of CT-based and clinically assessed parameters to use for modeling (Approach B)
U nivar iat e Mult ivar iat e
v2 P-value v2 P-value Pointa
Radiographic
Peritoneal thickening, peritoneal implants 4 2 cm 16.34 0.0001 3.45 0.063 1
Bowel mesentery involvement 17.50 0.0001 5.35 0.0207 1
Omental extension (spleen, stomach, lesser sac) 11.13 0.0008 2.52 0.11 0
Pelvic sidewall involvement and/or hydroureter 2.28 0.13 — — 0
Suprarenal aortic lymph nodes 4 1 cm 4.21 0.040 4.36 0.036 1
Infrarenal aortic lymph nodes 4 2 cm 8.15 0.0043 — — 0
Superficial liver metastases 4 2 cm and/or intraparenchimal liver metastases any size 8.58 0.0034 — — 0
Large volume ascites (4 500 ml) 8.15 0.0043 — — 0
Diaphragmatic disease (widespread infiltrating carcinomasis, or confluent nodules) 25.35 0.0001 7.13 0.0076 1 Clinical
Age, years (p 65 vs 4 65) 2.51 0.08 — — 0
Ca125 levels (p 500 vs 4 500 IU ml 1) 2.98 0.11 — — 0
ECOG-PS (0,1 vs 2) 19.71 0.0001 14.22 0.0002 1
aOnly variable achieving a P–value o 0.10 were assigned a point value. Statistically significant values have been indicated as bold values.
0 10 20 30 40 50 60
0 1 2 3 4
Counts
PI
5
Model 3 Model 4
0 0.2 0.4 0.6 0.8 1.0
0 0.2 0.4 0.6 0.8 1.0
Sensitivity
1-Specificity
Model 3 Model 4
Figur e 2 Distribution of predictive index values (A ) and ROC curves (B) in Model 3 and Model 4.
T able 5 Pre-test probability, likelihood ratio, and post-test probability for different predictive models of primary optimal cytoreduction in ovarian cancer
T est Cut off
Pr e-t est pr obabilit y
Posit ive likelihood r at io
Post -t est pr obabilit y
Model 2 5 55.8 9.86 92.6
Model 4 3 55.8 10.25 92.8
T able 6 Performance of Approach A (Model 2) in defining the rate of patients unnecessarily explored or inappropriately unexplored
Model 2
PIV
U nnecessar i ly explor ed (1 N PV) (%)
Inappr opr iat ely unexplor ed (1 PPV) (%)
0 17.9 28.8
1 25.0 27.6
2 33.3 19.4
3 39.0 18.2
4 48.1 16.3
5 50.0 7.4
6 53.6 5.0
7 54.3 0
CT scan and cyt or educt ion in ovar ian cancer G Ferrandina et al 1070
British Journal of Cancer (2009) 101(7), 1066–1073 & 2009 Cancer Research UK
C lin ic a l S tu d ie s
Ferrandina G, BJC, 2009
1-Specificity
Sensitivity
0.0 0.2 0.4 0.6 0.8 1.0
0.00.20.40.60.81.0
AUC= 0.758
Suidan RS, Gyn Onc, 2014 AUC3= 0.78
AUC4= 0.82
Rutten IJGC, IJGC, 2016 Ferrandina (model B) AUC
0.82
Reader 1 0.55
Reader 2 0.60
Reader 3 0.59
NACT RATIONALE in ONCOLOGY
NACT in ADVANCED OVARIAN CANCER
Clinical evidences supporting NACT
Potential risks of NACT
Catholic University management
NACT PERSPECTIVES
“Tailored” treatment
ITEMS
CHORUS TRIAL
Kehoe et al, Lancet 2015
NACT vs PDS: RCTs
• Selection bias in recruitment of patiens believed to be inoperable with high tumor load
(Fotopolou at al. JCO-2017)
PFS = 12m (IDS) vs 10,7 m (PDS)
mOS= 24,6m (IDS) vs 22,6 m (PDS)
EORTC TRIAL
Vergote et al, NEJM, 2010
mOS = 30 m (IDS) vs 29 m (PDS)
Low survival rates due to:
• 1) patients’
selection;
• 2) surgery was substandard compared with that in other trials;
(S.Chi at al. “is the easy way ever the better way?”JCO- 2011)
• Multicentric RCT (87 hospitals in the UK and New Zealand)
• 550 women with FIGO stage III or IV of OC randomized
• 276 PDS vs 274 NACT/IDS
• Median FU: 52m
• Multicentric RCT (59 institutions)
• 718 pts enrolled, 670 women with biopsy- proven FIGO stage IIIC or IV OC randomized
• 336 PDS vs 334 NACT/IDS
• Median FU: 55m