Despite lacking clinical data, the Dutch government is considering increasing the minimum annual surgical volume per center from twenty to fifty cytoreductive surgeries (CRS) for advanced-stage ovarian cancer (OC). This study aims to evaluate whether this increase is warranted.
This population-based study included all CRS for FIGO-stage IIB-IVB OC registered in eighteen Dutch hospitals between 2019 and 2022. Short-term outcomes included result of CRS, length of stay, severe complications, 30-day mortality, time to adjuvant chemotherapy, and textbook outcome. Patients were stratified by annual volume: low-volume (nine hospitals, <25), medium-volume (four hospitals, 29-37), and high-volume (five hospitals, 54-84). Descriptive statistics and multilevel logistic regressions were used to assess the (case-mix adjusted) associations of surgical volume and outcomes.
A total of 1646 interval CRS (iCRS) and 789 primary CRS (pCRS) were included. No associations were found between surgical volume and different outcomes in the iCRS cohort. In the pCRS cohort, high-volume was associated with increased complete CRS rates (aOR 1.9, 95%-CI 1.2-3.1, p = 0.010). Furthermore, high-volume was associated with increased severe complication rates (aOR 2.3, 1.1-4.6, 95%-CI 1.3-4.2, p = 0.022) and prolonged length of stay (aOR 2.3, 95%-CI 1.3-4.2, p = 0.005). 30-day mortality, time to adjuvant chemotherapy, and textbook outcome were not associated with surgical volume in the pCRS cohort. Subgroup analyses (FIGO-stage IIIC-IVB) showed similar results. Various case-mix factors significantly impacted outcomes, warranting case-mix adjustment.
Our analyses do not support further centralization of iCRS for advanced-stage OC. High-volume was associated with higher complete pCRS, suggesting either a more accurate selection in these hospitals or a more aggressive approach. The higher completeness rates were at the expense of higher severe complications and prolonged admissions.

Textbook outcome (TO) is a composite outcome measure used in surgical oncology to compare hospital outcomes using multiple quality indicators. This study aimed to develop TO as an outcome measure to assess healthcare quality for patients undergoing cytoreductive surgery (CRS) for advanced-stage ovarian cancer.
This population-based study included all CRS for FIGO IIIC-IVB primary ovarian cancer registered in the Netherlands between 2017 and 2020. The primary outcome was TO, defined as a complete CRS, combined with the absence of 30-day mortality, severe complications, and prolonged length of admission (≥ten days). Delayed start of adjuvant chemotherapy (≥six weeks) was not included in TO because of missing data. Logistic regressions were used to assess the association of case-mix factors with TO. Hospital variation was displayed using funnel plots.
A total of 1909 CRS were included, of which 1434 were interval CRS and 475 were primary CRS. TO was achieved in 54% of the interval CRS cohort and 47% of the primary CRS cohort. Macroscopic residual disease after CRS was the most important factor for not achieving TO. Age ≥ 70 was associated with lower TO rates in multivariable logistic regressions. TO rates ranged from 40% to 69% between hospitals in the interval CRS cohort and 22% to 100% in the primary CRS cohort. In both analyses, one hospital had significantly lower TO rates (different hospitals). Case-mix adjustment significantly affected TO rates in the primary CRS analysis.
TO is a suitable composite outcome measure to detect hospital variation in healthcare quality for patients with advanced-stage ovarian cancer undergoing CRS. Case-mix adjustment improves the accuracy of the hospital comparison.

BACKGROUND: Patients with unresectable disease during cytoreductive surgery (CRS) for advanced-stage ovarian cancer are underreported. Knowledge of treatment and survival after surgery is limited. The aim of this study is to address the knowledge gap about postoperative treatment and survival of patients whose surgery was abandoned due to unresectability after abdominal exploration.
METHODS: Women with FIGO stage IIIB-IV epithelial ovarian cancer whose disease was considered to be unresectable during surgery were included in this prospective study, a post hoc analysis of the PlaComOv study. The unresectable disease was defined as the inability to achieve at least suboptimal CRS without attempted CRS after careful inspection of the entire abdomen. Preoperative clinical data, perioperative findings, postoperative treatment and survival data were analyzed.
RESULTS: From 2018 to 2020, 27 patients were included in this analysis. Treatment ranged from the cessation of treatment to one or several lines of chemotherapy with or without maintenance therapy. The median overall survival was 16 (IQR 5-21) months (95%CI 14-18). At 24 months of follow-up, four patients (15%) were alive.
CONCLUSIONS: This study indicated a two-year survival of 15%. Optimal treatment strategies in terms of survival benefits are still ill-defined. Further study of this specific group of patients is warranted. We advocate an (inter)national registry of patients with unresectable cancer and comprehensive follow-up.

Diaphragmatic surgery in advanced-stage ovarian cancer has been considered since long time to increase the rates of postoperative complications. However, improvement of surgical techniques and perioperative management of these patients has lead in the last decade to a safe association of such procedures as part of debulking process. The aim of the current paper was to report our experience regarding the role of diaphragmatic resections as part of debulking surgery for advanced stage ovarian cancer.
Between 2014 and 2016 diaphragmatic surgery was performed in 22 cases with advanced stage ovarian cancer.
Diaphragmatic surgery consisted of diaphragmatic peritoneal resection in 10 cases, full thickness diaphragmatic resections in four cases and coagulation of peritoneal nodules in eight cases. In all but two cases debulking surgery to no residual disease was achieved. Other upper abdominal resections consisted of splenectomy - in four cases, liver resections - in three cases, glissonian capsule resections - in eight cases, distal pancreatectomy - in one case and partial gastrectomies in two cases. The postoperative outcomes were similar irrespective of type of diaphragmatic surgical procedure.
Diaphragmatic surgery is a crucial procedure which can be safely associated as part of debulking surgery for advanced stage ovarian cancer.

OBJECTIVE: The aim of this study was to evaluate the use of neoadjuvant chemotherapy (NACT) and primary debulking surgery (PDS) before and after results from a randomized trial were published and showed non-inferiority between NACT and PDS in the management of advanced-stage ovarian carcinoma.
METHODS: We evaluated consecutive patients with advanced-stage ovarian cancer treated at our institution from 1/1/08-5/1/13, which encompassed 32 months before and 32 months after the randomized trial results were published. We included all newly diagnosed patients with high-grade histology and stage III/IV disease. Associations between the use of NACT and clinical variables over time were evaluated.
RESULTS: Our study included 586 patients. Median age was 62 years (range, 30-90); 406 patients (69%) had stage III disease, and 570 (97%) had disease of serous histology. Twenty-six percent (154/586) were treated with NACT and 74% (432/586) with PDS. NACT use increased significantly from 22% (56/256) before 2010 (at which point the results of the randomized trial were published) to 30% (98/330) after 2010 (p=0.037). Although patients who underwent PDS were more likely to experience grade 3/4 surgical complications than those who underwent NACT, those selected for PDS had a median OS of 71.7 months (CI, 59.8-not reached) compared with 42.9 months (CI 37.1-56.3) for those selected for NACT.
CONCLUSIONS: In this single-institution analysis, the best survival outcomes were observed in patients who were deemed eligible for PDS followed by platinum-based chemotherapy. Selection criteria for NACT require further definition and should take institutional surgical strategy into account.

OBJECTIVE: To demonstrate the efficacy of pancreatic resection as part of cytoreductive surgery for advanced-stage and recurrent epithelial ovarian cancer.
METHODS: Data of patients submitted to cytoreductive surgery for advanced-stage and relapsed epithelial ovarian cancer at the Dan Setlacec Center of Gastrointestinal Disease and Liver Transplantation, Fundeni Clinical Institute, Romania, treated between January 2002 and May 2014 were retrospectively reviewed.
RESULTS: A total of six cases were eligible for the study: one case was submitted to pancreatic resection in the context of primary cytoreduction, four cases were submitted to pancreatic resection during secondary cytoreduction, while the sixth case was submitted to distal pancreatectomy as part of tertiary cytoreduction. The early postoperative course was uneventful in four cases, while the other two developed pancreatic fistulas. In one case, the leak was managed in a conservative manner, while in the second case re-operation was required. Thirty-day mortality was zero. At the time of writing, the patient submitted to pancreatic resection during primary cytoreduction was still alive with disease at 54 months and proposed for secondary cytoreduction. The median overall survival for cases submitted to pancreatic resection in the context of secondary cytoreduction was 36.38 months, while the patient submitted to distal pancreatectomy at the moment of tertiary cytoreduction was dead of disease 10 months after surgery.
CONCLUSIONS: Pancreatic resections can be safely performed in the context of cytoreductive surgery for advanced-stage and relapsed epithelial ovarian cancer, with acceptable rates of morbidity, therefore benefit in terms of survival might be achieved.