Laparoscopy Compared With Laparotomy for Debulking Ovarian Cancer After Neoadjuvant Chemotherapy

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We read with great interest the study by Melamed et al.1 In this retrospective analysis, more than 3,071 (450 laparoscopy, 2,621 laparotomy) patients with stage IIIC–IV ovarian cancer underwent the intended interval debulking surgery. Three-year survival rates were similar between the surgical approach (laparoscopy compared with laparotomy) and when excluding the 72 (16%) women who converted from laparoscopy to laparotomy.
Given that the outcomes were no different between groups, a key question is how do we select which patients are preferred for laparoscopy? A couple of points deserve to be addressed. First, there is no mention of the drugs used and number of chemotherapy cycles performed before and after interval debulking surgery. Considering that the selection of surgical route could be affected by response to chemotherapy, that point could be of interest. Furthermore, according to Bristow's meta-analysis,2 each incremental increase in preoperative chemotherapy cycles was associated with a decrease in median survival time of 4.1 months (P=.046). These data need to be evaluated when comparing survival rates.
Secondly, patients in the laparoscopy group had procedures limited to only gynecologic organs more frequently than those in the laparotomy group (16.7% compared with 10.1%; P<.001). This is an indirect expression of lower burden of disease. So, even if in the laparoscopy group there were more patients with stage IV cancer (16% compared with 13%; P=.02), we do not know what kind of response they had to chemotherapy.
Minimally invasive surgery is widely adopted to treat endometrial3 and cervical cancers, but it is not the standard for advanced ovarian cancer. The minimally invasive approach has advantages in terms of recovery, length of hospital stay, and cosmetics and should be offered to any patient unless it compromises the oncologic outcome. The point that needs to be stressed is the selection of patients who will benefit more from the minimally invasive approach. We agree with the authors when they write, “in well-selected patients, such as those who have a complete response to neoadjuvant chemotherapy, laparoscopic interval debulking surgery may be a safe and effective alternative to laparotomy.” So the questions we have to answer are, “Which patients will benefit from laparoscopy?” and “How do we select patients for laparoscopy?” Further attempts are needed to improve patients' care in the era of personalized medicine.

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