Journal of Surgical Oncology

LETTER TO THE EDITOR

Commentary on ‘‘Response Criteria Can be Misleading

When Drawing Conclusion Regarding Neoadjuvant

Chemotherapy in Advanced Ovarian Cancer’’

YUSUF YILDIRIM, MD, PhD AND IBRAHIM E. ERTAS, MD*Department of Gynecologic Oncology, Aegean Obstetrics and Gynecology Education and Research Hospital, Izmir, Turkey

Dear Editor,

We appreciate the insightful comments from Bellati et al. and

welcome the opportunity to discuss and explain some findings of our

article further. They present a letter to the editor entitled ‘‘Response

criteria can be misleading when drawing conclusion regarding

neoadjuvant chemotherapy in advanced ovarian cancer’’ and consider

that the results of Yildirim et al. would be highly informative if

compared the prognosis between primary surgery and neoadjuvant

chemotherapy (NACT) plus interval cytoreductive surgery. In this

context, there are many large sampled studies evaluating the

prognostic consequences between women treated with primary cytor-

eductive surgery followed by platinum-based chemotherapy and

NACT followed by interval surgical cytoreduction [1–3]. First of all,

the aim and different side of our study were to identify disease and

treatment-related predictors of response to NACT in 35 patients with

advanced stage epithelial ovarian cancer (EOC) who were not

optimally cytoreductable.

In the literature, there were no uniform applicable selection crite-

ria to consistently identify patients with surgically unresectable dis-

ease and thus for administrating NACT. In our clinical practice, we

generally prefer primer cytoreductive surgery followed by platinum-

based chemotherapy because we believe that primary surgery, when

technically feasible, intuitively appears as the most direct way to

eliminate tumor burden. However, whether selecting primary surgery

or NACT often depends on experience of the surgical team and there

is a widespread lack of surgical expertise for the management of

ovarian cancer in different centers. In our institution, we are able to

carry out some aggressive upper abdominal surgical cytoreductive

procedures such as resections of pancreas, liver, and diaphragma and

therefore perform NACT for only small part of the patients [4]. We

performed NACT to 20% of all of patients with advanced stage EOC

45/224 of whom 35 were eligible for the current study. Clinical re-

sponse after NACT was found to be 34.3% and this rate was lower

than Mazzeo et al.’s study having rate of about 75% [5]. Our low-

response rate can be explained by our different and relatively strict

patient selection criteria for NACT summarized in Table 1 available

with the full text of the article at J Surg Oncol 2012. Especially,

patients with very extensive omental and upper abdominal disease

and large bulky paraortic nodal metastases are the candidates for

NACT in our setting and our selection criteria differ from 2011

Leuven criteria [6].

Bellati et al. state that in our study at least 9/35 (26%) patients

did have a reduction in their tumors bulk. We do not agree with their

statement and this is an incorrect opinion since optimal cytoreduc-

tion (with or without macroscopic residual disease) was subsequently

achieved in 32 of 35 patients (91%) after NACT followed by interval

cytoreductive surgery and the rate in our study is concordant with

those in published data [1–6]. Moreover, Bellati et al. state that there

is a large debate by physicians worldwide on what criteria RECIST,

WHO criteria, or incorporating CA-125 (GCIG criteria) should be

used to define a disease response in ovarian cancer. We agree with

this statement because there is no study prospectively evaluating

which criteria RECIST (monodimensional) [7], WHO (bidimen-

sional) [8], or GCIG criteria [9] are adequate to measure the true

tumor burden and progression in advanced EOC. However, similar to

our approach, a 2012 study by Chi et al. [1] performing NACT for

31 patients (10% of all stage IIIC-IV patients) evaluated responses

with CT-based RECIST system. We therefore consider that overall

the results of our study would not have changed if WHO criteria had

been used instead of RECIST. Of course, imaging modalities does

not have an excellent sensitivity and accuracy rates in staging and

re-evaluating of solid tunors. Also, as stated by Bellati et al., CT

might show a decrease in only solid component and therefore not

reflect true changes in actual tumor size including cumulative de-

crease in both solid and liqued components. However, imaging tech-

niques among all evaluation methods have continued to become the

mostly used methods for this condition. In a recent meta-analysis,

the common selected methods reported for NACT candidates were

pre-surgical imaging screening with or without laparoscopy (in 16 of

21 studies) [3].

The conclusion from our retrospective and small sampled study

should be that patients with extensive omental disease may have less

Conflict of interest: Nothing to declare.

*Correspondence to: Ibrahim E. Ertas, MD, Department of GynecologicOncology, Aegean Obstetrics and Gynecology Education and ResearchHospital, Gaziler St., No: 468, 35120, Izmir, Turkey. Fax: þ90-232-457-96-51. E-mail: drertas@gmail.com

Received 6 February 2012; Accepted 10 February 2012

DOI 10.1002/jso.23083

Published online in Wiley Online Library(wileyonlinelibrary.com).

� 2012 Wiley Periodicals, Inc.

response to NACT and these patients are possibly better treated with

primary surgery.

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2 Yildirim and Ertas

Journal of Surgical Oncology