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: [email protected]
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