Most Patients With Mucinous Ovarian Cancer Don't Need Perioperative GI Endoscopy

There is no significant difference in overall survival (OS) between patients with mucinous ovarian cancer who underwent gastrointestinal (GI) endoscopy compared with those who did not, according to a study published in the European Journal of Obstetrics & Gynecology and Reproductive Biology. The findings suggest routine use of GI endoscopy for mucinous ovarian cancer in the perioperative setting should only be used routinely for patients at a high risk of metastatic disease.

Mucinous ovarian cancer is rare, with an incidence rate low as 3% among those with any type of ovarian cancer, and it often presents in early stages and is common in young women. When diagnosed early, the prognosis is better than in serous ovarian cancer, but when mucinous ovarian cancer is diagnosed in late stages, the prognosis is worse than serous ovarian cancer.

The management of mucinous ovarian cancer can be challenging due to its rarity and because many mucinous ovarian cancers are metastases from the GI tract or other sites. Unidirectional or bidirectional GI endoscopy is therefore commonly used to identify metastatic tumors to the ovary, but there is a lack of data on the value of GI endoscopy in mucinous ovarian cancer management.

“These investigations might cause a significant delay in the treatment and are also exposing the patients to risks and complications,” the authors wrote. “Moreover, a proportion of patients have their procedure abandoned due to pain, which in turn leads to further treatment delay.”

The single-center, retrospective study reported on clinicopathological features and survival rates of patients with mucinous ovarian cancer at Nottingham Gynecological Oncology Centre in the United Kingdom, also assessing the role of perioperative GI endoscopy on OS. The authors also conducted a literature review to examine current evidence.

Ovarian cancer illustration | Image credit: Crystal light - stock.adobe.com

A total of 43 cases were included in the final analysis. The median age at diagnosis was 58 years, and the median maximal tumor diameter was 180 mm. In 32 cases (74.5%) tumors were unilateral, and 11 (25.5%) patients had bilateral tumors. Thirty cases (69.7%) were stage I, 1 case (2.3%) was stage II, 7 cases (16.4%) were stage III, and 5 cases (11.6%) were stage IV disease. In 4 cases (9.3%) histological examination determined the disease was metastatic to the ovary vs primary mucinous ovarian cancer. Overall, 41 patients had staging surgical procedures, and 2 had limited surgery due to poor performance status.

In 14 cases (32.5%), patients underwent GI endoscopy, with 12 cases including GI endoscopy as part of perioperative assessments and 2 cases performing endoscopy due to dyspepsia in a later stage. There were 2 cases of GI cancer diagnosed by GI endoscopy—1 case of bowel cancer not related to ovarian cancer and 1 case of primary gastric cancer. The estimated total cost of the endoscopies was £5635 ($7,006.11 USD).

The 5-year OS among those included in the study was 62.8%, with a 5-year OS of 60% in the endoscopy group and 64.3% in the non-endoscopy group, although this finding was not statistically significant (P = .767). A total of 9 patients (20.9%) experienced disease recurrence, all of which occurred within 5 years of surgery. The median time to recurrence was 11.5 months post surgery.

“Our findings show that the survival rates of patients treated for MOC in our center are similar to other relevant published studies,” the authors wrote. “In addition, we did not find any statistically significant difference in the OS of the patients who underwent GI endoscopy as part of their perioperative assessment versus those who did not.”

The study was limited by its retrospective design and some missing data in older notes that may have led to bias. The small sample size was also a limitation that could have led to overestimation or underestimation of survival and disease recurrence rates. While a larger multicenter trial could address the sample size limitation, the authors noted that conducting clinical trials in mucinous ovarian cancer is difficult due to its rarity.

Overall, the authors concluded the findings suggest routine GI endoscopy is not needed for most patients in the perioperative setting due to the lack of statistically significant benefits in terms of OS and because it cannot identify all GI lesions, notably appendiceal lesions.

“However, the authors believe that GI endoscopy is crucial and should be performed in cases where imaging and clinical picture raise the suspicion of metastatic disease,” they concluded. “Future research could focus on organizing a multi-center database and a prospective study on mucinous ovarian cancer, in order to obtain a larger sample and to provide robust evidence and guidance regarding the management of this rare type of cancer.”


Reference
Katsanevakis E, Addo-Yobo W, Bharathan B, et al. Is routine gastrointestinal endoscopy required in every woman with mucinous ovarian cancer? An analysis of survival rates and metastatic tumours in a cancer centre. Eur J Obstet Gynecol Reprod Biol. 2024;294:105-110. doi:10.1016/j.ejogrb.2024.01.012