Effects of neoadjuvant chemotherapy on prognosis and platinum resistance of advanced ovarian cancer

Effects of neoadjuvant chemotherapy on prognosis and platinum resistance of advanced ovarian cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of neoadjuvant chemotherapy on prognosis and platinum resistance of advanced ovarian cancer Weishan Li, Jia Liu, Peng Chen, Zhihui Liu, Danbo Wang, Zhuo Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6195402/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Objective: Primary Debulking Surgery (PDS) combined with platinum-based chemotherapy is the standard therapy for ovarian cancer. Some trials have suggested that neoadjuvant chemotherapy-Intermittent Debulking Surgery(NACT-IDS) can achieve equivalent efficacy in the chemotherapy of combining PDS, without influencing OS. This study aimed to explore the effects of NACT-IDS on the prognosis and platinum resistance of advanced ovarian cancer, so as to provide a certain basis for the selection of suitable clinical therapies. Methods: The patients with advanced ovarian cancer were selected from January 1, 2014 to January 1, 2017. The patients were assigned to NACT-IDS group or PDS group after evaluation by gynecological oncologists. We analysed the clinical data and collected the follow-up data of cases over 5 years. Results: Totally 173 patients were enrolled into the study, including 52 cases in NACT-IDS group and 121 cases in PDS group.The platinum-resistant relapse rate in NACT-IDS group was evidently greater than that in PDS group (22.9% vs 4.5%, P<0.001), and the multi-factor analysis results also proved that NACT (OR=7.822, 95%CI 2.121-28.855) was an independent risk factor for platinum-resistant relapse of ovarian cancer. No significant differences in PFS, RS and OS were found between two groups. Conclusion: NACT-IDS may increase the risk of platinum resistance, and it is not advisable to expand its indications blindly. During the IDS procedure, the surgical standard should aim for a more thorough tumor bed resection, achieving an R0 resection, in order to avoid the increased risk of recurrence. Precise selection of indications and comprehensive precision management throughout the treatment course are essential, as neoadjuvant chemotherapy does not necessarily affect prognosis. Neoadjuvant chemotherapy-Intermittent Debulking Surgery Primary Debulking Surgery ovarian cancer platinum resistance Figures Figure 1 1 Introduction Ovarian cancer is a female reproductive system tumor with the highest mortality, and epithelial ovarian cancer is seen most frequently. According to the latest data statistics published, the annual number and annual death number of patients with ovarian cancer are 52,100 and 22,500 in China and trend to increase continuously, while the 5-year overall survival (OS) is still < 44% [ 1 ] . Primary Debulking Surgery (PDS) combined with platinum-based chemotherapy is the standard therapy for ovarian cancer. However, due to lack of accurate techniques for early diagnosis and evaluation, about 70% ovarian cancer patients are in the advanced stage at the initial diagnosis [ 2 ] . For extensive abdominopelvic transcoelomic metastasis, primary surgery sometimes difficultly achieves satisfactory cytoreduction, and postoperative residual tumor will result in significantly poor prognosis, thus neoadjuvant chemotherapy with Interval Debulking Surgery (NACT-IDS) is another therapy for advanced ovarian cancer [ 1 ] . In recent years, the results of two international randomized controlled trials have suggested that NACT-IDS can achieve equivalent efficacy in the chemotherapy of combining PDS, without influencing OS [ 2 , 3 ] . However, some studies have indicated that neoadjuvant chemotherapy (NACT) may induce chemotherapeutic resistance [ 4 ] and thus affect the prognosis [ 5 – 7 ] , and it becomes a hot clinical concern whether NACT-IDS applies to and benefits advanced ovarian cancer. This study aimed to explore the effects of NACT-IDS on the prognosis and platinum resistance of advanced ovarian cancer, so as to provide a certain basis for the selection of suitable clinical therapies. 2 Materials and Methods 2.1 Subjects The patients with advanced ovarian cancer were selected who were admitted to the Department of Gynecology of Liaoning Cancer Hospital from January 1, 2014 to January 1, 2017. The inclusion criteria were as follows: ① patients whose surgery was completed by the gynecological oncologist in our hospital; ② patients with epithelial ovarian cancer FIGO stage IIIC or IV (surgical pathology); ③ patients who received the combined chemotherapy of platinum drugs and paclitaxel drugs and whose surgery was completed within 30 days after the last cycle of NACT; ④ patients who received chemotherapy for ≥ 6 cycles including ≤ 4 cycles of NACT; ⑤ patients who achieved complete remission (CR) or partial remission (PR) in the medical condition after all treatments. The exclusion criteria were described below: ① patients with other histological types of ovarian cancer, recurrent or metastastic ovarian cancer; ② patients complicated with other malignant tumors; ③ patients who failed to complete the initial full-course treatment including surgery and chemotherapy for various reasons; ④ patients treated with the combined chemotherapy of non-platinum drugs and paclitaxel drugs; ⑤ patients who received first-line maintenance treatments including combined chemotherapy of antiangiogenic agents or application of poly-ADP-ribose polymerase (PARP) inhibitors. The clinical data and follow-up data of all cases during study were collected. 2.2 Methods 2.2.1 Open grouping The patient's condition was assessed by gynecologic oncologists, who evaluated the tumor distribution, tumor burden, and Sudan score through comprehensive imaging and laboratory tests. The general health status was also assessed, including the presence of comorbidities and other diseases, as well as the ECOG performance status. The study was divided into two groups: the NACT-IDS group (52 cases) and the PDS group (121 cases). In the NACT-IDS group, chemotherapy was administered following a pathological diagnosis. Among these, 24 patients underwent one cycle of neoadjuvant chemotherapy. This included patients initially treated with one cycle of chemotherapy at local hospitals before being transferred to our institution for further evaluation and direct surgery, as well as patients who required medical treatment for comorbidities, such as hypertension and diabetes, before undergoing surgery after one cycle of chemotherapy. 2.2.2 Surgical treatment The operation range of cytoreduction (including primary surgery and interval surgery) contains the whole uterus, bilateral appendages, omentum majus, vermiform appendix and all resectable lesions at other sites, as well as spleen, intestine and other organs if necessary. Satisfactory cytoreduction was defined as no residual tumor after operation (R0) or residual tumor diameter ≤ 1cm (R1).Unsatisfactory cytoreduction was defined as the residual tumor diameter > 1cm (> R1). 2.2.3 Chemotherapy NACT and postoperative chemotherapy were performed with platinum drugs and paclitaxel drugs by intravenous infusion or intravenous infusion plus intraperitoneal perfusion at an interval of 21–28 days. The chemotherapy of 1–4 cycles was conducted in NACT-IDS group before operation, and there were totally ≥ 6 cycles of chemotherapy in two groups. 2.2.4 Efficacy evaluation In accordance with WHO efficacy evaluation standard for solid tumors, complete remission (CR) referred to complete disappearance of all tumor lesions with serum CA125 level ≤ 35U/ml; partial remission (PR) referred to a decrease of ≥ 50% in the sum of vertical diameter products of tumor lesions with double diameters measurable for at least 4 weeks, or a decrease of ≥ 50% in the sum of maximum diameters of various lesions with single diameter measurable for at least 4 weeks; progressive disease (PD) referred to a > 25% increase of one or more lesions, or appearance of new lesions, newly occurring hydrothorax or ascites; stable disease (SD) referred to a decrease of < 50% or an increase of ≤ 25% in the sum of maximum diameter products of various lesions with double diameters measurable for at least 4 weeks, and SD was assessed only after at least 2 cycles of treatment; overall remission rate (ORR) = CR + PR, and disease control rate (DCR) = CR + PR + SD. 2.2.5 Relapse judgment Relapse was defined as tumor relapse after achieving clinical remission following systematic and standard treatment.This study analyzed the first recurrence following initial systemic therapy.Platinum-sensitive relapse was defined as tumor progression or relapse at < 6 months after chemotherapy discontinuation when there was a definite response to platinum-based initial treatment and the clinical remission was achieved; partial sensitive relapse was defined as tumor progression or relapse at 6–12 months after chemotherapy discontinuation; complete sensitive relapse was defined as tumor progression or relapse at > 12 months after chemotherapy discontinuation. Platinum-resistant relapse was defined as tumor progression or relapse at < 6 months after chemotherapy when there was a response to initial chemotherapy. 2.2.6 Follow-up The patients were followed up by outpatient visits, hospitalization or telephone, with the following contents including but not limited to tumor evaluation (MRI/CT imaging examination and CA125 level), general condition, concomitant treatment and medication during treatment and follow-up. The follow-up for all cases was terminated till relapse, death or follow-up endpoints (deadline: May 31, 2022). Progress free survival (PFS) was defined as the time from the treatment starting to the first tumor progression or death; overall survival (OS) was defined as the time from the treatment starting to the patient death caused by various factors. All cases surviving at the end of follow-up were truncated at the follow-up endpoints. If there was a permanently progressive disease during treatment which was not effectively controlled and needed continuous treatment for no good control at the follow-up endpoints or death, PFS was 0. 2.3 Statistical analysis SPSS 25.0 statistical software was used for data processing. The qualitative data were compared with χ2 test or Fisher’s exact probability test. The quantitative data were firstly analyzed for distribution, those of normal distribution were compared with t test and expressed as mean ± standard deviation (SD), and those of skewed distribution were compared with nonparametric test and presented as median (lower quartile – upper quartile). The multi-factor analysis was performed using non-conditional Logistic regression model, and the survival analysis using Kalan-Meier survival curve. The survival was compared with Log-rank test, and the multi-factor survival analysis was conducted with Cox proportional hazard model. P < 0.05 indicated a statistically significant difference. 3 Results 3.1 General data Totally 173 patients were enrolled into the study, including 52 cases in NACT-IDS group and 121 cases in PDS group. The enrolled patients were aged as 30-76 (median: 55) years. According to the International Federation of Gynecologists and Obstetricians (FIGO) staging standard, there were 158 cases of stage IIIC ovarian cancer and 15 cases of stage IV ovarian cancer. Serous adenocarcinoma (159 cases, 91.9%) and high-grade ovarian cancer (132 cases, 76.3%) was dominant in pathology and histology, respectively. There was satisfactory surgical cytoreduction (R0+R1) in totally 137 cases (79.1%). No statistical difference was observed in the age, pathological type, postoperative residual tumor, and chemotherapy cycle between two groups (P>0.05). Compared with PDS group, the percentage of patients with stage IV ovarian cancer was significantly higher in NACT-IDS group (P<0.05), and that of patients with satisfactory cytoreduction was evidently greater (82.7% vs. 77.7%), while that of patients with the co-resection of spleen, intestine and other organs was markedly lower (P<0.05) (see Table 1). 3.2 Efficacy evaluation and relapse In this study, ORR (CR+PR) of 173 cases was up to 98.8% after initial treatment and DCR was 100%. There were 159 cases of follow-up and 14 cases of loss of follow-up, and the follow-up rate was 91.90%. The median follow up time of NACT-IDS group and PDS group were 56 months and 62 months(P<0.05).By the follow-up endpoints, there were 120 cases (75.5%) of relapse, including 104 cases (86.7%) of sensitive relapse; no statistical difference in the overall relapse rate was found between NACT-IDS group and PDS group, but the platinum-resistant relapse rate in NACT-IDS group was significantly higher than that in PDS group (P<0.05). (See Table 2) 3.3 Influential factors for platinum-resistant relapse of ovarian cancer For platinum-resistant relapse of ovarian cancer in 171 cases of clinical remission (except 2 cases of SD), the relevant factors were analyzed. The one-factor analysis results showed that the therapy (NACT-IDS or PDS) and CA125 level before treatment were correlated with platinum-resistant relapse (P<0.05) (see Table 3). As suggested by the multi-factor analysis results, NACT (OR=7.822, 95%CI 2.121-28.855) and a high CA125 level before treatment (OR=1.001, 95%CI 1.000-1.001) were two independent risk factors for platinum-resistant relapse of ovarian cancer (P<0.05) (see Table 4). The results of further stratified analysis revealed that only at R0 surgical cytoreduction, the platinum-resistant relapse rate in NACT-IDS group was higher than that in PDS group (P0.05; see Table 6). At either R1 or >R1 surgical cytoreduction, there was no statistical difference in the platinum-resistant relapse rate between two groups. 3.4 Analysis of prognosis and survival By the follow-up endpoints, the median PFS, survival number, 5-year survival rate and median relapse survival (RS) were 26 months(95%CI 20.236-29.764 months) and 27 months(95%CI 15.816-36.184 months), 17 and 45,39.6% and 51.3%,28 months(95%CI 16.694-39.306 months) and 35 months(95%CI 27.061-42.939 months) in NACT-IDS group and PDS group, respectively; however, there were no statistically significant differences in PFS, OS and RS between two groups (P>0.05).(see Figure 1).The survival analysis was performed with Cox proportional hazard model, and the results showed that platinum-resistant relapse was an independent risk factor for decreased OS (P<0.001) (see Table 7). 4 Discussion Cytoreduction + platinum-based combined chemotherapy is the standard therapy for advanced ovarian cancer, while satisfactory cytoreduction achieved by primary surgery is the most important independent factor influencing the prognosis of ovarian cancer [ 4 ] . Due to lack of accurate techniques for early diagnosis and screening, over 70% ovarian cancer patients are in the advanced stage at the initial diagnosis, and it is difficult for a part of patients to realize satisfactory surgical cytoreduction after comprehensive evaluation or allow for direct surgical treatment because of serious medical co-morbidities. Therefore, NACT-IDS becomes one of optional therapies preferred by gynecological oncologists, and it is also recommended as level 1 evidence in FIGO Guideline (2019) and NCCN Guideline (2022). However, the indications and efficacy of NACT-IDS therapy as well as its prognostic influence and increase of platinum resistance risk are still hot concerns in the current clinical research and need to be further studied and explored. Several studies have suggested that neoadjuvant chemotherapy (NACT) may increase the risk of platinum resistance. The study by Rauh-Hain [ 8 ] found that the proportion of platinum resistance was significantly higher in the NACT-IDS group compared to the PDS group (88.8% vs 55.3%, P < 0.05). Particularly, the analysis of resistance factors showed that patients receiving more than six total cycles of chemotherapy had a 2.59-fold increased risk of resistance. Similarly, Petrillo [ 9 ] observed that the platinum-resistant recurrence rate was significantly higher in the NACT-IDS group than in the PDS group (35.9% vs 5.0%, P < 0.05). Studies by Da Costa [ 6 ] and Luo Y [ 7 ] also suggested that NACT-IDS increases the risk of platinum resistance.Consistent with these findings, our study revealed that the platinum-resistant recurrence rate in the NACT-IDS group was significantly higher than in the PDS group (22.9% vs 4.5%, P < 0.001).These results indicate that while NACT plays an important role in ovarian cancer treatment, it should be reserved for patients in whom achieving optimal PDS is unlikely. Blindly expanding the indications for NACT may increase the risk of resistance, leading to more harm than benefit. Additionally, some researchers have proposed that larger tumor burdens at the time of initial chemotherapy increase the possibility of mutations and chemotherapy resistance [ 10 , 11 ] . In our study, the proportion of patients with stage IV disease was higher in the NACT-IDS group than in the PDS group (15.4% vs 5.8%), and the tumor burden was greater in the NACT-IDS group. Multivariate analysis confirmed that NACT is an independent risk factor for the development of platinum resistance (OR = 7.822, 95%CI 2.121–28.855).Several basic research studies have elucidated potential molecular mechanisms by which NACT may contribute to platinum resistance. These include the induction of DNA repair mechanisms by NACT, which leads to recovery mutations in key genes involved in DNA repair, enhancing the tumor cells' ability to repair DNA and thus increasing resistance to platinum-based drugs [ 12 ] . NACT has also been shown to promote the expression of cell membrane transport proteins ATP7A and ceruloplasmin (CP), which enhance the antioxidant stress capacity of tumor cells and reduce the toxic accumulation of platinum drugs, thereby promoting resistance [ 13 ] . Additionally, NACT-induced alterations in the extracellular matrix components and the creation of an immunosuppressive tumor microenvironment can promote epithelial-mesenchymal transition (EMT) and immune evasion [ 14 , 15 , 16 ] . NACT may also induce the sustained proliferation of cancer stem cells, further contributing to resistance [ 17 ] . Given the potential risk of platinum resistance associated with NACT, the impact of the NACT-IDS treatment approach on patient prognosis compared to PDS has become a significant area of interest. However, conclusions from various studies remain inconsistent. A meta-analysis and systematic review by Qin [ 18 ] on patients with stage III-IV ovarian cancer suggested that the PDS group demonstrated better survival benefits compared to the NACT-IDS group, with NACT-IDS only improving the rate of optimal cytoreductive surgery. Similarly, May [ 19 ] reported that the 5-year survival rate was significantly higher in the PDS group compared to the NACT-IDS group (39% vs 27%, P < 0.05). On the other hand, several studies have shown that NACT-IDS can achieve similar outcomes as PDS combined with chemotherapy, with no significant impact on overall survival (OS) [ 2 , 3 , 20 , 21 , 22 ] .Vergote and colleagues performed a re-analysis of the cases from the randomized controlled trials EORTC55971 and CHORUS, finding no significant difference in overall survival between the NACT-IDS and PDS groups [ 23 ] . A randomized controlled trial by Kehoe [ 2 ] involving 451 patients with advanced ovarian cancer also demonstrated similar outcomes, with the median PFS being 12 months in the NACT-IDS group and 10.7 months in the PDS group, and the median OS being 24.1 months and 22.6 months, respectively. However, some critics pointed out that the PFS and OS in this study were slightly lower than in other studies, raising questions about potential bias.Our study also revealed no significant statistical difference between the NACT-IDS and PDS groups in terms of 5-year survival rate (39.6% vs 51.3%, P > 0.05). It is clear that the primary goal of NACT is to enable optimal cytoreductive surgery, and there is ample evidence suggesting that only R0 resection provides significant benefit to patients [ 24 ] . In our study, the R0 resection rate was 55.8% in the NACT-IDS group, compared to 44.6% in the PDS group. Moreover, IDS significantly reduced the rate of combined organ resections, such as spleen and bowel, compared to PDS (25.0% vs 41.3%, P < 0.05). However, despite the higher R0 rate, the NACT-IDS group did not achieve better survival outcomes, which may be related to the increased risk of resistance. This hypothesis requires further confirmation through large prospective studies.It has been frequently reported that the number of NACT cycles is positively correlated with the incidence of platinum resistance [ 25 , 26 ] . In our study, 24 patients (46.1%) in the NACT group received only one cycle of NACT for reasons unrelated to disease progression. In subgroup analysis, six cases (25.0%) of platinum-resistant recurrence were observed in the group that received one cycle of NACT, the highest proportion, while patients receiving two or more cycles did not show an increased proportion of resistant recurrence. This finding raises new questions—does surgery after chemotherapy create a false impression of visual R0? In recent years, "total peritonectomy" has been widely applied in clinical practice. Sinukumar [ 27 ] studied 79 cases of stage IIIC/IVA ovarian cancer, with 30 undergoing total peritonectomy and 49 undergoing selective peritonectomy. The disease-free survival (DFS) was 37 months vs 33 months, and the 3-year OS was 95% vs 70.8% (P < 0.05), suggesting that complete resection of cancer-infiltrated peritoneum, or "tumor bed" resection, is more beneficial for improving prognosis. Could the disappearance of some tumors after NACT prevent true "tumor bed" resection, leading to the resurgence of residual cells and increasing the risk of platinum-resistant recurrence? This phenomenon merits closer attention in future assessments of IDS surgical quality. This study has certain limitations. First, as a retrospective study, the case records lacked a standardized format, and the distribution of disease severity between the two groups was not well balanced. The clinical choice of treatment was not subject to uniform standardized management, leaving room for subjectivity, which may have introduced selection bias and affected the study results. Second, the sample size in this study was insufficient, necessitating larger prospective studies in the future to provide stronger evidence for evidence-based medicine. In conclusion, NACT-IDS can serve as one of the treatment options for patients with advanced ovarian cancer. However, NACT-IDS may increase the risk of subsequent platinum resistance, and thus, the indications should not be expanded blindly. In particular, during IDS, the surgical standard should aim for more thorough tumor bed resection, achieving R0 resection, to avoid increasing the risk of recurrence from residual resistant tumor cells. Additionally, precise selection of indications and comprehensive management throughout the treatment course are essential, as neoadjuvant chemotherapy does not necessarily affect prognosis. Declarations Conflict of Interest The authors have no conflict of interest. Ethics Statement This study was approved by the Ethics Committee of Cancer Hospital of China Medical University. Funding Information This study was funded by the National Natural Science Foundation of China grant numbers:82103056; “the Fundamental Research Funds for the Central Universities”2021-ZLLH-08. Author Contribution All authors contributed to the study conception and design. Material preparation were performed by Zhihui Liu and Peng Chen. The data collection and analysis were performed by Jia Liu. The first draft of the manuscript was written by Weishan Li and was reviewed and edited by Danbo Wang and Zhuo Yang. All authors read and approved the final manuscrip. References Moufarrij S, Dandapani M, Arthofer E, Gomez S, Srivastava A, Lopez-Acevedo M, Villagra A. and Chiappinelli K B. Epigenetic therapy for ovarian cancer: promise and progress. Clin Epigenetics. 2019;11(1):7. Kehoe S, Hook J, Nankivell M, Jayson GC, Kitchener H, Lopes T, et al. 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Tables Table 1 Comparison of general data of patients between two groups (n, %, x ±s) NACT-IDS group n=52 PDS group n=121 P Age (year) 54.82±8.87(36-72) 55.35±9.45(30-76) 0.56 ≤60 38(73.0) 83(68.6) >60 14(27.0) 38(31.4) FIGO staging 0.04 * Stage IIIC 44(74.6) 114(94.2) Stage IV 8(15.4) 7(5.8) Pathological type 0.52 Serous adenocarcinoma 46(88.5) 113(93.4) Endometrioid adenocarcinoma 4(7.7) 6(4.9) Mixed type 2(3.8) 2(1.7) Histological grading 0.03 * High grade 45(86.5) 87(71.9) Low grade 7(13.5) 34(28.1) Postoperative residual tumor 0.40 R0 29(55.8) 54(44.6) R1 14(26.9) 40(33.1) >R1 9(17.3) 27(22.3) Co-resection of other organs 0.04 * Yes 13(25.0) 50(41.3) No 39(75.0) 71(58.7) Chemotherapy cycle 0.07 6 25(48.1) 41(33.9) >6 27(51.9) 80(66.1) Note: P:T test, Mann-Whitney U test, Pearson X 2 test, and Fisher’s exact test. * P<0.05 Table 2 Comparison of relapse between NACT-IDS group and PDS group (n, %) NACT-IDS group PDS group P N 48 111 Overall relapse 39(81.2) 81(73.0) 0.26 Sensitive relapse 28(58.3) 76(68.5) 0.22 Resistant relapse 11(22.9) 5(4.5) ＜0.001 * Note: P: Pearson X 2 test and Fisher’s exact test. * P60 52 5 9.6 FIGO staging 0.15 Stage IIIC 156 13 8.3 Stage IV 15 3 20.0 Pathological type 0.20 Serous adenocarcinoma 154 13 8.4 Other 17 3 17.7 Histological grading 0.36 High grade 130 14 10.8 Low grade 41 2 4.9 Therapy 0.001 * NACT-IDS 52 11 21.2 PDS 119 5 4.2 Postoperative residual tumor 0.56 R0 82 7 8.5 R1 53 4 7.6 >R1 36 5 13.9 Chemotherapy cycle 0.78 6 64 5 7.8 >6 107 11 10.3 Chemotherapy 0.21 Carboplatin 132 10 7.6 Other platinum drugs 39 6 15.4 CA125 level before treatment (U/ml) 1500.93(1052.75-3415.75) 0.004 * Note: P:Mann-Whitney U test, Pearson X 2 test, and Fisher’s exact test. * P<0.05 Table 4 Multi-factor analysis of platinum-resistant relapse of ovarian cancer B S.E. Wald P OR Age 0.028 0.035 0.670 0.413 1.029 FIGO staging 0.634 0.797 0.632 0.426 1.885 Pathological type 0.559 0.799 0.490 0.484 1.749 Histological grading 0.694 0.867 0.641 0.423 2.002 Therapy 2.057 0.666 9.540 0.002 * 7.822 Postoperative residual tumor 0.206 0.389 0.280 0.597 1.229 Chemotherapy cycle 0.409 0.644 0.403 0.526 1.505 CA125 level before treatment 0.001 0.000 7.221 0.007 * 1.001 Note: Logistic Regression Analysis. * P<0.05 Table 5 Relationship between surgical cytoreduction and platinum-resistant relapse between NACT-IDS group and PDS group NACT-IDS group PDS group P N Platinum-resistant relapse (n, %) N Platinum-resistant relapse (n, %) Postoperative residual tumor R0 29 6(20.7) 54 1(1.3) 0.007 * R1 14 2(14.3) 40 2(5.0) 0.274 ＞ R1 9 3(33.3) 25 2(8.0) 0.102 Note: P:Pearson X 2 test, and Fisher’s exact test. * P<0.05 Table 6 Analysis on platinum-resistant relapse in NACT-IDS group after satisfactory R0 cytoreduction and NACT-related factors N Platinum-resistant relapse (n) Platinum-resistant relapse rate (%) P NACT chemotherapy cycle 1 24 6 25.0 0.73 ≥2 28 5 17.9 Chemotherapy Paclitaxel + Carboplatin 45 8 17.8 0.15 Paclitaxel +other platinum drugs 7 3 42.9 Note: P:Pearson X 2 test, and Fisher’s exact test. Table 7 Survival analysis of ovarian cancer patients using Cox proportional hazard model HR 95%CI P Age 1.198 0.726～1.978 0.480 FIGO staging 0.913 0.452～1.845 0.800 Pathological type 0.750 0.334～1.683 0.486 Histological grading 1.121 0.972～1.293 0.115 Therapy (IDS or PDS) 0.756 0.477～1.198 0.234 Postoperative residual tumor 1.285 0.986～1.676 0.064 Co-resection of other organs 1.234 0.793～1.921 0.351 Chemotherapy cycle 0.942 0.601～1.477 0.795 CA125 level before treatment 0.906 0.590～1.392 0.654 Platinum - resistan t relapse 11.151 5.873～21.171 ＜0.001 * Note: * P<0.001 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 12 Mar, 2025 Editor assigned by journal 11 Mar, 2025 Submission checks completed at journal 11 Mar, 2025 First submitted to journal 10 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6195402","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":427898239,"identity":"70c97680-bf07-4257-ab95-8d66092bff14","order_by":0,"name":"Weishan Li","email":"","orcid":"","institution":"Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute","correspondingAuthor":false,"prefix":"","firstName":"Weishan","middleName":"","lastName":"Li","suffix":""},{"id":427898241,"identity":"e78d94ff-87d2-44e1-8ee0-34f3904baccd","order_by":1,"name":"Jia Liu","email":"","orcid":"","institution":"Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute","correspondingAuthor":false,"prefix":"","firstName":"Jia","middleName":"","lastName":"Liu","suffix":""},{"id":427898242,"identity":"7b3357e0-64d1-40e3-892e-51a89832ab5f","order_by":2,"name":"Peng Chen","email":"","orcid":"","institution":"Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute","correspondingAuthor":false,"prefix":"","firstName":"Peng","middleName":"","lastName":"Chen","suffix":""},{"id":427898244,"identity":"02c40cb6-c4e1-4545-a490-473907c60d73","order_by":3,"name":"Zhihui Liu","email":"","orcid":"","institution":"Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute","correspondingAuthor":false,"prefix":"","firstName":"Zhihui","middleName":"","lastName":"Liu","suffix":""},{"id":427898246,"identity":"6d197b30-b884-467d-9833-b5fc9f016f2a","order_by":4,"name":"Danbo Wang","email":"","orcid":"","institution":"Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute","correspondingAuthor":false,"prefix":"","firstName":"Danbo","middleName":"","lastName":"Wang","suffix":""},{"id":427898248,"identity":"6e576b29-b3cb-4a34-b308-29aa64f40586","order_by":5,"name":"Zhuo Yang","email":"data:image/png;base64,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","orcid":"","institution":"Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute","correspondingAuthor":true,"prefix":"","firstName":"Zhuo","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2025-03-10 12:08:37","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6195402/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6195402/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78644052,"identity":"9d3b4399-7795-4184-ad02-9466828260e8","added_by":"auto","created_at":"2025-03-17 07:18:45","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":271940,"visible":true,"origin":"","legend":"\u003cp\u003eSurvival analysis in NACT-IDS group and PDS group (1) PFS comparison; (2) OS comparison; (3) RS comparison.\u003c/p\u003e","description":"","filename":"floatimage15.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6195402/v1/c8d9f470b3ebce8337a72b76.jpeg"},{"id":78644991,"identity":"42a354b1-26a9-4ec9-b535-ec6f41729917","added_by":"auto","created_at":"2025-03-17 07:34:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1920037,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6195402/v1/88acad77-c488-4e84-a271-a99fe98d04ad.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of neoadjuvant chemotherapy on prognosis and platinum resistance of advanced ovarian cancer","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eOvarian cancer is a female reproductive system tumor with the highest mortality, and epithelial ovarian cancer is seen most frequently. According to the latest data statistics published, the annual number and annual death number of patients with ovarian cancer are 52,100 and 22,500 in China and trend to increase continuously, while the 5-year overall survival (OS) is still\u0026thinsp;\u0026lt;\u0026thinsp;44% \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Primary Debulking Surgery (PDS) combined with platinum-based chemotherapy is the standard therapy for ovarian cancer. However, due to lack of accurate techniques for early diagnosis and evaluation, about 70% ovarian cancer patients are in the advanced stage at the initial diagnosis \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. For extensive abdominopelvic transcoelomic metastasis, primary surgery sometimes difficultly achieves satisfactory cytoreduction, and postoperative residual tumor will result in significantly poor prognosis, thus neoadjuvant chemotherapy with Interval Debulking Surgery (NACT-IDS) is another therapy for advanced ovarian cancer \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. In recent years, the results of two international randomized controlled trials have suggested that NACT-IDS can achieve equivalent efficacy in the chemotherapy of combining PDS, without influencing OS \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. However, some studies have indicated that neoadjuvant chemotherapy (NACT) may induce chemotherapeutic resistance \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e and thus affect the prognosis \u003csup\u003e[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e, and it becomes a hot clinical concern whether NACT-IDS applies to and benefits advanced ovarian cancer. This study aimed to explore the effects of NACT-IDS on the prognosis and platinum resistance of advanced ovarian cancer, so as to provide a certain basis for the selection of suitable clinical therapies.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Subjects\u003c/h2\u003e \u003cp\u003eThe patients with advanced ovarian cancer were selected who were admitted to the Department of Gynecology of Liaoning Cancer Hospital from January 1, 2014 to January 1, 2017. The inclusion criteria were as follows: ① patients whose surgery was completed by the gynecological oncologist in our hospital; ② patients with epithelial ovarian cancer FIGO stage IIIC or IV (surgical pathology); ③ patients who received the combined chemotherapy of platinum drugs and paclitaxel drugs and whose surgery was completed within 30 days after the last cycle of NACT; ④ patients who received chemotherapy for \u0026ge;\u0026thinsp;6 cycles including\u0026thinsp;\u0026le;\u0026thinsp;4 cycles of NACT; ⑤ patients who achieved complete remission (CR) or partial remission (PR) in the medical condition after all treatments. The exclusion criteria were described below: ① patients with other histological types of ovarian cancer, recurrent or metastastic ovarian cancer; ② patients complicated with other malignant tumors; ③ patients who failed to complete the initial full-course treatment including surgery and chemotherapy for various reasons; ④ patients treated with the combined chemotherapy of non-platinum drugs and paclitaxel drugs; ⑤ patients who received first-line maintenance treatments including combined chemotherapy of antiangiogenic agents or application of poly-ADP-ribose polymerase (PARP) inhibitors. The clinical data and follow-up data of all cases during study were collected.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Methods\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003e2.2.1 Open grouping\u003c/h2\u003e \u003cp\u003eThe patient's condition was assessed by gynecologic oncologists, who evaluated the tumor distribution, tumor burden, and Sudan score through comprehensive imaging and laboratory tests. The general health status was also assessed, including the presence of comorbidities and other diseases, as well as the ECOG performance status. The study was divided into two groups: the NACT-IDS group (52 cases) and the PDS group (121 cases). In the NACT-IDS group, chemotherapy was administered following a pathological diagnosis. Among these, 24 patients underwent one cycle of neoadjuvant chemotherapy. This included patients initially treated with one cycle of chemotherapy at local hospitals before being transferred to our institution for further evaluation and direct surgery, as well as patients who required medical treatment for comorbidities, such as hypertension and diabetes, before undergoing surgery after one cycle of chemotherapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section3\"\u003e \u003ch2\u003e2.2.2 Surgical treatment\u003c/h2\u003e \u003cp\u003eThe operation range of cytoreduction (including primary surgery and interval surgery) contains the whole uterus, bilateral appendages, omentum majus, vermiform appendix and all resectable lesions at other sites, as well as spleen, intestine and other organs if necessary. Satisfactory cytoreduction was defined as no residual tumor after operation (R0) or residual tumor diameter\u0026thinsp;\u0026le;\u0026thinsp;1cm (R1).Unsatisfactory cytoreduction was defined as the residual tumor diameter\u0026thinsp;\u0026gt;\u0026thinsp;1cm (\u0026gt;\u0026thinsp;R1).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.2.3 Chemotherapy\u003c/h2\u003e \u003cp\u003eNACT and postoperative chemotherapy were performed with platinum drugs and paclitaxel drugs by intravenous infusion or intravenous infusion plus intraperitoneal perfusion at an interval of 21\u0026ndash;28 days. The chemotherapy of 1\u0026ndash;4 cycles was conducted in NACT-IDS group before operation, and there were totally\u0026thinsp;\u0026ge;\u0026thinsp;6 cycles of chemotherapy in two groups.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003e2.2.4 Efficacy evaluation\u003c/h2\u003e \u003cp\u003eIn accordance with WHO efficacy evaluation standard for solid tumors, complete remission (CR) referred to complete disappearance of all tumor lesions with serum CA125 level\u0026thinsp;\u0026le;\u0026thinsp;35U/ml; partial remission (PR) referred to a decrease of \u0026ge;\u0026thinsp;50% in the sum of vertical diameter products of tumor lesions with double diameters measurable for at least 4 weeks, or a decrease of \u0026ge;\u0026thinsp;50% in the sum of maximum diameters of various lesions with single diameter measurable for at least 4 weeks; progressive disease (PD) referred to a\u0026thinsp;\u0026gt;\u0026thinsp;25% increase of one or more lesions, or appearance of new lesions, newly occurring hydrothorax or ascites; stable disease (SD) referred to a decrease of \u0026lt;\u0026thinsp;50% or an increase of \u0026le;\u0026thinsp;25% in the sum of maximum diameter products of various lesions with double diameters measurable for at least 4 weeks, and SD was assessed only after at least 2 cycles of treatment; overall remission rate (ORR)\u0026thinsp;=\u0026thinsp;CR\u0026thinsp;+\u0026thinsp;PR, and disease control rate (DCR)\u0026thinsp;=\u0026thinsp;CR\u0026thinsp;+\u0026thinsp;PR\u0026thinsp;+\u0026thinsp;SD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003e2.2.5 Relapse judgment\u003c/h2\u003e \u003cp\u003eRelapse was defined as tumor relapse after achieving clinical remission following systematic and standard treatment.This study analyzed the first recurrence following initial systemic therapy.Platinum-sensitive relapse was defined as tumor progression or relapse at \u0026lt;\u0026thinsp;6 months after chemotherapy discontinuation when there was a definite response to platinum-based initial treatment and the clinical remission was achieved; partial sensitive relapse was defined as tumor progression or relapse at 6\u0026ndash;12 months after chemotherapy discontinuation; complete sensitive relapse was defined as tumor progression or relapse at \u0026gt;\u0026thinsp;12 months after chemotherapy discontinuation. Platinum-resistant relapse was defined as tumor progression or relapse at \u0026lt;\u0026thinsp;6 months after chemotherapy when there was a response to initial chemotherapy.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003e2.2.6 Follow-up\u003c/h2\u003e \u003cp\u003eThe patients were followed up by outpatient visits, hospitalization or telephone, with the following contents including but not limited to tumor evaluation (MRI/CT imaging examination and CA125 level), general condition, concomitant treatment and medication during treatment and follow-up. The follow-up for all cases was terminated till relapse, death or follow-up endpoints (deadline: May 31, 2022). Progress free survival (PFS) was defined as the time from the treatment starting to the first tumor progression or death; overall survival (OS) was defined as the time from the treatment starting to the patient death caused by various factors. All cases surviving at the end of follow-up were truncated at the follow-up endpoints. If there was a permanently progressive disease during treatment which was not effectively controlled and needed continuous treatment for no good control at the follow-up endpoints or death, PFS was 0.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Statistical analysis\u003c/h2\u003e \u003cp\u003eSPSS 25.0 statistical software was used for data processing. The qualitative data were compared with χ2 test or Fisher\u0026rsquo;s exact probability test. The quantitative data were firstly analyzed for distribution, those of normal distribution were compared with \u003cem\u003et\u003c/em\u003e test and expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and those of skewed distribution were compared with nonparametric test and presented as median (lower quartile \u0026ndash; upper quartile). The multi-factor analysis was performed using non-conditional Logistic regression model, and the survival analysis using Kalan-Meier survival curve. The survival was compared with Log-rank test, and the multi-factor survival analysis was conducted with Cox proportional hazard model. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 indicated a statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003e\u003cstrong\u003e3.1 General data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTotally 173 patients were enrolled into the study, including 52 cases in NACT-IDS group and 121 cases in PDS group.\u003c/p\u003e\n\u003cp\u003eThe enrolled patients were aged as 30-76 (median: 55) years. According to the International Federation of Gynecologists and Obstetricians (FIGO) staging standard, there were 158 cases of stage IIIC ovarian cancer and 15 cases of stage IV ovarian cancer. Serous adenocarcinoma (159 cases, 91.9%) and high-grade ovarian cancer (132 cases, 76.3%) was dominant in pathology and histology, respectively. There was satisfactory surgical cytoreduction (R0+R1) in totally 137 cases (79.1%). No statistical difference was observed in the age, pathological type, postoperative residual tumor, and chemotherapy cycle between two groups (P\u0026gt;0.05). Compared with PDS group, the percentage of patients with stage IV ovarian cancer was significantly higher in NACT-IDS group (P\u0026lt;0.05), and that of patients with satisfactory cytoreduction was evidently greater (82.7% vs. 77.7%), while that of patients with the co-resection of spleen, intestine and other organs was markedly lower (P\u0026lt;0.05) (see Table 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.2 Efficacy evaluation and relapse\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn this study, ORR (CR+PR) of 173 cases was up to 98.8% after initial treatment and DCR was 100%. There were 159 cases of follow-up and 14 cases of loss of follow-up, and the follow-up rate was 91.90%. The median follow up time of NACT-IDS group and PDS group were 56 months and 62 months(P\u0026lt;0.05).By the follow-up endpoints, there were 120 cases (75.5%) of relapse, including 104 cases (86.7%) of sensitive relapse; no statistical difference in the overall relapse rate was found between NACT-IDS group and PDS group, but the platinum-resistant relapse rate in NACT-IDS group was significantly higher than that in PDS group (P\u0026lt;0.05). (See Table 2)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.3 Influential factors for platinum-resistant relapse of ovarian cancer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFor platinum-resistant relapse of ovarian cancer in 171 cases of clinical remission (except 2 cases of SD), the relevant factors were analyzed. The one-factor analysis results showed that the therapy (NACT-IDS or PDS) and CA125 level before treatment were correlated with platinum-resistant relapse (P\u0026lt;0.05) (see Table 3).\u003c/p\u003e\n\u003cp\u003eAs suggested by the multi-factor analysis results, NACT (OR=7.822, 95%CI 2.121-28.855) and a high CA125 level before treatment (OR=1.001, 95%CI 1.000-1.001) were two independent risk factors for platinum-resistant relapse of ovarian cancer (P\u0026lt;0.05) (see Table 4).\u003c/p\u003e\n\u003cp\u003eThe results of further stratified analysis revealed that only at R0 surgical cytoreduction, the platinum-resistant relapse rate in NACT-IDS group was higher than that in PDS group (P\u0026lt;0.05; see Table 5), unrelated with chemotherapeutic regimen and NACT cycle (P\u0026gt;0.05; see Table 6). At either R1 or \u0026gt;R1 surgical cytoreduction, there was no statistical difference in the platinum-resistant relapse rate between two groups.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3.4 Analysis of prognosis and survival\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBy the follow-up endpoints, the median PFS, survival number, 5-year survival rate and median relapse survival (RS) were 26 months(95%CI 20.236-29.764 months) and 27 months(95%CI 15.816-36.184 months), 17 and 45,39.6% and 51.3%,28 months(95%CI 16.694-39.306 months) and 35 months(95%CI 27.061-42.939 months) in NACT-IDS group and PDS group, respectively; however, there were no statistically significant differences in PFS, OS and RS between two groups (P\u0026gt;0.05).(see Figure 1).The survival analysis was performed with Cox proportional hazard model, and the results showed that platinum-resistant relapse was an independent risk factor for decreased OS (P\u0026lt;0.001) (see Table 7).\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eCytoreduction\u0026thinsp;+\u0026thinsp;platinum-based combined chemotherapy is the standard therapy for advanced ovarian cancer, while satisfactory cytoreduction achieved by primary surgery is the most important independent factor influencing the prognosis of ovarian cancer \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Due to lack of accurate techniques for early diagnosis and screening, over 70% ovarian cancer patients are in the advanced stage at the initial diagnosis, and it is difficult for a part of patients to realize satisfactory surgical cytoreduction after comprehensive evaluation or allow for direct surgical treatment because of serious medical co-morbidities. Therefore, NACT-IDS becomes one of optional therapies preferred by gynecological oncologists, and it is also recommended as level 1 evidence in FIGO Guideline (2019) and NCCN Guideline (2022). However, the indications and efficacy of NACT-IDS therapy as well as its prognostic influence and increase of platinum resistance risk are still hot concerns in the current clinical research and need to be further studied and explored.\u003c/p\u003e \u003cp\u003eSeveral studies have suggested that neoadjuvant chemotherapy (NACT) may increase the risk of platinum resistance. The study by Rauh-Hain\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e found that the proportion of platinum resistance was significantly higher in the NACT-IDS group compared to the PDS group (88.8% vs 55.3%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Particularly, the analysis of resistance factors showed that patients receiving more than six total cycles of chemotherapy had a 2.59-fold increased risk of resistance. Similarly, Petrillo\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e observed that the platinum-resistant recurrence rate was significantly higher in the NACT-IDS group than in the PDS group (35.9% vs 5.0%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Studies by Da Costa \u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e and Luo Y \u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e also suggested that NACT-IDS increases the risk of platinum resistance.Consistent with these findings, our study revealed that the platinum-resistant recurrence rate in the NACT-IDS group was significantly higher than in the PDS group (22.9% vs 4.5%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).These results indicate that while NACT plays an important role in ovarian cancer treatment, it should be reserved for patients in whom achieving optimal PDS is unlikely. Blindly expanding the indications for NACT may increase the risk of resistance, leading to more harm than benefit. Additionally, some researchers have proposed that larger tumor burdens at the time of initial chemotherapy increase the possibility of mutations and chemotherapy resistance \u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. In our study, the proportion of patients with stage IV disease was higher in the NACT-IDS group than in the PDS group (15.4% vs 5.8%), and the tumor burden was greater in the NACT-IDS group. Multivariate analysis confirmed that NACT is an independent risk factor for the development of platinum resistance (OR\u0026thinsp;=\u0026thinsp;7.822, 95%CI 2.121\u0026ndash;28.855).Several basic research studies have elucidated potential molecular mechanisms by which NACT may contribute to platinum resistance. These include the induction of DNA repair mechanisms by NACT, which leads to recovery mutations in key genes involved in DNA repair, enhancing the tumor cells' ability to repair DNA and thus increasing resistance to platinum-based drugs \u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. NACT has also been shown to promote the expression of cell membrane transport proteins ATP7A and ceruloplasmin (CP), which enhance the antioxidant stress capacity of tumor cells and reduce the toxic accumulation of platinum drugs, thereby promoting resistance \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Additionally, NACT-induced alterations in the extracellular matrix components and the creation of an immunosuppressive tumor microenvironment can promote epithelial-mesenchymal transition (EMT) and immune evasion \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. NACT may also induce the sustained proliferation of cancer stem cells, further contributing to resistance \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGiven the potential risk of platinum resistance associated with NACT, the impact of the NACT-IDS treatment approach on patient prognosis compared to PDS has become a significant area of interest. However, conclusions from various studies remain inconsistent. A meta-analysis and systematic review by Qin \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e on patients with stage III-IV ovarian cancer suggested that the PDS group demonstrated better survival benefits compared to the NACT-IDS group, with NACT-IDS only improving the rate of optimal cytoreductive surgery. Similarly, May\u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e reported that the 5-year survival rate was significantly higher in the PDS group compared to the NACT-IDS group (39% vs 27%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). On the other hand, several studies have shown that NACT-IDS can achieve similar outcomes as PDS combined with chemotherapy, with no significant impact on overall survival (OS) \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.Vergote and colleagues performed a re-analysis of the cases from the randomized controlled trials EORTC55971 and CHORUS, finding no significant difference in overall survival between the NACT-IDS and PDS groups\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. A randomized controlled trial by Kehoe\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e involving 451 patients with advanced ovarian cancer also demonstrated similar outcomes, with the median PFS being 12 months in the NACT-IDS group and 10.7 months in the PDS group, and the median OS being 24.1 months and 22.6 months, respectively. However, some critics pointed out that the PFS and OS in this study were slightly lower than in other studies, raising questions about potential bias.Our study also revealed no significant statistical difference between the NACT-IDS and PDS groups in terms of 5-year survival rate (39.6% vs 51.3%, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05). It is clear that the primary goal of NACT is to enable optimal cytoreductive surgery, and there is ample evidence suggesting that only R0 resection provides significant benefit to patients \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]\u003c/sup\u003e. In our study, the R0 resection rate was 55.8% in the NACT-IDS group, compared to 44.6% in the PDS group. Moreover, IDS significantly reduced the rate of combined organ resections, such as spleen and bowel, compared to PDS (25.0% vs 41.3%, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). However, despite the higher R0 rate, the NACT-IDS group did not achieve better survival outcomes, which may be related to the increased risk of resistance. This hypothesis requires further confirmation through large prospective studies.It has been frequently reported that the number of NACT cycles is positively correlated with the incidence of platinum resistance \u003csup\u003e[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. In our study, 24 patients (46.1%) in the NACT group received only one cycle of NACT for reasons unrelated to disease progression. In subgroup analysis, six cases (25.0%) of platinum-resistant recurrence were observed in the group that received one cycle of NACT, the highest proportion, while patients receiving two or more cycles did not show an increased proportion of resistant recurrence. This finding raises new questions\u0026mdash;does surgery after chemotherapy create a false impression of visual R0? In recent years, \"total peritonectomy\" has been widely applied in clinical practice. Sinukumar\u003csup\u003e[\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e studied 79 cases of stage IIIC/IVA ovarian cancer, with 30 undergoing total peritonectomy and 49 undergoing selective peritonectomy. The disease-free survival (DFS) was 37 months vs 33 months, and the 3-year OS was 95% vs 70.8% (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05), suggesting that complete resection of cancer-infiltrated peritoneum, or \"tumor bed\" resection, is more beneficial for improving prognosis. Could the disappearance of some tumors after NACT prevent true \"tumor bed\" resection, leading to the resurgence of residual cells and increasing the risk of platinum-resistant recurrence? This phenomenon merits closer attention in future assessments of IDS surgical quality.\u003c/p\u003e \u003cp\u003eThis study has certain limitations. First, as a retrospective study, the case records lacked a standardized format, and the distribution of disease severity between the two groups was not well balanced. The clinical choice of treatment was not subject to uniform standardized management, leaving room for subjectivity, which may have introduced selection bias and affected the study results. Second, the sample size in this study was insufficient, necessitating larger prospective studies in the future to provide stronger evidence for evidence-based medicine.\u003c/p\u003e \u003cp\u003eIn conclusion, NACT-IDS can serve as one of the treatment options for patients with advanced ovarian cancer. However, NACT-IDS may increase the risk of subsequent platinum resistance, and thus, the indications should not be expanded blindly. In particular, during IDS, the surgical standard should aim for more thorough tumor bed resection, achieving R0 resection, to avoid increasing the risk of recurrence from residual resistant tumor cells. Additionally, precise selection of indications and comprehensive management throughout the treatment course are essential, as neoadjuvant chemotherapy does not necessarily affect prognosis.\u003c/p\u003e"},{"header":"Declarations","content":" \u003ch2\u003eConflict of Interest\u003c/h2\u003e \u003cp\u003eThe authors have no conflict of interest.\u003c/p\u003e \u003ch2\u003eEthics Statement\u003c/h2\u003e \u003cp\u003eThis study was approved by the Ethics Committee of Cancer Hospital of China Medical University.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding Information\u003c/h2\u003e \u003cp\u003eThis study was funded by the National Natural Science Foundation of China grant numbers:82103056; \u0026ldquo;the Fundamental Research Funds for the Central Universities\u0026rdquo;2021-ZLLH-08.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation were performed by Zhihui Liu and Peng Chen. The data collection and analysis were performed by Jia Liu. The first draft of the manuscript was written by Weishan Li and was reviewed and edited by Danbo Wang and Zhuo Yang. All authors read and approved the final manuscrip.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMoufarrij S, Dandapani M, Arthofer E, Gomez S, Srivastava A, Lopez-Acevedo M, Villagra A. and Chiappinelli K B. Epigenetic therapy for ovarian cancer: promise and progress. Clin Epigenetics. 2019;11(1):7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKehoe S, Hook J, Nankivell M, Jayson GC, Kitchener H, Lopes T, et al. Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial[J]. 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Interval debulking surgery is not worth the wait:a National Cancer Database study comparing primary cytoreductive surgery versus neoadjuvant chemotherapy[J]. Int J Gynecol Cancer. 2020;30(6):845\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBristow RE. Chi DS.Platinum-based neoadjuvant chemotherapy interval surgical cytoreduction for advanced ovarian cancer:a meta-analysis[J]. Gycecol Oncol. 2006;103(3):1070\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGupta D, et al. Longitudinal monitoring of CA125 levels provides additional information about survival in ovarian cancer. J Ovarian Res. 2010;3:22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnita S. Firoz Rajan,Sanket Mehta,et al.A comparison of outcomes following total and selective peritonectomy performed at the time of internal cytoreductive surgery for advanced serous epithelial ovarian,fallopian tube and primary peritoneal cancer-A study by INDEPSO[J]. Eur J Surg Oncol. 2021;47(1):75\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1 Comparison of general data of patients between two groups (n, %, x\u003c/strong\u003e\u0026plusmn;s)\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNACT-IDS\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=52\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePDS\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=121\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(year)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e54.82\u0026plusmn;8.87(36-72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e55.35\u0026plusmn;9.45(30-76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026le;60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e38(73.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e83(68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14(27.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e38(31.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFIGO\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.04\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage IIIC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e44(74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e114(94.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage IV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e8(15.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e7(5.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathological type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.52\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSerous adenocarcinoma\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e46(88.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e113(93.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEndometrioid adenocarcinoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e4(7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e6(4.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMixed type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e2(3.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e2(1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistological grading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.03\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e45(86.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e87(71.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e7(13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e34(28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative residual tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e29(55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e54(44.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e14(26.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e40(33.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;R1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e9(17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e27(22.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCo-resection of other organs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.04\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e13(25.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e50(41.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e39(75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e71(58.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy cycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 12px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e25(48.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e41(33.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 27px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e27(51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e80(66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: P:T test, Mann-Whitney U test, Pearson X\u003csup\u003e2\u003c/sup\u003e test, and Fisher\u0026rsquo;s exact test. \u003csup\u003e*\u003c/sup\u003eP\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e2 Comparison of relapse between NACT-IDS group and PDS group (n, %)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"left\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNACT-IDS group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePDS group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e111\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall relapse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e39(81.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e81(73.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e0.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSensitive relapse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e28(58.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e76(68.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e0.22\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResistant relapse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e11(22.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 24px;\"\u003e\n \u003cp\u003e5(4.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 25px;\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: P: Pearson X\u003csup\u003e2\u003c/sup\u003e test and Fisher\u0026rsquo;s exact test.\u003csup\u003e*\u003c/sup\u003eP\u0026lt;0.001\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e3 One-factor analysis on platinum-resistant relapse of ovarian cancer (n, %)\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum\u003c/strong\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003cstrong\u003eresistan\u003c/strong\u003e\u003cstrong\u003et relapse\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum\u003c/strong\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003cstrong\u003eresistan\u003c/strong\u003e\u003cstrong\u003et relapse\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;rate\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(\u003c/strong\u003e\u003cstrong\u003eyear\u003c/strong\u003e\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026le;60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e9.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFIGO staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage IIIC\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e156\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e8.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStage IV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e20.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathological type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSerous adenocarcinoma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e154\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e8.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e17.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistological grading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e10.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow grade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNACT-IDS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e21.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePDS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e119\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e4.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative residual tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"4\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.56\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e82\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e8.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;R1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e13.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy cycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.78\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026gt;6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e10.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCarboplatin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther platinum drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e15.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA125 level before treatment (U/ml)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e1500.93(1052.75-3415.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e0.004\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: P:Mann-Whitney U test, Pearson X\u003csup\u003e2\u003c/sup\u003e test, and Fisher\u0026rsquo;s exact test.\u003csup\u003e*\u003c/sup\u003eP\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4 Multi-factor analysis of platinum-resistant relapse of ovarian cancer\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eB\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eS.E.\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWald\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.028\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.035\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.670\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.413\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.029\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFIGO staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.634\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.797\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.632\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.426\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.885\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathological type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.559\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.799\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.490\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.484\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.749\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistological grading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.694\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.867\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.641\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.423\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e2.057\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.666\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e9.540\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.002\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e7.822\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative residual tumor\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.206\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.389\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.280\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.597\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.229\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy cycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.409\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.644\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.403\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.526\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.505\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA125 level before treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e7.221\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e0.007\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 15px;\"\u003e\n \u003cp\u003e1.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Logistic Regression Analysis. \u003csup\u003e*\u003c/sup\u003eP\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5 Relationship between surgical cytoreduction and platinum-resistant relapse between NACT-IDS group and PDS group\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 30px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNACT-IDS group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePDS group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum-resistant relapse (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum-resistant relapse (n, %)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative residual tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR0\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e6(20.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e1(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.007\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eR1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e2(14.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e2(5.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.274\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e＞\u003c/strong\u003e\u003cstrong\u003eR1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e3(33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 2px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e2(8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e0.102\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: P:Pearson X\u003csup\u003e2\u003c/sup\u003e test, and Fisher\u0026rsquo;s exact test.\u003csup\u003e*\u003c/sup\u003eP\u0026lt;0.05\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6 Analysis on platinum-resistant relapse in NACT-IDS group after satisfactory R0 cytoreduction and NACT-related factors\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"99%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum-resistant relapse (n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum-resistant relapse rate (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNACT chemotherapy cycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e25.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.73\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026ge;2\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e17.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaclitaxel + Carboplatin\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e0.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePaclitaxel +other platinum drugs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 13px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15px;\"\u003e\n \u003cp\u003e42.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eNote: P:Pearson X\u003csup\u003e2\u003c/sup\u003e test, and Fisher\u0026rsquo;s exact test.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 7 Survival analysis of ovarian cancer patients using Cox proportional hazard model\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"571\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95%CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.726～1.978\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.480\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFIGO\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;staging\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.913\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.452～1.845\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.800\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathological type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.750\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.334～1.683\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHistological grading\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.121\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.972～1.293\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.115\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTherapy\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(IDS\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;or\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003ePDS)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.477～1.198\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.234\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePostoperative residual tumor\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.285\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.986～1.676\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.064\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCo-resection of other organs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e1.234\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.793～1.921\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.351\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eChemotherapy cycle\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.942\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.601～1.477\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.795\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA125\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;level before treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e0.906\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e0.590～1.392\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e0.654\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 191px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum\u003c/strong\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003cstrong\u003eresistan\u003c/strong\u003e\u003cstrong\u003et\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;relapse\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e11.151\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 186px;\"\u003e\n \u003cp\u003e5.873～21.171\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e＜0.001\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: \u003csup\u003e*\u003c/sup\u003eP\u0026lt;0.001\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neoadjuvant chemotherapy-Intermittent Debulking Surgery, Primary Debulking Surgery, ovarian cancer, platinum resistance","lastPublishedDoi":"10.21203/rs.3.rs-6195402/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6195402/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003ePrimary Debulking Surgery (PDS) combined with platinum-based chemotherapy is the standard therapy for ovarian cancer. Some trials have suggested that neoadjuvant chemotherapy-Intermittent Debulking Surgery(NACT-IDS) can achieve equivalent efficacy in the chemotherapy of combining PDS, without influencing OS. This study aimed to explore the effects of NACT-IDS on the prognosis and platinum resistance of advanced ovarian cancer, so as to provide a certain basis for the selection of suitable clinical therapies.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe patients with advanced ovarian cancer were selected from January 1, 2014 to January 1, 2017. The patients were assigned to NACT-IDS group or PDS group after evaluation by gynecological oncologists. We analysed the clinical data and collected the follow-up data of cases over 5 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eTotally 173 patients were enrolled into the study, including 52 cases in NACT-IDS group and 121 cases in PDS group.The platinum-resistant relapse rate in NACT-IDS group was evidently greater than that in PDS group (22.9% vs 4.5%, P\u0026lt;0.001), and the multi-factor analysis results also proved that NACT (OR=7.822, 95%CI 2.121-28.855) was an independent risk factor for platinum-resistant relapse of ovarian cancer. No significant differences in PFS, RS and OS were found between two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e NACT-IDS may increase the risk of platinum resistance, and it is not advisable to expand its indications blindly. During the IDS procedure, the surgical standard should aim for a more thorough tumor bed resection, achieving an R0 resection, in order to avoid the increased risk of recurrence. Precise selection of indications and comprehensive precision management throughout the treatment course are essential, as neoadjuvant chemotherapy does not necessarily affect prognosis.\u003c/p\u003e","manuscriptTitle":"Effects of neoadjuvant chemotherapy on prognosis and platinum resistance of advanced ovarian cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-17 07:18:40","doi":"10.21203/rs.3.rs-6195402/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-12T12:11:39+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-11T09:00:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-11T08:55:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2025-03-10T11:58:05+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d6826bc8-8b47-4365-9505-26f2a0e31a4a","owner":[],"postedDate":"March 17th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-03-17T07:18:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-17 07:18:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6195402","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6195402","identity":"rs-6195402","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}