Perioperative and Oncologic Outcomes of Secondary Cytoreductive Surgery: A Retrospective Analysis from a Cancer Care Centre of Southern India

Perioperative and Oncologic Outcomes of Secondary Cytoreductive Surgery: A Retrospective Analysis from a Cancer Care Centre of Southern India | 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 Perioperative and Oncologic Outcomes of Secondary Cytoreductive Surgery: A Retrospective Analysis from a Cancer Care Centre of Southern India Z. A. Usofi, R. Surapaneni, S. Thammineedi, Nusrath . Syed, S. Patnaik, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7369696/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Epithelial ovarian cancer (EOC) frequently relapses despite optimal primary treatment, with platinum-sensitive disease presenting a therapeutic challenge. Secondary cytoreductive surgery (SCS) may improve outcomes in select patients, but evidence from randomized trials is mixed. This study evaluates perioperative and oncologic outcomes of SCS in platinum-sensitive relapsed EOC, comparing upfront SCS (primary surgery [PS]) versus SCS after systemic therapy (AS). Methods In this retrospective cohort study at a tertiary cancer center in Southern India (April 2017–December 2024), 47 patients with platinum-sensitive relapsed EOC meeting AGO DESKTOP III criteria (prior complete cytoreduction, ECOG 0–2, no ascites) underwent SCS. Patients were stratified into PS (n = 30) and AS (n = 17) groups. Progression-free survival (PFS) was from SCS to recurrence/death or censoring (December 31, 2024). Post-recurrence survival (PRS) was from relapse to death/censoring. Survival was analyzed using Kaplan-Meier curves, log-rank tests, and Cox models. Complications were graded by Clavien-Dindo classification. Results Groups were comparable in age (mean 50.8 years), BMI (27 kg/m²), and histology (high-grade serous: 80%). Mean platinum-free interval was 33.4 months (38 PS vs. 28 AS). Complete cytoreduction was achieved in all; hyperthermic intraperitoneal chemotherapy was used in 36.2%. Complications occurred in 34% (mostly grade 1–2); one mortality (neutropenia). Mean PFS was 21.8 months (21.4 PS vs. 20.1 AS; HR 0.98, 95% CI 0.52–1.83; P = 0.95). Mean PRS was 38 months (32.7 PS vs. 44.7 AS; HR 1.73, 95% CI 0.87–3.44; P = 0.121). Conclusions SCS yields favorable PFS and PRS in selected platinum-sensitive relapsed EOC patients, with a nonsignificant trend toward better PRS after upfront systemic therapy. Perioperative morbidity is acceptable. Prospective studies are needed to confirm benefits and refine selection criteria. Figures Figure 1 Figure 2 Introduction Epithelial ovarian cancer (EOC) remains one of the most lethal gynecologic malignancies worldwide, accounting for approximately 70% of cases diagnosed at an advanced stage (International Federation of Gynecology and Obstetrics [FIGO] stages III-IV), where peritoneal dissemination occurs early in the disease course 1 . Despite advances in primary treatment, which typically involves optimal cytoreductive surgery followed by platinum-based chemotherapy, relapse is inevitable in the majority of patients. Epidemiologic data indicate that up to 80% of women with advanced EOC experience recurrence following initial therapy, highlighting the aggressive nature of the disease 2 . Relapsed patients often present in a compromised general condition, exacerbated by a confluence of factors including cancer cachexia, treatment-related toxicities, and disease progression, leading to malnutrition and impaired immunity 3 , 4 , 5 , 6 . Malnutrition is prevalent in up to one-third of ovarian cancer patients during treatment, adversely affecting food intake, surgical outcomes, and overall prognosis 7 , 8 . Similarly, chemotherapy-induced immune impairment and tumor-mediated immunosuppression contribute to reduced antitumor responses, further complicating management in the relapsed setting 9 , 10 Long-term survival remains dismal, with 10-year overall survival rates reported as low as 13–29% for advanced-stage disease, underscoring the need for improved therapeutic strategies 11 , 12 . A longstanding debate persists regarding the optimal management of relapse, particularly in platinum-sensitive disease (defined as recurrence ≥ 6 months after primary platinum-based therapy). While systemic chemotherapy has been the cornerstone, the role of secondary cytoreductive surgery (SCS) in select patients with limited, resectable disease continues to evolve 13 , 14 . Phase III randomized controlled trials (RCTs) evaluating SCS versus chemotherapy alone in recurrent EOC have yielded mixed results, with some demonstrating progression-free survival (PFS) benefits but inconclusive overall survival (OS) advantages, often attributed to patient selection, completeness of resection, and crossover effects 15 – 18 . For instance, the GOG-0213 trial showed no OS benefit with SCS, whereas the AGO DESKTOP III and SOC-1 trials reported improved PFS and OS in carefully selected patients meeting specific criteria, such as a positive AGO score 15 , 17 , 18 . These discrepancies fuel ongoing discussions on the integration of SCS into standard care for platinum-sensitive relapse 20 , 21 .The objective of this retrospective study was to evaluate the perioperative and oncologic outcomes of SCS in a cohort of well-selected patients with platinum-sensitive relapsed EOC at a high-volume tertiary cancer center in Southern India, comparing outcomes between upfront SCS and SCS following systemic therapy. Materials and Methods Study Design This was a single-center, retrospective cohort study conducted at Basavatarakam Indo American Cancer Hospital and Research Institute, a high-volume tertiary cancer care center in Hyderabad, Southern India. The study aimed to evaluate perioperative and oncologic outcomes in patients undergoing secondary cytoreductive surgery (SCS) for relapsed epithelial ovarian cancer (EOC). Data were collected from electronic medical records, operative notes, pathology reports, and follow-up clinic documentation. The study period spanned from April 2017 to December 2024, with survival data censored on December 31, 2024. Informed consent and ethics: The protocol was approved by the institutional ethics committee ( IEC approval number IEC/2025/AC/41 ), and a waiver of informed consent was granted owing to the retrospective design and anonymity of the patient’s identification in data . All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Patient confidentiality was strictly maintained throughout the study. No identifiable personal information was recorded or published. Patient Selection and Stratification Patients were eligible if they had histologically confirmed relapsed EOC with evidence of biochemical (e.g., elevated CA-125 levels) or radiological recurrence. Inclusion criteria included: Platinum-sensitive disease, defined as a platinum-free interval (PFI) of ≥6 months from the completion of primary platinum-based therapy. Positive AGO score, as established in the DESKTOP trials, comprising prior complete cytoreduction (no residual disease at primary surgery), good Eastern Cooperative Oncology Group (ECOG) performance status (0-2), and absence of ascites (defined as <500 mL of peritoneal fluid) 21 . Ability to undergo surgery based on multidisciplinary tumor board evaluation, including no extensive comorbidities precluding general anesthesia. Exclusion criteria encompassed platinum-resistant disease (PFI 2), presence of unresectable extra-abdominal metastases, or patient refusal of surgical intervention. A total of 47 patients met the criteria and were stratified into two groups based on the treatment sequence for relapse: Primary surgery (PS) group: Upfront SCS (n=30). After systemic therapy (AS) group: SCS following initial systemic chemotherapy for relapse (n=17). All patients underwent SCS with the goal of achieving complete cytoreduction (R0 resection, defined as no macroscopic residual disease). Surgical procedures were performed by experienced surgical oncologists with extensive expertise in gynaecologic oncology and included peritoneal stripping, bowel resections, splenectomy, or other organ resections as necessary to achieve R0 status. Hyperthermic intraperitoneal chemotherapy (HIPEC) was administered intraoperatively in selected cases (n=17), typically for patients with diffuse peritoneal carcinomatosis, using cisplatin-based regimens at 41-43°C for 60-90 minutes, in accordance with our institutional protocols. Postoperative complications were systematically graded using the Clavien-Dindo classification system 22 . Data Collection Demographic and clinical data were abstracted, including age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, histological subtype, CA-125 levels at relapse, recurrence patterns (e.g., isolated pelvic vs. diffuse carcinomatosis), operative details (e.g., duration, blood loss, HIPEC use), perioperative outcomes (e.g., intensive care unit [ICU] and hospital length of stay, complications), and oncologic variables (e.g., adjuvant therapies such as bevacizumab or olaparib post-primary treatment). Recurrence was diagnosed based on rising CA-125 levels (>2× upper limit of normal) confirmed by imaging (computed tomography or positron emission tomography) or biopsy, in line with Gynecologic Cancer InterGroup (GCIG) criteria. Endpoints The primary endpoints were progression-free survival (PFS) and post-recurrence survival (PRS). PFS was defined as the interval from the date of SCS to the date of disease progression, death from any cause, or censoring at the last follow-up (December 31, 2024), whichever occurred first. Disease progression was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 or GCIG CA-125 criteria. PRS was calculated from the date of relapse diagnosis to death or censoring at December 31, 2024. Secondary endpoints included perioperative morbidity, mortality, and time to adjuvant chemotherapy initiation. The PFI was computed from the end of primary treatment to relapse detection. Statistical Analysis Continuous variables were summarized as means with standard deviations or medians with interquartile ranges, as appropriate, and compared using Mann-Whitney U test. Categorical variables were expressed as frequencies and percentages and analyzed with chi-square or Fisher's exact tests. Survival outcomes were estimated using the Kaplan-Meier method, with intergroup comparisons performed via the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from univariable Cox proportional hazards models. The proportional hazards assumption was verified using Schoenfeld residuals. A two-sided P-value <0.05 was considered statistically significant. Missing data (e.g., survival in 16% of cases) were handled by listwise deletion for complete-case analysis. All analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). No multivariable adjustments were performed due to the small sample size and exploratory nature of the study. Results Patient Characteristics A total of 47 women with relapsed epithelial ovarian cancer (EOC) underwent secondary cytoreductive surgery (SCS), with 30 in the primary surgery (PS) group and 17 in the after systemic therapy (AS) group. Baseline characteristics were comparable between groups (Table 1). The mean age was 50.76 years (range: 31–70; SD: 8.95), with no significant difference between PS (50.37 years) and AS (50.35 years) groups (P=0.99). The mean BMI was 27 kg/m² (range: 16–39.54; SD: 5.022), similar across groups (P=0.85). Patients in the AS group were more likely to be ASA class 3 (median ASA: 2 in PS vs. 3 in AS; P=0.28). The mean CA-125 at recurrence was 470 U/mL (range: 5.5–3480; SD: 807.9), with no intergroup difference (P=0.17). Recurrence Patterns Diffuse carcinomatosis was the most common recurrence pattern (20/47, 42.6%), followed by isolated pelvic recurrences (12/47, 25.5%) and 1–2 non-pelvic deposits (8/47, 17.0%). Diffuse carcinomatosis was more frequent in the AS group (12/17, 70.6%) than the PS group (8/30, 26.7%; P=0.8). Isolated pelvic recurrences were more common in the PS group (9/30, 30% vs. 3/17, 17.6%; P=0.11) (Table 2). Perioperative Outcomes Postoperative complications were observed in 16 patients (34.0%), with Grade 1–2 events (ileus, atelectasis) occurring equally in both groups (10 patients total: 5 PS, 5 AS) (Table 3). Six patients experienced Grade 3 complications: three required image-guided drainage of collections (2 PS, 1 AS), while three others needed reoperation (2 PS: 1 fecal fistula with diversion stoma; 1 AS: ureteric leak managed via Boari flap reconstruction). One Grade 5 mortality (PS group) resulted from fulminant neutropenia. Hyperthermic intraperitoneal chemotherapy (HIPEC) was utilized in 17 patients (36.2%; 9 PS, 8 AS; P=0.46). The mean ICU stay was 6.08 days (PS: 6.37, AS: 5.4; P=0.46), with comparable hospital stays (9.52 days overall; P=0.83). Adjuvant chemotherapy was administered to 68% of patients (PS: 70%, AS: 64.5%; P=0.8), commencing at a mean of 38.6 days postoperatively (P=0.58). Oncologic Outcomes Mean Platinum-Free Interval (PFI) was 33.4 months (PS: 38, AS: 28; P=0.23) (Table 4). Mean progression free survival (PFS) was 21.8 months (PS: 21.4, AS: 20.06; HR: 0.98, 95% CI: 0.52–1.83; P=0.95; Figure 1 ). Mean Post-Recurrence Survival (PRS) was 38 months (PS: 32.7, AS: 44.7; HR: 1.73, 95% CI: 0.87–3.44; P=0.121; Figure 2 ). Adjuvant Therapies : Bevacizumab was given to 17 patients (36%; PS: 43.3%, AS: 23.5%); olaparib to 3 patients (6.4%; all in PS group). Table 1: Baseline Patient Characteristics Characteristic Overall (n=47) PS Group (n=30) AS Group (n=17) P-value Age (years) Mean ± SD (Range) 50.76 ± 8.95 (31–70) 50.37 ± 8.95 50.35 ± 8.95 0.99 BMI (kg/m²) Mean ± SD (Range) 27 ± 5.02 (16–39.5) 27.11 ± 4.9 26.8 ± 5.41 0.85 ASA Class (Median) 2 2 3 0.28 CA-125 at Recurrence Mean ± SD (Range) 470 ± 807.9 (5.5–3480) 284 ± 654 626.8 ± 1004 0.17 Abbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; PS, primary surgery; AS, after systemic therapy; SD, standard deviation. Table 2: Patterns of Recurrence After Primary Treatment Recurrence Pattern Overall (n=47), n (%) PS Group (n=30), n (%) AS Group (n=17), n (%) P-value Diffuse carcinomatosis 20 (42.6%) 8 (26.7%) 12 (70.6%) 0.8 Isolated pelvic 12 (25.5%) 9 (30%) 3 (17.6%) 0.11 1–2 non-pelvic deposits 8 (17.0%) 6 (20%) 2 (11.8%) 0.21 Lymph nodes 4 (8.5%) 4 (13.3%) 0 (0%) — Nodes + peritoneal deposits 3 (6.4%) 3 (10%) 0 (0%) — Abbreviations: PS, primary surgery; AS, after systemic therapy Table 3: Postoperative Complications graded by Clavien-Dindo Scale Grade Description Overall (n=47), n (%) PS Group (n=30), n (%) AS Group (n=17), n (%) 0 No complications 30 (63.8%) 20 (66.7%) 10 (58.8%) 1–2 Ileus, atelectasis 10 (21.3%) 5 (16.7%) 5 (29.4%) 3a Collections drained (image-guided) 3 (6.4%) 2 (6.7%) 1 (5.9%) 3b Fecal fistula/ureteric leak (reoperation) 3 (6.4%) 2 (6.7%) 1 (5.9%) 4 — 0 (0%) 0 (0%) 0 (0%) 5 Mortality (fulminant neutropenia) 1 (2.1%) 1 (3.3%) 0 (0%) Abbreviations: PS, primary surgery; AS, after systemic therapy Table 4: Summary of Key Oncologic Outcomes Outcome Overall (n=47) PS Group (n=30) AS Group (n=17) HR (95% CI) P-value Platinum-Free Interval (months) Mean ± SD (Range) 33.4 ± 25.35 (9–143) 38 ± 28 28 ± 18.73 — 0.23 Progression-Free Survival (months) Mean ± SD 21.8 ± 12.2 21.4 ± 10.9 20.06 ± 16.62 0.98 (0.52–1.83) 0.95 Post-Recurrence Survival (months) Mean ± SD 38 ± 20 32.7 ± 20.4 44.7 ± 20.9 1.73 (0.87–3.44) 0.121 Adjuvant Therapies Bevacizumab, n (%) 17 (36%) 13 (43.3%) 4 (23.5%) — — Olaparib, n (%) 3 (6.4%) 3 (10%) 0 (0%) — Abbreviations: AS, after systemic therapy; CI, confidence interval; HR, hazard ratio; PS, primary surgery; SD, standard deviation. P-values for survival from log-rank test; HR from Cox proportional hazards model. Discussion In this retrospective analysis of 47 patients undergoing secondary cytoreductive surgery (SCS) for platinum-sensitive relapsed epithelial ovarian cancer (EOC) at a high-volume tertiary center in Southern India, we observed a median progression-free survival (PFS) of 21.8 months and post-recurrence survival (PRS) of 38 months, with complete cytoreduction achieved in all cases. These outcomes align closely with data from landmark phase III trials evaluating SCS in similar patient populations. For instance, the AGO DESKTOP III trial reported a median PFS of 18.4 months and overall survival (OS) of 53.7 months in the SCS arm among 407 patients with a positive AGO score, demonstrating a significant OS benefit over chemotherapy alone (hazard ratio [HR] 0.75; 95% confidence interval [CI] 0.59-0.96; P=0.02) 17 . Similarly, the SOC-1 trial, conducted in a Chinese cohort of 357 patients, showed a median PFS of 17.4 months with SCS plus chemotherapy versus 11.9 months with chemotherapy alone (HR 0.58; 95% CI 0.45-0.74; P<0.0001), supporting the role of surgery in extending PFS in platinum-sensitive relapse 18 .Our slightly longer PFS may reflect stringent patient selection, including adherence to AGO criteria and prior complete primary cytoreduction, which are known predictors of favorable outcomes in SCS. A notable finding was the nonsignificant trend toward improved PRS in the after systemic therapy (AS) group (44.7 months) compared to the primary surgery (PS) group (32.7 months; HR 1.73; 95% CI 0.87-3.44; P=0.121). This suggests potential benefits from upfront systemic therapy in downstaging disease, facilitating more effective cytoreduction, particularly in cases with diffuse carcinomatosis, which was more prevalent in the AS cohort (70.6% vs. 26.7%). While our sample size limits statistical power, this observation echoes subgroup analyses from the GOG-0213 trial, where SCS did not confer an OS benefit overall (median OS 50.6 months vs. 64.7 months with chemotherapy alone; HR 1.29; 95% CI 0.97-1.72; P=0.08), but benefits were seen in select patients with limited disease burden 15 . Meta-analyses further corroborate the PFS advantage of SCS with complete resection (HR 0.69; 95% CI 0.61-0.78; P<0.001) but highlight equivocal OS gains, often due to heterogeneity in patient selection and residual disease 16 . The trend in our AS group warrants prospective validation, as neoadjuvant approaches may optimize surgical feasibility in relapsed settings, akin to primary EOC management. Perioperative morbidity in our study was acceptable, with 34% of patients experiencing complications (mostly low-grade) and a single mortality (2.1%) attributed to neutropenia. This rate is consistent with reported figures of 20-40% in SCS trials, where major complications (Clavien-Dindo grade ≥3) range from 9-20% 23 . Hyperthermic intraperitoneal chemotherapy (HIPEC) was employed in 36.2% of cases, primarily for diffuse disease, without increasing morbidity significantly. Emerging evidence supports HIPEC as an adjunct in selected relapsed EOC, with a recent review indicating potential PFS benefits (median 18-22 months) when combined with SCS, though randomized data remain limited 19 . Our mean ICU and hospital stays (6.08 and 9.52 days, respectively) were comparable between groups, underscoring the feasibility of SCS in resource-constrained settings like Southern India, where high-volume centers can mitigate risks through multidisciplinary care. Despite these encouraging results, our study has limitations inherent to its retrospective design, including a small sample size (n=47 over 7.5 years), potential selection bias toward operable patients, and missing survival data in 16% of cases. The lack of a chemotherapy-only control arm precludes direct comparisons of SCS benefits, and the imbalance in group sizes (30 PS vs. 17 AS) may have underpowered subgroup analyses. Furthermore, while high-grade serous histology dominated (80%), the inclusion of other subtypes limits generalizability, as low-grade serous EOC may respond differently to SCS 23 . These constraints reflect the rarity of ideal SCS candidates, even in a center performing ~250 primary cytoreductions annually, emphasizing the need for multicenter prospective studies to refine selection criteria and evaluate novel adjuncts like PARP inhibitors post-SCS. Limitations of the Study This study has several important limitations that should be considered when interpreting its findings. The retrospective nature of this study appears to be one of the most important limitations. The small sample size—particularly in the after-systemic-therapy (AS) group (n=17)—reduces statistical power, making it difficult to detect meaningful differences in survival outcomes. Additionally, the single-center nature of the study may limit generalizability, as results could reflect institutional expertise rather than broader applicability. Missing survival data (16% of patients) further complicates the interpretation of oncologic outcomes. Treatment heterogeneity also poses a challenge, as not all patients received HIPEC (only 36%), and adjuvant therapies like bevacizumab and olaparib were not uniformly administered. The study period ended in December 2024, which may not provide sufficient follow-up for recently treated patients to assess long-term survival. Furthermore, since all patients were pre-selected for surgery, the results do not account for outcomes in those managed non-operatively. The lack of a chemotherapy-only control group prevents definitive conclusions about the comparative efficacy of secondary cytoreduction. These limitations underscore the need for prospective, multicenter studies with standardized protocols to validate these findings and better define the role of secondary cytoreductive surgery in platinum-sensitive recurrent ovarian cancer. Conclusion Secondary cytoreductive surgery (SCS) offers favorable outcomes in selected platinum-sensitive relapsed epithelial ovarian cancer patients, achieving complete cytoreduction with mean PFS of 21.8 months and PRS of 38 months, alongside acceptable morbidity (34% complications, 2.1% mortality). A nonsignificant trend toward better PRS after upfront systemic therapy (44.7 vs. 32.7 months) suggests benefits in disease downstaging. These findings support SCS for AGO-eligible patients at high-volume centers, though retrospective limitations necessitate prospective validation to refine selection and integrate targeted therapies for improved survival. Future research should focus on biomarkers for patient selection and integration of targeted therapies to further optimize survival. Abbreviations Abbreviation Full Form AGO Arbeitsgemeinschaft Gynäkologische Onkologie (German Study Group for Gynecologic Oncology) AS After systemic therapy ASA American Society of Anesthesiologists BMI Body Mass Index CA-125 Cancer Antigen 125 CI Confidence Interval EOC Epithelial Ovarian Cancer ECOG Eastern Cooperative Oncology Group EMR Electronic Medical Records FIGO International Federation of Gynecology and Obstetrics GCIG Gynecologic Cancer InterGroup HIPEC Hyperthermic Intraperitoneal Chemotherapy HR Hazard Ratio ICU Intensive Care Unit IEC Institutional Ethics Committee OS Overall Survival P P-value PARP Poly (ADP-Ribose) Polymerase PFI Platinum-Free Interval PFS Progression-Free Survival PMC PubMed Central PRS Post-Recurrence Survival PS Primary Surgery RCT Randomized Controlled Trial RECIST Response Evaluation Criteria In Solid Tumors SD Standard Deviation SCS Secondary Cytoreductive Surgery SOC-1 Surgery in Ovarian Cancer Trial-1 SPSS Statistical Package for the Social Sciences TCR/BCR T-cell Receptor / B-cell Receptor Declarations *Ethics approval and consent to participate As of date: 16/05/2025, under Ethics Reference Code IEC/2025/AC/41at Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, the authors have secured approval for collecting, processing and publishing retrospective data. *Consent for publication Not applicable *Availability of data and materials Data was collected retrospectively using electronic medical records (EMR) system of the hospital and is available for your reference. *Competing interests None *Funding None *Authors' contributions : Z.A. U. conceptualized, collected data, performed stats, wrote the manuscript, tables and figures and wrote the discussion S. N. edited and corrected format R.R. did the final editing All authors contributing in reviewing the manuscript and supervision Acknowledgement Dr. Astik Mane, MD Psychiatry: Contributed significantly in medical biostatistics. The article could not be written without his help. Data Availability Availability of data and materials : Data was collected retrospectively using electronic medical records (EMR) system of the hospital and is available for your reference.The authors declare waiver of consent for this retrospective study. We declare to have adhered to the Declaration of Helsinki for this study References Dhiman P, Bapsy PP, Patil CN, Raghupathi R. Is Optimal Cytoreduction Post Neoadjuvant Chemotherapy the Only Prognostic Factor in Advanced Ovarian Cancer? South Asian J Cancer. 2022 Dec 30;11(3):207-212. doi: 10.1055/s-0042-1755291. PMID: 36588609; PMCID: PMC10497344 Al Rawahi T, Lopes AD, Bristow RE, Bryant A, Elattar A, Chattopadhyay S, Galaal K. Surgical cytoreduction for recurrent epithelial ovarian cancer. Cochrane Database Syst Rev. 2013 Feb 28;2013(2):CD008765. doi: 10.1002/14651858.CD008765.pub3. PMID: 23450588; PMCID: PMC6457850, Gadducci A, Cosio S, Zizioli V, Notaro S, Tana R, Panattoni A, Sartori E. Patterns of Recurrence and Clinical Outcome of Patients With Stage IIIC to Stage IV Epithelial Ovarian Cancer in Complete Response After Primary Debulking Surgery Plus Chemotherapy or Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery: An Italian Multicenter Retrospective Study. Int J Gynecol Cancer. 2017 Jan;27(1):28-36. doi: 10.1097/IGC.0000000000000843. PMID: 27870700. Pischart K, Khemworapong K, Chaopotong P, Achariyapota V. Malnutrition Prevalence and Its Implications on Surgical and Oncological Outcomes in Advanced Ovarian Cancer Patients: A Comprehensive Analysis. Obstet Gynecol Int. 2025 May 10;2025:2918759. doi: 10.1155/ogi/2918759. PMID: 40384994; PMCID: PMC12085243 Johnston EA, Ibiebele TI, Friedlander ML, Grant PT, van der Pols JC, Webb PM; Ovarian cancer Prognosis And Lifestyle (OPAL) Study Group. Association of Protein Intake with Recurrence and Survival Following Primary Treatment of Ovarian Cancer. Am J Clin Nutr. 2023 Jul;118(1):50-58. doi: 10.1016/j.ajcnut.2023.05.002. Epub 2023 May 3. PMID: 37146759. Ren Y, Li R, Feng H, Xie J, Gao L, Chu S, Li Y, Meng F, Ning Y. Single-cell sequencing reveals effects of chemotherapy on the immune landscape and TCR/BCR clonal expansion in a relapsed ovarian cancer patient. Front Immunol. 2022 Sep 28;13:985187. doi: 10.3389/fimmu.2022.985187. PMID: 36248860; PMCID: PMC9555851. Levin L, McHardy JE, Poulton TA, Curling OM, Hudson CN. Tumour associated immunity and immunocompetence in ovarian cancer. Br J Obstet Gynaecol. 1976 May;83(5):393-9. doi: 10.1111/j.1471-0528.1976.tb00850.x. PMID: 1268151. Johnston EA, Ibiebele TI, Friedlander ML, Grant PT, van der Pols JC, Webb PM; Ovarian cancer Prognosis And Lifestyle (OPAL) Study Group. Association of Protein Intake with Recurrence and Survival Following Primary Treatment of Ovarian Cancer. Am J Clin Nutr. 2023 Jul;118(1):50-58. doi: 10.1016/j.ajcnut.2023.05.002. Epub 2023 May 3. PMID: 37146759. Yim GW, Eoh KJ, Kim SW, Nam EJ, Kim YT. Malnutrition Identified by the Nutritional Risk Index and Poor Prognosis in Advanced Epithelial Ovarian Carcinoma. Nutr Cancer. 2016 Jul;68(5):772-9. doi: 10.1080/01635581.2016.1159702. Epub 2016 Apr 4. PMID: 27044606..govpubmed.ncbi.nlm.nih.gov Ren Y, Li R, Feng H, Xie J, Gao L, Chu S, Li Y, Meng F, Ning Y. Single-cell sequencing reveals effects of chemotherapy on the immune landscape and TCR/BCR clonal expansion in a relapsed ovarian cancer patient. Front Immunol. 2022 Sep 28;13:985187. doi: 10.3389/fimmu.2022.985187. PMID: 36248860; PMCID: PMC9555851. Drakes ML, Stiff PJ. Regulation of Ovarian Cancer Prognosis by Immune Cells in the Tumor Microenvironment. Cancers (Basel). 2018 Sep 1;10(9):302. doi: 10.3390/cancers10090302. PMID: 30200478; PMCID: PMC6162424. Kahn R, Filippova O, Gordhandas S, An A, Straubhar AM, Zivanovic O, Gardner GJ, O'Cearbhaill RE, Tew WP, Grisham RN, Sonoda Y, Long Roche K, Abu-Rustum NR, Chi DS. Ten-year conditional probability of survival for patients with ovarian cancer: A new metric tailored to Long-term survivors. Gynecol Oncol. 2023 Feb;169:85-90. doi: 10.1016/j.ygyno.2022.11.030. Epub 2022 Dec 13. PMID: 36521353; PMCID: PMC10364188. Timmermans M, Sonke GS, Van de Vijver KK, van der Aa MA, Kruitwagen RFPM. No improvement in long-term survival for epithelial ovarian cancer patients: A population-based study between 1989 and 2014 in the Netherlands. Eur J Cancer. 2018 Jan;88:31-37. doi: 10.1016/j.ejca.2017.10.030. Epub 2017 Nov 25. PMID: 29179135. de Bree E, Michelakis D, Anagnostopoulou E. The current role of secondary cytoreductive surgery for recurrent ovarian cancer. Front Oncol. 2022 Oct 21;12:1029976. doi: 10.3389/fonc.2022.1029976. PMID: 36338689; PMCID: PMC9633943 Armstrong DK, Coleman RL, Penson RT. Emerging therapeutic options for platinum-sensitive ovarian cancer patients. Clin Adv Hematol Oncol. 2011 Apr;9(4 Suppl 5):1-16. PMID: 21558997 Coleman RL, Spirtos NM, Enserro D, Herzog TJ, Sabbatini P, Armstrong DK, Kim JW, Park SY, Kim BG, Nam JH, Fujiwara K, Walker JL, Casey AC, Alvarez Secord A, Rubin S, Chan JK, DiSilvestro P, Davidson SA, Cohn DE, Tewari KS, Basen-Engquist K, Huang HQ, Brady MF, Mannel RS. Secondary Surgical Cytoreduction for Recurrent Ovarian Cancer. N Engl J Med. 2019 Nov 14;381(20):1929-1939. doi: 10.1056/NEJMoa1902626. PMID: 31722153; PMCID: PMC6941470 Marchetti C, Fagotti A, Tombolini V, Scambia G, De Felice F. The Role of Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer: A Systematic Review and Meta-Analysis. Ann Surg Oncol. 2021 Jun;28(6):3258-3263. doi: 10.1245/s10434-020-09226-7. Epub 2020 Oct 16. PMID: 33067742. Harter P, Sehouli J, Vergote I, Ferron G, Reuss A, Meier W, Greggi S, Mosgaard BJ, Selle F, Guyon F, Pomel C, Lécuru F, Zang R, Avall-Lundqvist E, Kim JW, Ponce J, Raspagliesi F, Kristensen G, Classe JM, Hillemanns P, Jensen P, Hasenburg A, Ghaem-Maghami S, Mirza MR, Lund B, Reinthaller A, Santaballa A, Olaitan A, Hilpert F, du Bois A; DESKTOP III Investigators. Randomized Trial of Cytoreductive Surgery for Relapsed Ovarian Cancer. N Engl J Med. 2021 Dec 2;385(23):2123-2131. doi: 10.1056/NEJMoa2103294. Erratum in: N Engl J Med. 2022 Feb 17;386(7):704. doi: 10.1056/NEJMx220002. PMID: 34874631 Shi T, Zhu J, Feng Y, Tu D, Zhang Y, Zhang P, Jia H, Huang X, Cai Y, Yin S, Jiang R, Tian W, Gao W, Liu J, Yang H, Cheng X, Zang R. Secondary cytoreduction followed by chemotherapy versus chemotherapy alone in platinum-sensitive relapsed ovarian cancer (SOC-1): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2021 Apr;22(4):439-449. doi: 10.1016/S1470-2045(21)00006-1. Epub 2021 Mar 8. PMID: 33705695. de Bree E, Michelakis D, Anagnostopoulou E. The current role of secondary cytoreductive surgery for recurrent ovarian cancer. Front Oncol. 2022 Oct 21;12:1029976. doi: 10.3389/fonc.2022.1029976. PMID: 36338689; PMCID: PMC9633943. Conte C, Fagotti A, Avesani G, Trombadori C, Federico A, D'Indinosante M, Giudice MT, Pelligra S, Lodoli C, Marchetti C, Ferrandina G, Scambia G, Gallotta V. Update on the secondary cytoreduction in platinum-sensitive recurrent ovarian cancer: a narrative review. Ann Transl Med. 2021 Mar;9(6):510. doi: 10.21037/atm-20-4690. PMID: 33850907; PMCID: PMC8039681. Bogani G, Tagliabue E, Signorelli M, Ditto A, Martinelli F, Chiappa V, Mosca L, Sabatucci I, Leone Roberti Maggiore U, Lorusso D, Raspagliesi F. A score system for complete cytoreduction in selected recurrent ovarian cancer patients undergoing secondary cytoreductive surgery: predictors- and nomogram-based analyses. J Gynecol Oncol. 2018 May;29(3):e40. doi: 10.3802/jgo.2018.29.e40. Epub 2018 Feb 23. PMID: 29533023; PMCID: PMC5920224. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae. PMID: 15273542; PMCID: PMC1360123 Goldberg RM, Kim SR, Fazelzad R, Li X, Brown TJ, May T. Secondary cytoreductive surgery for recurrent low-grade serous ovarian carcinoma: A systematic review and meta-analysis. Gynecol Oncol. 2022 Jan;164(1):212-220. doi: 10.1016/j.ygyno.2021.10.080. Epub 2021 Oct 28. PMID: 34756470. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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-7369696","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":522684907,"identity":"a6ae8135-cd9d-4a7c-b99e-12f0f64c75e3","order_by":0,"name":"Z. A. Usofi","email":"","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Z.","middleName":"A.","lastName":"Usofi","suffix":""},{"id":522684908,"identity":"f1490ab0-04ce-43a5-832d-da9eaa497fee","order_by":1,"name":"R. Surapaneni","email":"","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"R.","middleName":"","lastName":"Surapaneni","suffix":""},{"id":522684909,"identity":"807c8f47-29b5-4537-8241-36f900ed5012","order_by":2,"name":"S. Thammineedi","email":"","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"S.","middleName":"","lastName":"Thammineedi","suffix":""},{"id":522684910,"identity":"acb80ae1-6ef3-4cc7-b7c4-c95c03e2a941","order_by":3,"name":"Nusrath . Syed","email":"","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Nusrath","middleName":".","lastName":"Syed","suffix":""},{"id":522684911,"identity":"a2224098-1742-4ac6-9c06-9858d303398f","order_by":4,"name":"S. Patnaik","email":"","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"S.","middleName":"","lastName":"Patnaik","suffix":""},{"id":522684912,"identity":"e0577529-a25e-454a-9875-b98797afafa7","order_by":5,"name":"S. Shukla","email":"","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"S.","middleName":"","lastName":"Shukla","suffix":""},{"id":522684913,"identity":"b1f06e02-aaa1-42b7-981e-28d727549f23","order_by":6,"name":"R. Rajagopalan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABC0lEQVRIiWNgGAWjYHCCBDDJx8DA+OBDBZDFzNxAnBY2oFrDGWdAWhgJamGAaWGT5m0DMQloMW8/8PDjl4o78mzsZ49J886rjeZvB2r5UbENpxaZMwnJ0jJnnhm28eQlW87ddjx3xmHGBsaeM7dxapFgSEiQlmw7zNjGkGN44+22Y7kNQC3MjG14tPA/SP4N1GLfxv/GQIJ3zrHc+QS1SCSkSX5sO5zYJpFjJMnbUJO7gbCWB2nWDGeeJbdJvDE2nHHsQO5GoJaDeP3Cn5N880fFHdt+/hzDBx9q6nLnnT988MGPCtxaGBh4Eph5GA7AeIfB5AEcaqGA/QDjD4SaOvyKR8EoGAWjYEQCAIg9YAC0/xMNAAAAAElFTkSuQmCC","orcid":"","institution":"Basavatarakam Indo American Cancer Hospital and Research Institute","correspondingAuthor":true,"prefix":"","firstName":"R.","middleName":"","lastName":"Rajagopalan","suffix":""}],"badges":[],"createdAt":"2025-08-14 04:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7369696/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7369696/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":93336376,"identity":"07c810ce-4c87-4792-aa76-1b30d320baea","added_by":"auto","created_at":"2025-10-12 14:05:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":674838,"visible":true,"origin":"","legend":"","description":"","filename":"SecondaryCRSFinal3.docx","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/4f4c2d53affc767d2abf6bd4.docx"},{"id":93336375,"identity":"6e6acd21-c60f-417e-87b1-e772a2143c19","added_by":"auto","created_at":"2025-10-12 14:05:07","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":8833,"visible":true,"origin":"","legend":"","description":"","filename":"f14e295ce3fb48c9859a7afaa0dc1b69.json","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/4398b5235878b459e187faa4.json"},{"id":93335086,"identity":"8547e23e-491c-4da6-96d3-d370d19f20a9","added_by":"auto","created_at":"2025-10-12 13:57:07","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":105010,"visible":true,"origin":"","legend":"","description":"","filename":"f14e295ce3fb48c9859a7afaa0dc1b691enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/6902c2da8e9dc48db16f04a8.xml"},{"id":93335089,"identity":"3fdace34-1841-41a2-9a76-9c06e5be6324","added_by":"auto","created_at":"2025-10-12 13:57:07","extension":"png","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23982,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/d988e848b8860cdb3f598d01.png"},{"id":93335085,"identity":"14b192a5-9a85-404a-bbc2-0331455f201c","added_by":"auto","created_at":"2025-10-12 13:57:07","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117522,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/15b8e2dbd2546be9efcc8e16.jpeg"},{"id":93336379,"identity":"e879ad1a-c4cc-4976-bf2f-fbd4589ce403","added_by":"auto","created_at":"2025-10-12 14:05:07","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7798,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/b28943a9016fe47c58d8a512.png"},{"id":93336378,"identity":"e99951b6-ebdc-4297-bca3-31ab695d84d3","added_by":"auto","created_at":"2025-10-12 14:05:07","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":27099,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/61b6c66e03acb669150b08d6.png"},{"id":93335090,"identity":"cfd610a0-9aed-4902-be99-48d7ab319541","added_by":"auto","created_at":"2025-10-12 13:57:07","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":101612,"visible":true,"origin":"","legend":"","description":"","filename":"f14e295ce3fb48c9859a7afaa0dc1b691structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/12a08063897d4f0793d7371f.xml"},{"id":93335092,"identity":"cf9c3ecb-f841-4daf-b306-326261d6836d","added_by":"auto","created_at":"2025-10-12 13:57:07","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":111460,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/be58dfd7fa3e69617f835ee2.html"},{"id":93335082,"identity":"1b00ab1a-7a6b-403a-99f8-074d998b5ac4","added_by":"auto","created_at":"2025-10-12 13:57:07","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":29150,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve for progression-free survival (PFS), stratified by treatment group (PS vs. AS). No significant difference (log-rank P=0.95). X Axis denoted PFS in months (M), Y Axis cumulative survival.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/f4e2a800608cacc1dad556ae.png"},{"id":93337903,"identity":"e22f8407-2d78-4929-9355-24dc3f3b8945","added_by":"auto","created_at":"2025-10-12 14:13:07","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":34830,"visible":true,"origin":"","legend":"\u003cp\u003eKaplan-Meier curve for post-recurrence survival (PRS), stratified by treatment group (PS vs. AS). Trend toward improved survival in AS group (log-rank P=0.121).X Axis denoted PRS in months (M), Y Axis cumulative survival.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/89ac99a82be8f58b9699a3ef.png"},{"id":102296850,"identity":"22791447-c0bc-4b1b-a371-403b7d059792","added_by":"auto","created_at":"2026-02-10 10:22:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1066887,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7369696/v1/b00a4d30-41ff-4c4e-9d06-2e60f26273b6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perioperative and Oncologic Outcomes of Secondary Cytoreductive Surgery: A Retrospective Analysis from a Cancer Care Centre of Southern India","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEpithelial ovarian cancer (EOC) remains one of the most lethal gynecologic malignancies worldwide, accounting for approximately 70% of cases diagnosed at an advanced stage (International Federation of Gynecology and Obstetrics [FIGO] stages III-IV), where peritoneal dissemination occurs early in the disease course\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Despite advances in primary treatment, which typically involves optimal cytoreductive surgery followed by platinum-based chemotherapy, relapse is inevitable in the majority of patients. Epidemiologic data indicate that up to 80% of women with advanced EOC experience recurrence following initial therapy, highlighting the aggressive nature of the disease\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Relapsed patients often present in a compromised general condition, exacerbated by a confluence of factors including cancer cachexia, treatment-related toxicities, and disease progression, leading to malnutrition and impaired immunity \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eMalnutrition is prevalent in up to one-third of ovarian cancer patients during treatment, adversely affecting food intake, surgical outcomes, and overall prognosis \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Similarly, chemotherapy-induced immune impairment and tumor-mediated immunosuppression contribute to reduced antitumor responses, further complicating management in the relapsed setting \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e Long-term survival remains dismal, with 10-year overall survival rates reported as low as 13\u0026ndash;29% for advanced-stage disease, underscoring the need for improved therapeutic strategies\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. A longstanding debate persists regarding the optimal management of relapse, particularly in platinum-sensitive disease (defined as recurrence\u0026thinsp;\u0026ge;\u0026thinsp;6 months after primary platinum-based therapy). While systemic chemotherapy has been the cornerstone, the role of secondary cytoreductive surgery (SCS) in select patients with limited, resectable disease continues to evolve\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePhase III randomized controlled trials (RCTs) evaluating SCS versus chemotherapy alone in recurrent EOC have yielded mixed results, with some demonstrating progression-free survival (PFS) benefits but inconclusive overall survival (OS) advantages, often attributed to patient selection, completeness of resection, and crossover effects\u003csup\u003e\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. For instance, the GOG-0213 trial showed no OS benefit with SCS, whereas the AGO DESKTOP III and SOC-1 trials reported improved PFS and OS in carefully selected patients meeting specific criteria, such as a positive AGO score\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e,\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. These discrepancies fuel ongoing discussions on the integration of SCS into standard care for platinum-sensitive relapse\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.The objective of this retrospective study was to evaluate the perioperative and oncologic outcomes of SCS in a cohort of well-selected patients with platinum-sensitive relapsed EOC at a high-volume tertiary cancer center in Southern India, comparing outcomes between upfront SCS and SCS following systemic therapy.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a single-center, retrospective cohort study conducted at Basavatarakam Indo American Cancer Hospital and Research Institute, a high-volume tertiary cancer care center in Hyderabad, Southern India. The study aimed to evaluate perioperative and oncologic outcomes in patients undergoing secondary cytoreductive surgery (SCS) for relapsed epithelial ovarian cancer (EOC). Data were collected from electronic medical records, operative notes, pathology reports, and follow-up clinic documentation. The study period spanned from April 2017 to December 2024, with survival data censored on December 31, 2024.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent and ethics:\u003c/strong\u003e The protocol was approved by the institutional ethics committee (\u003cem\u003eIEC approval number IEC/2025/AC/41\u003c/em\u003e), and a waiver of informed consent was granted owing to the retrospective design and anonymity of the patient\u0026rsquo;s identification in data . All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Patient confidentiality was strictly maintained throughout the study. No identifiable personal information was recorded or published.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Selection and Stratification\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were eligible if they had histologically confirmed relapsed EOC with evidence of biochemical (e.g., elevated CA-125 levels) or radiological recurrence. Inclusion criteria included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePlatinum-sensitive disease, defined as a platinum-free interval (PFI) of \u0026ge;6 months from the completion of primary platinum-based therapy.\u003c/li\u003e\n \u003cli\u003ePositive AGO score, as established in the DESKTOP trials, comprising prior complete cytoreduction (no residual disease at primary surgery), good Eastern Cooperative Oncology Group (ECOG) performance status (0-2), and absence of ascites (defined as \u0026lt;500 mL of peritoneal fluid)\u003csup\u003e21\u003c/sup\u003e.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAbility to undergo surgery based on multidisciplinary tumor board evaluation, including no extensive comorbidities precluding general anesthesia.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eExclusion criteria encompassed platinum-resistant disease (PFI \u0026lt;6 months), poor performance status (ECOG \u0026gt;2), presence of unresectable extra-abdominal metastases, or patient refusal of surgical intervention.\u003c/p\u003e\n\u003cp\u003eA total of 47 patients met the criteria and were stratified into two groups based on the treatment sequence for relapse:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003ePrimary surgery (PS) group: Upfront SCS (n=30).\u003c/li\u003e\n \u003cli\u003eAfter systemic therapy (AS) group: SCS following initial systemic chemotherapy for relapse (n=17).\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eAll patients underwent SCS with the goal of achieving complete cytoreduction (R0 resection, defined as no macroscopic residual disease). Surgical procedures were performed by experienced surgical oncologists with extensive expertise in \u0026nbsp;gynaecologic oncology and included peritoneal stripping, bowel resections, splenectomy, or other organ resections as necessary to achieve R0 status. Hyperthermic intraperitoneal chemotherapy (HIPEC) was administered intraoperatively in selected cases (n=17), typically for patients with diffuse peritoneal carcinomatosis, using cisplatin-based regimens at 41-43\u0026deg;C for 60-90 minutes, in accordance with our \u0026nbsp;institutional protocols. Postoperative complications were systematically graded using the Clavien-Dindo classification system\u003csup\u003e22\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDemographic and clinical data were abstracted, including age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status classification, histological subtype, CA-125 levels at relapse, recurrence patterns (e.g., isolated pelvic vs. diffuse carcinomatosis), operative details (e.g., duration, blood loss, HIPEC use), perioperative outcomes (e.g., intensive care unit [ICU] and hospital length of stay, complications), and oncologic variables (e.g., adjuvant therapies such as bevacizumab or olaparib post-primary treatment). Recurrence was diagnosed based on rising CA-125 levels (\u0026gt;2\u0026times; upper limit of normal) confirmed by imaging (computed tomography or positron emission tomography) or biopsy, in line with Gynecologic Cancer InterGroup (GCIG) criteria.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEndpoints\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary endpoints were progression-free survival (PFS) and post-recurrence survival (PRS). PFS was defined as the interval from the date of SCS to the date of disease progression, death from any cause, or censoring at the last follow-up (December 31, 2024), whichever occurred first. Disease progression was assessed using Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1 or GCIG CA-125 criteria. PRS was calculated from the date of relapse diagnosis to death or censoring at December 31, 2024. Secondary endpoints included perioperative morbidity, mortality, and time to adjuvant chemotherapy initiation. The PFI was computed from the end of primary treatment to relapse detection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eContinuous variables were summarized as means with standard deviations or medians with interquartile ranges, as appropriate, and compared using Mann-Whitney U test. Categorical variables were expressed as frequencies and percentages and analyzed with chi-square or Fisher\u0026apos;s exact tests. Survival outcomes were estimated using the Kaplan-Meier method, with intergroup comparisons performed via the log-rank test. Hazard ratios (HRs) and 95% confidence intervals (CIs) were derived from univariable Cox proportional hazards models. The proportional hazards assumption was verified using Schoenfeld residuals. A two-sided P-value \u0026lt;0.05 was considered statistically significant. Missing data (e.g., survival in 16% of cases) were handled by listwise deletion for complete-case analysis. All analyses were conducted using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).\u003cbr\u003e\u0026nbsp;No multivariable adjustments were performed due to the small sample size and exploratory nature of the study.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003ePatient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 47 women with relapsed epithelial ovarian cancer (EOC) underwent secondary cytoreductive surgery (SCS), with 30 in the primary surgery (PS) group and 17 in the after systemic therapy (AS) group. Baseline characteristics were comparable between groups (Table 1). The mean age was 50.76 years (range: 31\u0026ndash;70; SD: 8.95), with no significant difference between PS (50.37 years) and AS (50.35 years) groups (P=0.99). The mean BMI was 27 kg/m\u0026sup2; (range: 16\u0026ndash;39.54; SD: 5.022), similar across groups (P=0.85). Patients in the AS group were more likely to be ASA class 3 (median ASA: 2 in PS vs. 3 in AS; P=0.28). The mean CA-125 at recurrence was 470 U/mL (range: 5.5\u0026ndash;3480; SD: 807.9), with no intergroup difference (P=0.17).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRecurrence Patterns\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiffuse carcinomatosis was the most common recurrence pattern (20/47, 42.6%), followed by isolated pelvic recurrences (12/47, 25.5%) and 1\u0026ndash;2 non-pelvic deposits (8/47, 17.0%). Diffuse carcinomatosis was more frequent in the AS group (12/17, 70.6%) than the PS group (8/30, 26.7%; P=0.8). Isolated pelvic recurrences were more common in the PS group (9/30, 30% vs. 3/17, 17.6%; P=0.11) (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePerioperative Outcomes\u003cbr\u003e\u003c/strong\u003ePostoperative complications were observed in 16 patients (34.0%), with Grade 1\u0026ndash;2 events (ileus, atelectasis) occurring equally in both groups (10 patients total: 5 PS, 5 AS) (Table 3). Six patients experienced Grade 3 complications: three required image-guided drainage of collections (2 PS, 1 AS), while three others needed reoperation (2 PS: 1 fecal fistula with diversion stoma; 1 AS: ureteric leak managed via Boari flap reconstruction). One Grade 5 mortality (PS group) resulted from fulminant neutropenia. Hyperthermic intraperitoneal chemotherapy (HIPEC) was utilized in 17 patients (36.2%; 9 PS, 8 AS; P=0.46). The mean ICU stay was 6.08 days (PS: 6.37, AS: 5.4; P=0.46), with comparable hospital stays (9.52 days overall; P=0.83). Adjuvant chemotherapy was administered to 68% of patients (PS: 70%, AS: 64.5%; P=0.8), commencing at a mean of 38.6 days postoperatively (P=0.58).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOncologic Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMean\u003cstrong\u003e\u0026nbsp;Platinum-Free Interval (PFI)\u003c/strong\u003e was 33.4 months (PS: 38, AS: 28; P=0.23) (Table 4). Mean progression free survival (PFS) was \u0026nbsp;21.8 months (PS: 21.4, AS: 20.06; HR: 0.98, 95% CI: 0.52\u0026ndash;1.83; P=0.95; \u003cstrong\u003eFigure 1\u003c/strong\u003e). Mean \u003cstrong\u003ePost-Recurrence Survival (PRS)\u003c/strong\u003e was 38 months (PS: 32.7, AS: 44.7; HR: 1.73, 95% CI: 0.87\u0026ndash;3.44; P=0.121; \u003cstrong\u003eFigure 2\u003c/strong\u003e). \u003cstrong\u003eAdjuvant Therapies\u003c/strong\u003e: Bevacizumab was given to 17 patients (36%; PS: 43.3%, AS: 23.5%); olaparib to 3 patients (6.4%; all in PS group).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Baseline Patient Characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=47)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePS Group (n=30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAS Group (n=17)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\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: 152px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e50.76 \u0026plusmn; 8.95 (31\u0026ndash;70)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e50.37 \u0026plusmn; 8.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e50.35 \u0026plusmn; 8.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI (kg/m\u0026sup2;)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\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: 152px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e27 \u0026plusmn; 5.02 (16\u0026ndash;39.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e27.11 \u0026plusmn; 4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e26.8 \u0026plusmn; 5.41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.85\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eASA Class (Median)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 152px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA-125 at Recurrence\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\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: 152px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 149px;\"\u003e\n \u003cp\u003e470 \u0026plusmn; 807.9 (5.5\u0026ndash;3480)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 118px;\"\u003e\n \u003cp\u003e284 \u0026plusmn; 654\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e626.8 \u0026plusmn; 1004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 61px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: ASA, American Society of Anesthesiologists; BMI, body mass index; PS, primary surgery; AS, after systemic therapy; SD, standard deviation.\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Patterns of Recurrence After Primary Treatment\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"609\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRecurrence Pattern\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=47),\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePS Group (n=30), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAS Group (n=17), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eDiffuse carcinomatosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e20 (42.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e8 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e12 (70.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eIsolated pelvic\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e12 (25.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e9 (30%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e3 (17.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003e1\u0026ndash;2 non-pelvic deposits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e8 (17.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e6 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e2 (11.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\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: 154px;\"\u003e\n \u003cp\u003eLymph nodes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e4 (8.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e4 (13.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 154px;\"\u003e\n \u003cp\u003eNodes + peritoneal deposits\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 134px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: PS, primary surgery; AS, after systemic therapy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3: Postoperative Complications \u0026nbsp;graded by Clavien-Dindo Scale\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGrade\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDescription\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=47), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePS Group (n=30), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAS Group (n=17), n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003eNo complications\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30 (63.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e20 (66.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e10 (58.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e1\u0026ndash;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003eIleus, atelectasis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e10 (21.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5 (16.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e5 (29.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003eCollections drained (image-guided)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e3b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003eFecal fistula/ureteric leak (reoperation)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e2 (6.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e1 (5.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 54px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 185px;\"\u003e\n \u003cp\u003eMortality (fulminant neutropenia)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e1 (2.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 124px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations: PS, primary surgery; AS, after systemic therapy\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4: Summary of Key Oncologic Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"601\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOutcome\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall (n=47)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePS Group (n=30)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAS Group (n=17)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHR (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePlatinum-Free Interval (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\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: 172px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD (Range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e33.4 \u0026plusmn; 25.35 (9\u0026ndash;143)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e38 \u0026plusmn; 28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e28 \u0026plusmn; 18.73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.23\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProgression-Free Survival (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\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: 172px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e21.8 \u0026plusmn; 12.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e21.4 \u0026plusmn; 10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e20.06 \u0026plusmn; 16.62\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0.98 (0.52\u0026ndash;1.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-Recurrence Survival (months)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\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: 172px;\"\u003e\n \u003cp\u003eMean \u0026plusmn; SD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e38 \u0026plusmn; 20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e32.7 \u0026plusmn; 20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e44.7 \u0026plusmn; 20.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e1.73 (0.87\u0026ndash;3.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e0.121\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjuvant Therapies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\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: 172px;\"\u003e\n \u003cp\u003eBevacizumab, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e17 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e13 (43.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e4 (23.5%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 172px;\"\u003e\n \u003cp\u003eOlaparib, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e3 (6.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e3 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0 (0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u0026mdash;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 55px;\"\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\u003cp\u003e\u003cem\u003eAbbreviations: AS, after systemic therapy; CI, confidence interval; HR, hazard ratio; PS, primary surgery; SD, standard deviation. P-values for survival from log-rank test; HR from Cox proportional hazards model.\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this retrospective analysis of 47 patients undergoing secondary cytoreductive surgery (SCS) for platinum-sensitive relapsed epithelial ovarian cancer (EOC) at a high-volume tertiary center in Southern India, we observed a median progression-free survival (PFS) of 21.8 months and post-recurrence survival (PRS) of 38 months, with complete cytoreduction achieved in all cases. These outcomes align closely with data from landmark phase III trials evaluating SCS in similar patient populations. For instance, the AGO DESKTOP III trial reported a median PFS of 18.4 months and overall survival (OS) of 53.7 months in the SCS arm among 407 patients with a positive AGO score, demonstrating a significant OS benefit over chemotherapy alone (hazard ratio [HR] 0.75; 95% confidence interval [CI] 0.59-0.96; P=0.02)\u003csup\u003e17\u0026nbsp;\u003c/sup\u003e. Similarly, the SOC-1 trial, conducted in a Chinese cohort of 357 patients, showed a median PFS of 17.4 months with SCS plus chemotherapy versus 11.9 months with chemotherapy alone (HR 0.58; 95% CI 0.45-0.74; P\u0026lt;0.0001), supporting the role of surgery in extending PFS in platinum-sensitive relapse\u003csup\u003e18\u003c/sup\u003e.Our slightly longer PFS may reflect stringent patient selection, including adherence to AGO criteria and prior complete primary cytoreduction, which are known predictors of favorable outcomes in SCS.\u003c/p\u003e\n\u003cp\u003eA notable finding was the nonsignificant trend toward improved PRS in the after systemic therapy (AS) group (44.7 months) compared to the primary surgery (PS) group (32.7 months; HR 1.73; 95% CI 0.87-3.44; P=0.121). This suggests potential benefits from upfront systemic therapy in downstaging disease, facilitating more effective cytoreduction, particularly in cases with diffuse carcinomatosis, which was more prevalent in the AS cohort (70.6% vs. 26.7%). While our sample size limits statistical power, this observation echoes subgroup analyses from the GOG-0213 trial, where SCS did not confer an OS benefit overall (median OS 50.6 months vs. 64.7 months with chemotherapy alone; HR 1.29; 95% CI 0.97-1.72; P=0.08), but benefits were seen in select patients with limited disease burden\u003csup\u003e15\u003c/sup\u003e.\u0026nbsp;Meta-analyses further corroborate the PFS advantage of SCS with complete resection (HR 0.69; 95% CI 0.61-0.78; P\u0026lt;0.001) but highlight equivocal OS gains, often due to heterogeneity in patient selection and residual disease\u003csup\u003e16\u003c/sup\u003e. \u0026nbsp;The trend in our AS group warrants prospective validation, as neoadjuvant approaches may optimize surgical feasibility in relapsed settings, akin to primary EOC management.\u003c/p\u003e\n\u003cp\u003ePerioperative morbidity in our study was acceptable, with 34% of patients experiencing complications (mostly low-grade) and a single mortality (2.1%) attributed to neutropenia. This rate is consistent with reported figures of 20-40% in SCS trials, where major complications (Clavien-Dindo grade ≥3) range from 9-20%\u0026nbsp;\u003csup\u003e23\u003c/sup\u003e. Hyperthermic intraperitoneal chemotherapy (HIPEC) was employed in 36.2% of cases, primarily for diffuse disease, without increasing morbidity significantly. Emerging evidence supports HIPEC as an adjunct in selected relapsed EOC, with a recent review indicating potential PFS benefits (median 18-22 months) when combined with SCS, though randomized data remain limited\u003csup\u003e19\u003c/sup\u003e. Our mean ICU and hospital stays (6.08 and 9.52 days, respectively) were comparable between groups, underscoring the feasibility of SCS in resource-constrained settings like Southern India, where high-volume centers can mitigate risks through multidisciplinary care.\u003c/p\u003e\n\u003cp\u003eDespite these encouraging results, our study has limitations inherent to its retrospective design, including a small sample size (n=47 over 7.5 years), potential selection bias toward operable patients, and missing survival data in 16% of cases. The lack of a chemotherapy-only control arm precludes direct comparisons of SCS benefits, and the imbalance in group sizes (30 PS vs. 17 AS) may have underpowered subgroup analyses. Furthermore, while high-grade serous histology dominated (80%), the inclusion of other subtypes limits generalizability, as low-grade serous EOC may respond differently to SCS\u003csup\u003e23\u003c/sup\u003e. These constraints reflect the rarity of ideal SCS candidates, even in a center performing ~250 primary cytoreductions annually, emphasizing the need for multicenter prospective studies to refine selection criteria and evaluate novel adjuncts like PARP inhibitors post-SCS.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations of the Study\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several important limitations that should be considered when interpreting its findings. The retrospective nature of this study appears to be one of the most important limitations. The small sample size—particularly in the after-systemic-therapy (AS) group (n=17)—reduces statistical power, making it difficult to detect meaningful differences in survival outcomes. Additionally, the single-center nature of the study may limit generalizability, as results could reflect institutional expertise rather than broader applicability. Missing survival data (16% of patients) further complicates the interpretation of oncologic outcomes.\u003c/p\u003e\n\u003cp\u003eTreatment heterogeneity also poses a challenge, as not all patients received HIPEC (only 36%), and adjuvant therapies like bevacizumab and olaparib were not uniformly administered. The study period ended in December 2024, which may not provide sufficient follow-up for recently treated patients to assess long-term survival. Furthermore, since all patients were pre-selected for surgery, the results do not account for outcomes in those managed non-operatively. The lack of a chemotherapy-only control group prevents definitive conclusions about the comparative efficacy of secondary cytoreduction.\u003c/p\u003e\n\u003cp\u003eThese limitations underscore the need for prospective, multicenter studies with standardized protocols to validate these findings and better define the role of secondary cytoreductive surgery in platinum-sensitive recurrent ovarian cancer.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSecondary cytoreductive surgery (SCS) offers favorable outcomes in selected platinum-sensitive relapsed epithelial ovarian cancer patients, achieving complete cytoreduction with mean PFS of 21.8 months and PRS of 38 months, alongside acceptable morbidity (34% complications, 2.1% mortality). A nonsignificant trend toward better PRS after upfront systemic therapy (44.7 vs. 32.7 months) suggests benefits in disease downstaging. These findings support SCS for AGO-eligible patients at high-volume centers, though retrospective limitations necessitate prospective validation to refine selection and integrate targeted therapies for improved survival. Future research should focus on biomarkers for patient selection and integration of targeted therapies to further optimize survival.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"602\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbbreviation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFull Form\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAGO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eArbeitsgemeinschaft Gynäkologische Onkologie (German Study Group for Gynecologic Oncology)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAfter systemic therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eASA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAmerican Society of Anesthesiologists\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBMI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBody Mass Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCA-125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCancer Antigen 125\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEOC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEpithelial Ovarian Cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eECOG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEastern Cooperative Oncology Group\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eElectronic Medical Records\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFIGO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInternational Federation of Gynecology and Obstetrics\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGCIG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGynecologic Cancer InterGroup\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHIPEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHyperthermic Intraperitoneal Chemotherapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHazard Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eICU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIntensive Care Unit\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIEC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInstitutional Ethics Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eOverall Survival\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eP-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePARP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePoly (ADP-Ribose) Polymerase\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePlatinum-Free Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePFS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eProgression-Free Survival\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePubMed Central\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePRS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePost-Recurrence Survival\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePrimary Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRCT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRandomized Controlled Trial\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRECIST\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eResponse Evaluation Criteria In Solid Tumors\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStandard Deviation\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSCS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSecondary Cytoreductive Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSOC-1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSurgery in Ovarian Cancer Trial-1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSPSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTCR/BCR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eT-cell Receptor / B-cell Receptor\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e*Ethics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs of date: 16/05/2025, under Ethics Reference Code IEC/2025/AC/41at Basavatarakam Indo American Cancer Hospital and Research Institute, Hyderabad, the authors have secured approval for collecting, processing and publishing retrospective data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*Consent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*Availability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was collected retrospectively using electronic medical records (EMR) system of the hospital and is available for your reference.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*Competing interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e*Funding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003ch2\u003e*Authors' contributions :\u003c/h2\u003e\n\u003cp\u003eZ.A. U. conceptualized, collected data, performed stats, wrote the manuscript, tables and figures and wrote the discussion\u003c/p\u003e\n\u003cp\u003eS. N. edited and corrected format\u003c/p\u003e\n\u003cp\u003eR.R. did the final editing\u003c/p\u003e\n\u003cp\u003eAll authors contributing in reviewing the manuscript and supervision\u003c/p\u003e\n\u003ch2\u003eAcknowledgement\u003c/h2\u003e\n\u003cp\u003eDr. Astik Mane, MD Psychiatry: Contributed significantly in medical biostatistics. The article could not be written without his help.\u003c/p\u003e\n\u003ch2\u003eData Availability\u003c/h2\u003e\n\u003cp\u003eAvailability of data and materials : Data was collected retrospectively using electronic medical records (EMR) system of the hospital and is available for your reference.The authors declare waiver of consent for this retrospective study. We declare to have adhered to the Declaration of Helsinki for this study\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eDhiman P, Bapsy PP, Patil CN, Raghupathi R. Is Optimal Cytoreduction Post Neoadjuvant Chemotherapy the Only Prognostic Factor in Advanced Ovarian Cancer? South Asian J Cancer. 2022 Dec 30;11(3):207-212. doi: 10.1055/s-0042-1755291. PMID: 36588609; PMCID: PMC10497344\u003c/li\u003e\n\u003cli\u003eAl Rawahi T, Lopes AD, Bristow RE, Bryant A, Elattar A, Chattopadhyay S, Galaal K. Surgical cytoreduction for recurrent epithelial ovarian cancer. Cochrane Database Syst Rev. 2013 Feb 28;2013(2):CD008765. doi: 10.1002/14651858.CD008765.pub3. PMID: 23450588; PMCID: PMC6457850, Gadducci A, Cosio S, Zizioli V, Notaro S, Tana R, Panattoni A, Sartori E. Patterns of Recurrence and Clinical Outcome of Patients With Stage IIIC to Stage IV Epithelial Ovarian Cancer in Complete Response After Primary Debulking Surgery Plus Chemotherapy or Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery: An Italian Multicenter Retrospective Study. Int J Gynecol Cancer. 2017 Jan;27(1):28-36. doi: 10.1097/IGC.0000000000000843. PMID: 27870700.\u003c/li\u003e\n\u003cli\u003ePischart K, Khemworapong K, Chaopotong P, Achariyapota V. Malnutrition Prevalence and Its Implications on Surgical and Oncological Outcomes in Advanced Ovarian Cancer Patients: A Comprehensive Analysis. Obstet Gynecol Int. 2025 May 10;2025:2918759. doi: 10.1155/ogi/2918759. PMID: 40384994; PMCID: PMC12085243 \u003c/li\u003e\n\u003cli\u003eJohnston EA, Ibiebele TI, Friedlander ML, Grant PT, van der Pols JC, Webb PM; Ovarian cancer Prognosis And Lifestyle (OPAL) Study Group. Association of Protein Intake with Recurrence and Survival Following Primary Treatment of Ovarian Cancer. Am J Clin Nutr. 2023 Jul;118(1):50-58. doi: 10.1016/j.ajcnut.2023.05.002. Epub 2023 May 3. PMID: 37146759.\u003c/li\u003e\n\u003cli\u003eRen Y, Li R, Feng H, Xie J, Gao L, Chu S, Li Y, Meng F, Ning Y. Single-cell sequencing reveals effects of chemotherapy on the immune landscape and TCR/BCR clonal expansion in a relapsed ovarian cancer patient. Front Immunol. 2022 Sep 28;13:985187. doi: 10.3389/fimmu.2022.985187. PMID: 36248860; PMCID: PMC9555851.\u003c/li\u003e\n\u003cli\u003eLevin L, McHardy JE, Poulton TA, Curling OM, Hudson CN. Tumour associated immunity and immunocompetence in ovarian cancer. Br J Obstet Gynaecol. 1976 May;83(5):393-9. doi: 10.1111/j.1471-0528.1976.tb00850.x. PMID: 1268151. \u003c/li\u003e\n\u003cli\u003eJohnston EA, Ibiebele TI, Friedlander ML, Grant PT, van der Pols JC, Webb PM; Ovarian cancer Prognosis And Lifestyle (OPAL) Study Group. Association of Protein Intake with Recurrence and Survival Following Primary Treatment of Ovarian Cancer. Am J Clin Nutr. 2023 Jul;118(1):50-58. doi: 10.1016/j.ajcnut.2023.05.002. Epub 2023 May 3. PMID: 37146759. \u003c/li\u003e\n\u003cli\u003eYim GW, Eoh KJ, Kim SW, Nam EJ, Kim YT. Malnutrition Identified by the Nutritional Risk Index and Poor Prognosis in Advanced Epithelial Ovarian Carcinoma. Nutr Cancer. 2016 Jul;68(5):772-9. doi: 10.1080/01635581.2016.1159702. Epub 2016 Apr 4. PMID: 27044606..govpubmed.ncbi.nlm.nih.gov \u003c/li\u003e\n\u003cli\u003eRen Y, Li R, Feng H, Xie J, Gao L, Chu S, Li Y, Meng F, Ning Y. Single-cell sequencing reveals effects of chemotherapy on the immune landscape and TCR/BCR clonal expansion in a relapsed ovarian cancer patient. Front Immunol. 2022 Sep 28;13:985187. doi: 10.3389/fimmu.2022.985187. PMID: 36248860; PMCID: PMC9555851.\u003c/li\u003e\n\u003cli\u003eDrakes ML, Stiff PJ. Regulation of Ovarian Cancer Prognosis by Immune Cells in the Tumor Microenvironment. Cancers (Basel). 2018 Sep 1;10(9):302. doi: 10.3390/cancers10090302. PMID: 30200478; PMCID: PMC6162424.\u003c/li\u003e\n\u003cli\u003eKahn R, Filippova O, Gordhandas S, An A, Straubhar AM, Zivanovic O, Gardner GJ, O\u0026apos;Cearbhaill RE, Tew WP, Grisham RN, Sonoda Y, Long Roche K, Abu-Rustum NR, Chi DS. Ten-year conditional probability of survival for patients with ovarian cancer: A new metric tailored to Long-term survivors. Gynecol Oncol. 2023 Feb;169:85-90. doi: 10.1016/j.ygyno.2022.11.030. Epub 2022 Dec 13. PMID: 36521353; PMCID: PMC10364188. \u003c/li\u003e\n\u003cli\u003eTimmermans M, Sonke GS, Van de Vijver KK, van der Aa MA, Kruitwagen RFPM. No improvement in long-term survival for epithelial ovarian cancer patients: A population-based study between 1989 and 2014 in the Netherlands. Eur J Cancer. 2018 Jan;88:31-37. doi: 10.1016/j.ejca.2017.10.030. Epub 2017 Nov 25. PMID: 29179135.\u003c/li\u003e\n\u003cli\u003ede Bree E, Michelakis D, Anagnostopoulou E. The current role of secondary cytoreductive surgery for recurrent ovarian cancer. Front Oncol. 2022 Oct 21;12:1029976. doi: 10.3389/fonc.2022.1029976. PMID: 36338689; PMCID: PMC9633943 \u003c/li\u003e\n\u003cli\u003eArmstrong DK, Coleman RL, Penson RT. Emerging therapeutic options for platinum-sensitive ovarian cancer patients. Clin Adv Hematol Oncol. 2011 Apr;9(4 Suppl 5):1-16. PMID: 21558997\u003c/li\u003e\n\u003cli\u003eColeman RL, Spirtos NM, Enserro D, Herzog TJ, Sabbatini P, Armstrong DK, Kim JW, Park SY, Kim BG, Nam JH, Fujiwara K, Walker JL, Casey AC, Alvarez Secord A, Rubin S, Chan JK, DiSilvestro P, Davidson SA, Cohn DE, Tewari KS, Basen-Engquist K, Huang HQ, Brady MF, Mannel RS. Secondary Surgical Cytoreduction for Recurrent Ovarian Cancer. N Engl J Med. 2019 Nov 14;381(20):1929-1939. doi: 10.1056/NEJMoa1902626. PMID: 31722153; PMCID: PMC6941470\u003c/li\u003e\n\u003cli\u003eMarchetti C, Fagotti A, Tombolini V, Scambia G, De Felice F. The Role of Secondary Cytoreductive Surgery in Recurrent Ovarian Cancer: A Systematic Review and Meta-Analysis. Ann Surg Oncol. 2021 Jun;28(6):3258-3263. doi: 10.1245/s10434-020-09226-7. Epub 2020 Oct 16. PMID: 33067742.\u003c/li\u003e\n\u003cli\u003eHarter P, Sehouli J, Vergote I, Ferron G, Reuss A, Meier W, Greggi S, Mosgaard BJ, Selle F, Guyon F, Pomel C, L\u0026eacute;curu F, Zang R, Avall-Lundqvist E, Kim JW, Ponce J, Raspagliesi F, Kristensen G, Classe JM, Hillemanns P, Jensen P, Hasenburg A, Ghaem-Maghami S, Mirza MR, Lund B, Reinthaller A, Santaballa A, Olaitan A, Hilpert F, du Bois A; DESKTOP III Investigators. Randomized Trial of Cytoreductive Surgery for Relapsed Ovarian Cancer. N Engl J Med. 2021 Dec 2;385(23):2123-2131. doi: 10.1056/NEJMoa2103294. Erratum in: N Engl J Med. 2022 Feb 17;386(7):704. doi: 10.1056/NEJMx220002. PMID: 34874631\u003c/li\u003e\n\u003cli\u003eShi T, Zhu J, Feng Y, Tu D, Zhang Y, Zhang P, Jia H, Huang X, Cai Y, Yin S, Jiang R, Tian W, Gao W, Liu J, Yang H, Cheng X, Zang R. Secondary cytoreduction followed by chemotherapy versus chemotherapy alone in platinum-sensitive relapsed ovarian cancer (SOC-1): a multicentre, open-label, randomised, phase 3 trial. Lancet Oncol. 2021 Apr;22(4):439-449. doi: 10.1016/S1470-2045(21)00006-1. Epub 2021 Mar 8. PMID: 33705695.\u003c/li\u003e\n\u003cli\u003ede Bree E, Michelakis D, Anagnostopoulou E. The current role of secondary cytoreductive surgery for recurrent ovarian cancer. Front Oncol. 2022 Oct 21;12:1029976. doi: 10.3389/fonc.2022.1029976. PMID: 36338689; PMCID: PMC9633943. \u003c/li\u003e\n\u003cli\u003eConte C, Fagotti A, Avesani G, Trombadori C, Federico A, D\u0026apos;Indinosante M, Giudice MT, Pelligra S, Lodoli C, Marchetti C, Ferrandina G, Scambia G, Gallotta V. Update on the secondary cytoreduction in platinum-sensitive recurrent ovarian cancer: a narrative review. Ann Transl Med. 2021 Mar;9(6):510. doi: 10.21037/atm-20-4690. PMID: 33850907; PMCID: PMC8039681.\u003c/li\u003e\n\u003cli\u003eBogani G, Tagliabue E, Signorelli M, Ditto A, Martinelli F, Chiappa V, Mosca L, Sabatucci I, Leone Roberti Maggiore U, Lorusso D, Raspagliesi F. A score system for complete cytoreduction in selected recurrent ovarian cancer patients undergoing secondary cytoreductive surgery: predictors- and nomogram-based analyses. J Gynecol Oncol. 2018 May;29(3):e40. doi: 10.3802/jgo.2018.29.e40. Epub 2018 Feb 23. PMID: 29533023; PMCID: PMC5920224.\u003c/li\u003e\n\u003cli\u003eDindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004 Aug;240(2):205-13. doi: 10.1097/01.sla.0000133083.54934.ae. PMID: 15273542; PMCID: PMC1360123\u003c/li\u003e\n\u003cli\u003eGoldberg RM, Kim SR, Fazelzad R, Li X, Brown TJ, May T. Secondary cytoreductive surgery for recurrent low-grade serous ovarian carcinoma: A systematic review and meta-analysis. Gynecol Oncol. 2022 Jan;164(1):212-220. doi: 10.1016/j.ygyno.2021.10.080. Epub 2021 Oct 28. PMID: 34756470.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"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":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7369696/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7369696/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eEpithelial ovarian cancer (EOC) frequently relapses despite optimal primary treatment, with platinum-sensitive disease presenting a therapeutic challenge. Secondary cytoreductive surgery (SCS) may improve outcomes in select patients, but evidence from randomized trials is mixed. This study evaluates perioperative and oncologic outcomes of SCS in platinum-sensitive relapsed EOC, comparing upfront SCS (primary surgery [PS]) versus SCS after systemic therapy (AS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eIn this retrospective cohort study at a tertiary cancer center in Southern India (April 2017\u0026ndash;December 2024), 47 patients with platinum-sensitive relapsed EOC meeting AGO DESKTOP III criteria (prior complete cytoreduction, ECOG 0\u0026ndash;2, no ascites) underwent SCS. Patients were stratified into PS (n\u0026thinsp;=\u0026thinsp;30) and AS (n\u0026thinsp;=\u0026thinsp;17) groups. Progression-free survival (PFS) was from SCS to recurrence/death or censoring (December 31, 2024). Post-recurrence survival (PRS) was from relapse to death/censoring. Survival was analyzed using Kaplan-Meier curves, log-rank tests, and Cox models. Complications were graded by Clavien-Dindo classification.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eGroups were comparable in age (mean 50.8 years), BMI (27 kg/m\u0026sup2;), and histology (high-grade serous: 80%). Mean platinum-free interval was 33.4 months (38 PS vs. 28 AS). Complete cytoreduction was achieved in all; hyperthermic intraperitoneal chemotherapy was used in 36.2%. Complications occurred in 34% (mostly grade 1\u0026ndash;2); one mortality (neutropenia). Mean PFS was 21.8 months (21.4 PS vs. 20.1 AS; HR 0.98, 95% CI 0.52\u0026ndash;1.83; P\u0026thinsp;=\u0026thinsp;0.95). Mean PRS was 38 months (32.7 PS vs. 44.7 AS; HR 1.73, 95% CI 0.87\u0026ndash;3.44; P\u0026thinsp;=\u0026thinsp;0.121).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eSCS yields favorable PFS and PRS in selected platinum-sensitive relapsed EOC patients, with a nonsignificant trend toward better PRS after upfront systemic therapy. Perioperative morbidity is acceptable. Prospective studies are needed to confirm benefits and refine selection criteria.\u003c/p\u003e","manuscriptTitle":"Perioperative and Oncologic Outcomes of Secondary Cytoreductive Surgery: A Retrospective Analysis from a Cancer Care Centre of Southern India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-12 13:57:03","doi":"10.21203/rs.3.rs-7369696/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"751abdd2-fa06-4f60-8961-faa47ae0b739","owner":[],"postedDate":"October 12th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T10:12:35+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-12 13:57:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7369696","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7369696","identity":"rs-7369696","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}