Efficiency of Laparoscopic Interval Cytoreductive Surgery After Neoadjuvant Chemotherapy in Patients With Stage III and IV Epithelial Ovarian Cancer
Phase: NA
Conditions: Ovarian Neoplasms
Sponsor: Instituto Nacional de Cancerologia de Mexico

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Efficiency of Laparoscopic Interval Cytoreductive Surgery After Neoadjuvant Chemotherapy in 
Patients with Stage III and IV Epithelial Ovarian Cancer 
 
NCT number: Not Applicable 
 
Date of Document: March 24, 2025 
 
 
 

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Abstract 
Purpose: Laparoscopic surgery may have the benefits of minimally invasive surgery (MIS). 
Laparoscopic interval cytoreduction may be effective for eradication of tumor implants in advanced 
ovarian cancer after NACT and similar complications. 
Methods: It was a prospective single-arm phase II clinical trial study. The efficacy and complications 
of laparoscopic interval cytoreduction in patients with COEA after NCT were evaluated. Patients 
diagnosed with advanced ovarian carcinoma who received NCT of 3 to 4 cycles of carboplatin/paclitaxel 
with or without bevacizumab were included. Interval cytoreductive laparoscopic surgery was performed.  
Results: 18 of 40 patients were included, with a median age of 45.5 years (range: 38-72). The most 
common histological type was high-grade serous carcinoma 14 (77.77%). 6 (33.33%) were stage IIIC, 
9 (50%) IVB and 3 (16.67%) IVA. 14 patients (77.78%) received 4 cycles of chemotherapy. 1 (5.56%) 
received standard surgery, 5 (27.78%) radical surgery, 10 (55.56%) supraradical surgery and 2 (11.11%) 
were non-cytoreducible. 16 (88.89%) had optimal R0 = no residual, and 2 (11.11%) were not resected. 
In complications, the median blood loss was 50 ml (range: 10 - 600 ml), 13 (72.2%) patients had no 
complications, and 1 patient had a grade III complication. 
Conclusion:   The primary objective was achieved, 88.89% of patients were cytoreduced. 4 (22.22%) 
patients presented mild complications while 1 (5.56%) patient presented moderate grade IIIa 
complications.  
 
Keywords: Laparoscopy, Cytoreduction Surgical Procedures, Ovarian Neoplasm 
 
INTRODUCTION 
Epithelial Ovarian Cancer (EOC) is the eighth cause of cancer worldwide in women according to the 
Global Cancer Observatory, World Health Organization (WHO), and the International Agency for 
Research on Cancer. The global incidence of ovarian cancer was 7.8 cases per 100,000 inhabitants in 

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2022. In Mexico, ovarian cancer has an incidence of 7.7 per 100,000 women. [1] 
Primary cytoreduction surgery (PCS) is the regular course of treatment for EOC. Cytoreduction can be 
categorized as “optimal” (residual disease <1cm), “suboptimal” (residual disease >1cm), or “complete” 
(with no macroscopic evidence of residual disease), this last one being considered the ultimate goal of 
cytoreduction surgery due to its impact on survival prognosis. [2] 
 
The use of neoadjuvant chemotherapy (NACT) has increased substantially in the last decade, four 
phase III non-inferiority trials randomly assigned women with advanced stage EOC to receive NACT 
followed by Interval Cytoreduction Surgery (ICS). They demonstrated similar percentages of optimal 
cytoreduction (most between 70 and 80%) and had the same survival outcomes as the women assigned 
to PCS and adjuvant chemotherapy; the results were consistent and demonstrated no inferiority. [3-6]  
The prognostic factor for survival is complete cytoreduction, so the objective of surgery should be 
laparotomy vs CMI. 
The use of CMI in the staging of EOC is feasible and safe in patients with suspected early-stage tumors 
without extraovarian involvement, with the benefits of CMI including: less bleeding, shorter hospital 
stays, and quick recovery to usual activities. (7-11) 
 
Some studies demonstrated that women who underwent ICS via Minimally Invasive Surgery (MIS) 
after NACT reported a high rate of complete cytoreduction, good perioperative reports, and excellent 
rates of disease-free survival. [12-15]   
 
Due to 70% of EOC being diagnosed in advanced stages, the majority of patients receive the 
standard course of treatment: initial NACT followed by ICS via laparotomy. However, this procedure 
can present high morbidity rates. A laparoscopic procedure allows for smaller incision sites and 
improved recovery; it also has similar oncological control and rates trans- and post-operative 
complications to laparotomies.  
 
The existing observational studies and case series suggest that laparoscopic surgery apports the 
benefits of MIS, such as: reduced bleeding, better vision, decreased length of hospital stay, and improved 
recovery from surgery. The finality of this study is to demonstrate the efficiency of laparoscopic 
cytoreduction in the eradication of tumoral implants in advanced stage ovarian cancer after NACT and 

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the similarity in rates of laparotomy complications by the surgical teams at the Instituto Nacional de 
Cancerología (INCan) and ABC Medical Center (ABCMC).  
 
 
MATERIALS AND METHODS 
Design 
This is phase two of a prospective clinical trial. The purpose is to evaluate the efficiency and 
complications of optimal laparoscopic cytoreduction in patients with advanced ovarian cancer after 
receiving NACT; the investigators will be comparing the results with those of open cytoreduction 
surgery as reported in the literature: interval cytoreduction of 70 to 80% and a 7% complication rate.  
The investigators included patients from the ABCMC and INCan, who were diagnosed with stage 
III-IV FIGO (16) classification for cancer of the ovary, fallopian tube and peritoneum. Had received 3 
to 4 cycles of NACT, and were then evaluated by CT imaging or PET-CT. The investigators excluded 
patients who had partial response to chemotherapy with persistent ascites or pleural drainage, and those 
who met any criteria for unresectable tumors. The selection of patients for the study is presented in 
Figure 1.  
Patients who received 3-4 cycles of NACT with carboplatin/paclitaxel were assessed with CT 
imaging or 18 FDG PET-CT 2-3 weeks after the last cycle of chemotherapy.   
The patient was introduced to the operating room, the anesthesia technique used was at the 
discretion of the anesthesiology team. Using a V-care type uterine manipulator that was placed prior to 
surgery, a trocar was introduced at a 12mm supraumbilical port for direct vision or open technique (as 
directed by the surgeon). The abdominal cavity is inflated with 12 to 14 mmHg of CO2 gas at a flow of 
3-6 L/min, 4 trocars were placed in 5mm ports in the lower quadrants and one was placed in a 5 or 12 
mm supraumbilical port at the midline. If necessary, additional trocars were placed in the superior 
quadrants to ensure the comfort of the surgeon and obtain the greatest possible cytoreduction. (Fig 2) 
The procedure started with the cytoreduction of highest complexity (determined at the time of 
initial inspection), after which, if necessary, the patient underwent a complete hysterectomy, bilateral 
salpingo-oophorectomy, omentectomy, or partial peritonectomy and excision of any peritoneal implants 

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present. The magnitude of the surgical procedures will be classified as: 
1. Standard surgery: minimal hysterectomy, adnexectomy y omentectomy 
2. Radical Surgery: included resection of the ovaries, of the rectouterine excavation (pouch of 
Douglas) and or the peritoneum between the bladder and uterus, hysterectomy, rectosigmoid 
colectomy, and complete omentectomy (Fig 3) 
3. Supra-radical Surgery: included other procedures such as splenectomy, diaphragm resection, or 
other intestinal resection.   
Any complications that arise will be documented at 30 days postop and measured according to 
Clavien Dindo score (17) (class III - V). The investigators did not include class 0 - II. Definition of 
Clavien Dindo scores as they relate to postoperative complications is presented in Table 2.  
Evaluation of the Cytoreduction will be done via surgical findings, the video of the laparoscopic 
surgery, and through imaging techniques. A second CT or PET-CT was realized 4 weeks after the 
conclusion of the laparoscopic cytoreduction surgery in order to evaluate the level of tumor eradication 
realized by the surgery; and prior to complementary chemotherapy. This was conducted by the imaging 
and nuclear medicine departments.  
Statistical Analysis 
The investigators conducted a descriptive analysis to determine the clinical and demographic 
characteristics of the patients included in the study. Qualitative variables will be presented as frequencies 
and proportions. For quantitative variables, the investigators will analyze the distribution as well as 
evaluate the asymmetry and kurtosis with critical values of ±0.5 and ±1 respectively. The investigators 
will also employ the Kolmogorov Smirnov or Shapiro Wilk tests to determine normal distribution; 
considering the data to be normal if the significance of the test is greater than 0.05. Variables with 
normal distribution will be represented by the mean and standard distribution. Variables with non-
normal distribution will be represented by the median and interquartile range. Survival curves will be 
calculated according to Kaplan-Meier global survival curves and compared using log rank tests.  
 
IRB/IACUC approval & informed consent 

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The investigators conducted this study in compliance with the principles in the Declaration of Helsinki. 
This study’s protocol was reviewed and approved by the Institutional Review Board of (022/014/GII) 
(CEI/022/22). Written informed consent was obtained from all the patients included in this study.  
 
RESULTS 
The investigators evaluated 40 patients diagnosed with advanced stage III or IV ovarian cancer who had 
received 3 to 4 cycles of NACT. Of these, only 18 met the inclusion criteria and subsequently underwent 
laparoscopic surgery. One patient was excluded because she had advanced stage endometrial cancer.  
The median age of participants was 45.5 years (range: 38-72). The most common histological type was 
high-grade serous carcinoma in 14 (77.77%) patients. Among the participants, 6 (33.33%) were in stage 
IIIC, 9 (50%) were in stage IVB, and 3 (16.67%) in stage IVA (Table 3). 14 (77.78%) participants 
received 4 cycles of chemotherapy; 16 (88.89%) participants had a partial response to treatment and 1 
(5.56%) had a complete response to treatment. (Table 4) All patients underwent laparoscopic surgery, 
of which 1 (5.56%) was standard surgery, 5 (27.78%) were radical surgery, 10 (55.56%) were 
supraradical surgery, and 2 (11.11%) were not cytoreducible. None of the procedures were converted to 
open surgery. Regarding the type of residual tumor after cytoreduction, 16 (88.89%) were classified as 
optimal R0 = no residual. (Table 5 ) 
Regarding trans and postoperative complications, the median blood loss was 50 ml (range: 10-600 ml) 
and there were no readmissions during the first 30 postoperative days. (Table 6) At 30 days 
postoperatively, 13 (72.22%) patients had no complications, 4 (22.22%) had grade I complications, and 
1 (5.56%) had a grade III complication: bleeding and vaginal opening, which required closure in the 
operating room with regional anesthesia.  
 
DISCUSSION 
EOC continues to be a world-wide health issue due to 75 – 80% of cases being diagnosed in advanced 
stages (III and IV) resulting in the deterioration of the patient´s functional state prior to reception of 
medical attention. A total of 40 patients were recruited at the INCan and ABCMC with the diagnosis of 

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stage III and IV EOC, who due to their functional and nutritional status received chemotherapy and were 
followed throughout their treatment. Of these, only 18 patients met the inclusion criteria, and were 
subsequently operated on by laparoscopy; 1 was excluded for having advanced endometrial cancer. 
As reported in the literature, the investigators identified that the most frequent histological type in our 
study was high-grade serous carcinoma in 14 patients (77.77%), stage FIGO IIIC in 6 (33.33%) and IVB 
in 9 (50%) patients, followed by IVA in 3 (16.67%). 
Though primary cytoreductive surgery remains the traditional treatment for EOC, the use of NCT has 
increased substantially for patients with either poor functional or nutritional status or for unresectable 
disease by imaging. 
Laparoscopy offers lower postoperative complication rates, shorter postoperative hospital stay, and less 
blood loss (7). However, intraoperative tumor rupture has been reported to occur more frequently in 
patients undergoing laparoscopy compared to laparotomy in retrospective cohort studies (8). There is 
no randomized data comparing laparotomy and laparoscopy staging for ovarian cancer (9-10), and there 
probably never will be. 
The use of laparoscopy for cytoreduction in advanced ovarian cancer is questionable. Nehzat et al. 
suggested that total or interval laparoscopic primary cytoreduction is technically feasible in a well-
selected population of patients with suspected stage IIC or higher ovarian cancer (11). Other authors 
have also suggested that laparoscopy may benefit select patients with recurrent ovarian cancer without 
compromising survival, but laparotomy is recommended for patients with widespread peritoneal 
implants, multiple sites of recurrence, and/or extensive adhesions (18-19).  
The studies have demonstrated a high rate of complete cytoreduction, good perioperative outcomes, and 
excellent disease-free survival in women who underwent interval cytoreduction for CMI, after a good 
response to NACT (12-15). In our series of cases, all patients underwent laparoscopic surgery, of which 
1 (5.56%) was standard surgery, 5 (27.78%) were radical surgery, 10 (55.56%) were supraradical 
surgery and 2 (14, 3%) were not cytoreducible. None of the procedures were converted to open surgery. 
Regarding the type of residual tumor after cytoreduction, 16 (88.89%) were classified as optimal R0 = 

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no residual, and the 2 (11.11%) patients who could not be resected due to unresectable carcinomatosis 
were classified as R2 = with residual. 
Gueli Alletti et al. performed cytoreduction by CMI in 30 women with a clinical response to NCT, 
achieving complete cytoreduction in 29 of them. At a mean follow-up of 10.5 months, all patients were 
alive. (12) 
Corrado et al. found that interval cytoreduction by CMI was associated with lower percentages of intra- 
and postoperative complications (3.3% and 6.6%, respectively). In a completed study, 26 of 30 patients 
were alive without recurrence with a median follow-up of 15 months. In a controlled study, in which 10 
women underwent interval cytoreduction by CMI and 11 women underwent laparotomy (13). In our 
study the median blood loss was 50 ml (range: 10-600 ml) and there were no readmissions during the 
first 30 postoperative days. At 30 postoperative days, 13 (72.22%) patients had no complications, 4 
(22.22%) had grade I complications, and 1 patient had a grade III complication, which was bleeding and 
vaginal opening, which required closure in the operating room with regional anesthesia. 
Favero et al., found a non-significant decrease in cancer-specific survival and a non-significant reduction 
in the chemotherapy-free interval in women undergoing CMI (14). 
Melamed et al. performed a retrospective cohort using the National Cancer Database to evaluate the use 
and effectiveness of laparoscopic cytoreductive surgery in patients with advanced EOC who have 
received NCT. This study also suggested that the CMI approach may be reasonable and effective in 
well-selected patients. Importantly, there was a significant increase in the frequency of interval 
cytoreduction by CMI in the United States from 2010 to 2012 (11-16%, P<0.001) (15) 
Therefore, the investigators consider that laparoscopic surgery in interval cytoreduction to be safe when 
performed by highly experienced surgeons; and in hospitals with high volume of ovarian cancer care 
and treatment, this procedure can be performed with high success rates and low complications. 
The Laparoscopic Cytoreduction After Neoadjuvant Chemotherapy (LANCE) trial is an international, 
prospective, randomized, multicenter, non-inferiority Phase III trial that compares minimally invasive 
surgery to laparotomy in women with high-risk epithelial ovarian cancer. These women had advanced 
stage grades, had complete or partial surgery and response to three or four cycles of neoadjuvant 

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chemotherapy with normalization of CA-125. The first 100 participants were enrolled in a pilot test and 
Phase III was determined to be feasible and currently ongoing. (20) 
Therefore, the results of this phase III trial will be of utmost importance to determine if minimally 
invasive surgery is not inferior to laparotomy. 
 
CONCLUSIONS 
The main objective of the study was met, optimal cytoreduction in 88.89% of the patients, without 
intraoperative complications and at 30 days, 4 patients (22.22%) had grade I complications and 1 patient 
presented a grade III complication: bleeding and vaginal opening, which required closure in the 
operating room with regional anesthesia. The median blood loss was 50 ml (range: 10-600 ml) and there 
were no readmissions during the first 30 postoperative days. 
The selection of post-chemotherapy advanced ovarian cancer patients to perform cytoreduction by 
interval laparoscopy was the most important part to achieve it successfully, the objective in the 
effectiveness of the procedure was met. 
The investigators consider up to this point that laparoscopic surgery in interval cytoreduction to be safe. 
When performed by experienced surgeons this procedure can be performed with high success rates and 
low complications. 
A phase III study is needed to confirm the previously issued results 
Limitations. 
It was a study has selection bias of patients to be operated by interval laparoscopy. Although it does not 
reflect the generality of patients with advanced ovarian cancer, since it identifies those who best respond 
to neoadjuvant chemotherapy, they are the best candidates to receive laparoscopic surgery. 
 
Strengths 
Being a prospective study, this patient selection bias means that the investigators have the best 
responders to chemotherapy and a low tumor burden, which makes laparoscopic surgery feasible, 
therefore making it a strength of the study. 

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7. Nezhat FR, Pejovic T, Finger TN, Khalil SS. Role of minimally invasive surgery in ovarian cancer. J 
Minim Invasive Gynecol 2013; 20: 754-765. 
8. 
Park HJ, Kim DW, Yim GW, Nam EJ, Kim S, Kim YT. Staging laparoscopy for the management 
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10.  Lawrie TA, Medeiros LR, Rosa DD, et al. Laparoscopy versus laparotomy for FIGO stage I ovarian 
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12. Gueli Alletti S, Bottoni C, Fanfani F, et al. Minimally invasive interval debulking surgery in 
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13. Corrado G, Mancini E, Cutillo G, et al. Laparoscopic Debulking Surgery in the Management of 
Advanced Ovarian Cancer After Neoadjuvant Chemotherapy. Int J Gynecol Cancer.2015; 25(7): 1253-
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001584. Epub 2020 Jul 20. 
 
 

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Table 1. Review of Literature 
Author 
N 
Cytoreduction Follow-up 
Complications 
Survival 
Gueli 
Alletti et al. 
(12) 
N=30 
Complete 
cytoreduction 
in 29 patients 
10.5 
months 
Most patients were 
discharged one the 
second day postop 
(range 2-3). There 
were no early postop 
complications 
registered.  
All survived at 
follow-up 
Corrado et 
al. (13) 
N=30 
Complete 
debulking 
surgery with 
no residua 
disease 
15 months 
3.3% had 
intraoperative 
complications and 
6.6% had 
postoperative 
complications 
26 of 30 patients 
had recurrence free 
survival at follow-
up 
Favero et 
al. (14) 
N=21 
Complete 
resection of 
macroscopic 
and 
microscopic 
disease 
24.2 
months 
No observed 
oncological 
differences between 
groups, no 
intraoperative 
complications were 
present in each group  
Non-significant 
reduction in cancer 
specific survival 
during the 
chemotherapy free 
interval 
Melamed at 
al. (15) 
N=450 
Suboptimal 
cytoreduction 
in 20.6% in 
patients who 
had a 
laparoscopic 
procedure 
compared to 
22.6% in 
patients who 
had a 
laparotomy. 
3 years 
Shorter hospital stays 
in laparoscopy group 
(median 4 days, 
p<0.001), hospital 
readmission rate 
5.3% versus 3.7% for 
laparotomy group.  
No significant 
difference in 
overall survival. 
90-day mortality at 
2.8% for 
laparoscopy group 
compared to 2.9% 
for laparotomy 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table 2. Clavien Dindo Classification of postoperative complications 
Grade 
Definition 
I  
Any deviation from the normal postoperative course without need for 
pharmacological 
treatment 
(with 
the 
exception 
of 
antipyretics, 
antidiarrheics, and antiemetics) or radioscopic or surgical intervention. 
II  
Any complication that may require pharmacological treatment or that may 
requires blood transfusion or parenteral nutrition. 
III  
Any complication that requires endoscopic, radiologic, or surgical 
intervention. Without the need of general anesthesia (IIIA) and with the use 
of general anesthesia (IIIB). 
IV  
Any potentially fatal complication that requires management in the ICU. 
Dysfunction of a single organ (IVA) or that involves multiple organs (IVB).  
V  
Death 
 
 
 
 
Table 3. Demographic and Epidemiological Characteristics 
Characteristic 
Total* 
Age 
45.5 (43 – 53) 
BMI 
25.85 (23.5 – 27.9) 
Papillary Serous Carcinoma 3 (16.67%) 
High Grade Serous 
Carcinoma 
 
14 (77.77%) 
Endometrioid Carcinoma 
4 (22.22%) 
FIGO Stage 
IIIC 
IVA 
IVB 
 
6 (33.33%) 
3 (16.67%) 
9 (50%) 
Number of Chemotherapy 
Cycles 
3 Cycles 
4 Cycles 
 
 
4 (22.22%) 
14 (77.78%) 
Response to Chemotherapy 
Partial 
Complete 
Not quantifiable 
 
16 (88.89%) 
1 (5.56%) 
1 (5.56%) 
CA-125 <200 after 
chemotherapy 
16 (88.89%) 
 *Data expressed as number (%) for categorical variables or median (interquartile range) for 
continuous variables 
BMI: body mass index, FIGO: International Federation of Gynecology and Obstetrics 
 
 
 
 
 
 
 
 

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Table 4. Descriptive analysis of patients included in the study 
Patient  Age 
BMI 
FIGO 
Stage 
Histological 
type 
Chemotherapy 
cycles 
Type of 
Chemotherapy 
Response to 
Chemotherapy 
as defined by 
imaging 
1 
45 
20.7 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
2 
42 
25 
IIIC 
HGSC 
4/4 
CBP/TXL/BVZ Partial 
3 
43 
27.2 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
4 
43 
35.6 
IIIC 
Poorly 
differentiated 
EC 
3/3 
CBP/TXL 
Partial 
5 
44 
25.4 
IVA 
HGSC 
3/3 
CBP/TXL/BVZ Partial 
6 
46 
23.5 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
7 
72 
23.7 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
8 
50 
27.9 
IIIC 
HGSC 
3/3 
CBP/TXL 
Partial 
9 
38 
21.4 
IIIC 
Well 
differentiated 
EC 
4/4 
CBP/TXL 
Partial 
10 
42 
22.2 
IIIC 
Well 
differentiated 
EC 
4/4 
CBP/TXL 
Complete 
11 
53 
25.2 
IVA 
HGSC 
4/4 
CBP/TXL 
Partial 
12 
57 
26.4 
IIIC 
HGSC 
4/4 
CBP/TXL 
Partial 
13 
47 
32.4 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
14 
45 
22.6 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
15 
60 
26.4 
IVB 
Poorly 
differentiated 
EC 
4/4 
CBP/TXL 
Not 
quantifiable 
16 
45 
32 
IVA 
HGSC 
3/3 
CBP/TXL 
Partial 
17 
61 
26.3 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
18 
52 
29 
IVB 
HGSC 
4/4 
CBP/TXL 
Partial 
BMI: body mass index, FIGO: international Federation of Gynecology and Obstetrics, HGSC: High 
Grade Serous Carcinoma, EC: Endometrioid Carcinoma, CBP: Carboplatin, TXL: Taxol, BVZ: 
Bevacizumab  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table 5. Descriptive Characteristics of the Surgical Procedures 
Characteristic 
Total* 
Classification of 
Laparoscopic Surgeries 
Standard 
Radical 
Supra-radical 
Non-cytoreductable 
 
 
1 (5.56%) 
5 (27.78%) 
10 (55.56%) 
2 (11.11%) 
Conversion to open 
surgery 
0 (0%) 
Type of residual 
R0 
R2  
 
16 (88.89%) 
2 (11.11%) 
Complications (Clavien-
Dindo Score) 
None 
I-II 
III-V 
 
 
13 (72.22%) 
4 (22.22%) 
1 (5.56%) 
Intraoperative 
hemorrhage (mL) 
 
50 (50 – 100) 
Hospital Readmission 
1 (5.56%) 
*Data expressed as number (%) for categorical variables or median (interquartile range) for continuous 
variables 
R0: no residual, R2: with residual 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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Table 6. Descriptive analysis of Performed Surgeries 
 
Patient Type of 
Surgery 
Residual 
Tumor 
Reason for 
not 
completing 
cytoreduction 
Hemmorhage 
(mL) 
Type of 
complication 
Complication 
Grade: 
Clavien 
Dindo 
1 
Radical 
R0 
N/A 
150 mL 
Pain at 
incision site 
I 
2 
Radical 
R0 
N/A 
50 mL 
No 
No 
3 
Not 
cytoreductable 
R2 
Fagotti score 
10 
20 mL 
No 
No 
4 
Radical 
R0 
N/A 
50 mL 
No 
No 
5 
Radical 
R0 
N/A 
100 mL 
No 
No 
6 
Radical 
R0 
N/A 
20 mL 
No 
No 
7 
Not 
cytoreductable 
R2 
Fagotti score 
12 
10 mL 
No 
No 
8 
Supra-radical 
R0 
N/A 
50 mL 
Pain at 
drainage site 
I 
9 
Standard 
R0 
N/A 
150 mL 
No 
No 
10 
Supra-radical 
R0 
N/A 
50 mL 
No 
No 
11 
Supra-radical 
R0 
N/A 
100 mL 
No 
No 
12 
Supra-radical 
R0 
N/A 
100 mL 
No 
No 
13 
Supra-radical 
R0 
N/A 
50 mL 
No 
No 
14 
Supra-radical 
R0 
N/A 
50 mL 
3 cm vaginal 
dehiscence 
 
III 
15 
Supra-radical 
R0 
N/A 
600 mL 
Haematuria 
I 
16 
Supra-radical 
R0 
N/A 
100 mL 
No 
No 
17 
Supra-radical 
R0 
N/A 
50 mL 
Vaginal 
dehiscence 
I 
18 
Supra-radical 
R0 
N/A 
50 mL 
No 
No 
R0: no residual, R2: with residual, N/A: not applicable 
 
 
 
 
 

18 
 
Figure Legends 
Fig. 1. Flowchart describing the selection of patients to be included in the study. Initially 40 patients 
identified and subjected to neoadjuvant chemotherapy. 29 patients excluded due to having no response 
to chemotherapy. 17 patients included in protocol and underwent laparoscopic cytoreduction. 1 patient 
excluded due to advanced endometrial cancer diagnosis.   
 
Fig 2. Image of final phase of laparoscopic cytoreduction for patient with ovarian cancer whom had 
been treated with neoadjuvant chemotherapy (pelvis). 
 
Fig 3. Image of resected tumors from ovary, uterus, and peritoneum from patient with ovarian cancer 
treated with neoadjuvant chemotherapy.