{'fraction_non_alphanumeric': 0.018370883882149046, 'fraction_numerical': 0.0013864818024263432, 'mean_word_length': 6.056234718826406, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 1, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
Neoadjuvant Chemotherapy Fails to Improve Survival in Advanced Ovarian Cancer: But Is It the Real Culprit?

To the Editor: T study by Milam et al 1 and other recently published articles on advanced epithelial ovarian cancer all report higher rates of optimal cytoreduction in patients who receive neoadjuvant chemotherapy than in those who undergo primary surgery. Although these studies again confirm the essential prognostic role of cytoreductive surgery in advanced ovarian cancer, none of them succeed in explaining why increasing the rate of optimal cytoreduction leaves survival almost unchanged. One explanation is that regardless of neoadjuvant chemotherapy, optimal cytoreduction, leaving 1 cm or less of residual tumor, rather than complete cytoreductive surgery, is not enough to improve survival. Management of patients with advanced epithelial ovarian cancer (stages IIIC and IV), such as those treated by Millam et al, comprises 2 basic treatment strategiesVchemotherapy and surgery. Whereas neoadjuvant or adjuvant chemotherapy is a fully standardized procedure, surgery remains open to wide patient-related and surgeon-related variability. Standard debulking surgery envisages bilateral hysteroadnexectomy, appendectomy, omentectomy, iliacobturator, and peri-aortocaval lymphadenectomy, associated with less standardized procedures to resect other organs and structures frequently involved by the malignant spread. Given the wide variability in the severity and location of malignant spread within the abdominal cavity, the type of resection needed for debulking surgery therefore varies equally widely. The extent and quality of multiorgan resections depend closely on the individual surgeon’s skill and cytoreductive aim. One of the recently published multicenter studies enrolling a large study sample clearly depicts the wide variability in surgical approaches used for debulking and cytoreduction many often failing to meet the standard requirements for treating ovarian cancer. Insofar as all investigators agree that the most reliable prognostic factor in advanced epithelial ovarian cancer is the degree of cytoreduction, the most pressing problems to face are identifying the best surgical strategies for multiorgan resection, finding reliable criteria for assessing endoperitoneal malignant spread, and, most importantly, improving the surgical skills and procedures needed to achieve complete cytoreduction. We should focus our interest on peritonectomy procedures to obtain complete cytoreduction combined with intraperitoneal hyperthermic chemotherapy to treat microscopic residual disease. Current evidence suggests that this complex strategy does much to benefit outcome. Angelo Di Giorgio, MD Paolo Sammartino, MD, PhD Daniele Biacchi, MD, PhD Department of Surgery ‘‘Pietro Valdoni’’ Sapienza University of Rome Rome, Italy angelo.digiorgio@uniroma1.it