Advanced Ovarian Cancer. A multimodal diagnostic approach to predict outcome

Research output: ThesisDoctoral Thesis (compilation)

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Primary debulking surgery (PDS) followed by platinum-based postoperative chemotherapy is
the standard of care for advanced ovarian cancer (AOC). Absence of macroscopic residual
disease after debulking surgery is the strongest prognostic factor achieved by surgery. Correct
characterization of the tumor specimen and tumor spread in combination with patient’s
characteristics such as age, comorbidity, and personal wishes, can help to select more effective
therapeutic approaches for each patient before initial intervention.
The overall aim of this thesis were to evaluate diagnostic, from the preoperative to the
intraoperative stage, to investigate how an accurate diagnosis could predict surgical outcome
and survival in patients with advanced ovarian cancer.
Study I: A retrospective population-based review was conducted of 328 biopsies, in order to
assess the adequacy, accuracy and safety of tru-cut biopsy in gynecological malignancies from
the perspective of a daily clinical practice. The tru-cut biopsy was shown to be a reliable and
safe diagnostic method, with adequacy of 86.3%, accuracy of 97.5% and a complication rate of
1.3%. The adequacy of tru-cut biopsy depends on the site of the tissue sample, indications for
the biopsy and the experience of the operator.
Study II: A single-center, retrospective population-based study was conducted on 358 patients,
to evaluate the reliability of intraoperative FS diagnosis for planning the treatment of patients
with suspected ovarian cancer (OC), from a multidisciplinary perspective. Prevalence,
sensitivity, specificity, positive predictive value and negative predictive value for invasive
malignancies on FS were 54.0%, 88.1%, 98.8%, 98.9% and 87.6% respectively. Malignancy
was observed to be underestimated, but overestimation in malignancy grading was rare.
Borderline-related tumors were more likely to be incorrectly graded by FS, as were rare tumor
types. Despite diagnostic difficulties, in some of the cases, the oral communication during
deliverance of frozen section diagnosis resulted in adequate treatment decisions, which
minimalized the risk for reoperation or delay of chemotherapy treatment.
Studies III and IV: A single-center, retrospective population-based study was conducted on 118
patients with AOC, to determine whether the PCI and the quantity of ascites visualized by
computed tomography (CT) could assess the extent of the tumor (S-PCI) and residual disease
(RD) for AOC patients treated with PDS. Furthermore, in study IV, we examine the impact of
the tumor extent on survival. CT-PCI correlated well with S-PCI and the risk of RD, with a cutoff
of 21 for CT-PCI (0.715, p = 0.000). The risk of RD was 3.5 times higher when the quantity
of ascites on CT (CTascites) was estimated to be above 1000ml. Regardless of the completeness
of cytoreductive surgery or the complication rate, the extent of the tumor at the beginning of
surgery seemed to affect OS in patients with AOC. PCI above 18.5 doubled the risk of dying
of the disease. CT-PCI seemed to play a prognostic role for PFS, but its prognostic role for OS
is still to be investigated.
Conclusions: The existing methods of preoperative material retrieval and histopathological
diagnosis of ovarian cancer are reliable, when performed by highly trained specialists. The
preoperative CT is accessible and can be used by an experienced radiologist as a single
technique to select patients as candidates for PDS. The complete removal of the tumor is a very
important prognostic factor for prognosis in AOC, but patient’s status and tumor biology are
also important factors in the decisionmaking on a treatment plan. This thesis maintain the idea
that centralization of cancer care to tertiary centres results in highly specialized pathology,
radiology, oncology and surgical departments, and that the multidisciplinary diagnostic and
therapeutic efforts improve health care, and possibly the outcome, for patients with AOC.
Original languageEnglish
Awarding Institution
  • Department of Clinical Sciences, Lund
  • Kannisto, Päivi, Supervisor
  • Malander, Susanne, Assistant supervisor
  • Måsbäck, Anna, Assistant supervisor
  • Sartor, Hanna, Assistant supervisor
Award date2022 Dec 2
Place of PublicationLund
ISBN (Print)978-91-8021-317-2
Publication statusPublished - 2022

Bibliographical note

Defence details
Date: 2022-12-02
Time: 09:00
Place: Föreläsningssalen, Avdelningen för obstetrik och gynekologi, Skånes Universitetssjukhus i Lund. Join by Zoom: Meeting ID: 683 8307 2041 Password: 892948
External reviewer(s)
Name: Stålberg, Karin
Affiliation: Department of Obstetrics and Gynaecology, Gynaecologic Cancer Surgery, Uppsala University Hospital/Uppsala University

Subject classification (UKÄ)

  • Cancer and Oncology
  • Obstetrics, Gynecology and Reproductive Medicine

Free keywords

  • Advanced ovarian cancer, multidisciplinary, tru-cut biopsy, frozen section, peritoneal cancer index, CT, primary debulking surgery, cytoreductive surgery, survival


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