Abstract
BACKGROUND:
Adult-type granulosa cell tumors are a rare form of ovarian cancer, 30% of which will recur. Cytoreductive surgery is often performed at the time of a first recurrence, but little is known about the impact of open versus minimally invasive surgical approaches on survival outcomes.
OBJECTIVE:
To examine associations between surgical approach, clinical variables, and survival outcomes among patients with adult-type granulosa cell tumors who underwent cytoreductive surgery at the time of first recurrence.
STUDY DESIGN:
This is a retrospective cohort study of patients with adult-type granulosa cell tumors enrolled in the MD Anderson Rare Gynecologic Malignancy Registry as of April 2024. Included patients had at least one documented recurrence and underwent secondary cytoreductive surgery as part of their treatment plan. Patients were excluded if surgery was performed prior to January 1, 2000, or if surgery was not intraabdominal. Demographics and clinical variables were compared using descriptive statistics. Surgical complexity was classified as either low, intermediate, or high based on procedures performed. Progression-free and overall survival outcomes were stratified by surgical approach and estimated using Kaplan-Meier curves. A multivariable Cox proportional hazards model was used to adjust progression-free survival at time of first recurrence for age, year of surgery, and extent of disease.
RESULTS:
Four hundred eighty-five patients with adult granulosa cell tumors were identified, 108 met inclusion criteria. Seventy-eight (72%) had open and 30 (28%) had minimally invasive secondary cytoreductive surgery. Baseline characteristics, including initial stage, self-identified race, or age at diagnosis, did not differ between open and minimally invasive surgery groups. Patients undergoing minimally invasive surgery were significantly younger at the time of surgery than the open group, with a median age of 42 vs 49, respectively (P=.03). For the open group, 33% of surgeries were considered intermediate complexity and 4% high complexity, compared to 7% and 0% in the minimally invasive surgery group, respectively (P=.004). There was no difference in achieving optimal cytoreduction, 85% in the open group and 88% in the minimally invasive surgery group (P=.68). Following secondary cytoreductive surgery, there was no difference in overall survival, median overall survival of 166 months in the open group and 94 months in the minimally invasive group (P=.27), or progression-free survival after first recurrence, 26 months in the open group compared to 21 months in the minimally invasive group (P=.42). The difference in progression-free survival after the first recurrence remained nonsignificant after adjustment for key potential variables, including age, surgical approach, year of surgery, and extent of disease. There was no difference in incisional or port site recurrences at the time of second recurrence among those undergoing open (8.3%) compared to minimally invasive surgery (7.4%) at time of first recurrence (P=.89).
CONCLUSION:
In patients with a first recurrence of adult-type granulosa cell tumors, open secondary cytoreductive surgery did not achieve superior outcomes compared to surgery via a minimally invasive approach. Minimally invasive surgery should be considered for carefully selected patients with recurrent adult-type granulosa cell tumors. Future research is needed on patient factors important to the selection of surgical approach in this setting.
Keywords: cohort studies, granulosa cell tumor of the ovary, gynecologic oncology, ovarian neoplasms, surgery, survival, tumor cytoreduction
Introduction
Granulosa cell tumors (GCTs) represent 2% to 5% of newly diagnosed ovarian cancers, with adult-type granulosa cell tumors (AGCTs) comprising 95% of GCTs.1 Most AGCTs are cured with initial surgery at diagnosis but 30% will recur.2 Secondary cytoreductive surgery is a common approach for recurrent AGCT when feasible,3–5 often followed by chemotherapy or endocrine therapy.6–12 Historically, open surgery was often employed for secondary cytoreduction of AGCT, but the disease’s localized nature makes minimally invasive surgery (MIS) a potential alternative. However, data comparing outcomes between open and MIS approaches in recurrent AGCT are limited.
MIS has been widely studied across cancer types, often showing comparable survival outcomes and reduced morbidity compared to open surgery. Randomized trials in primary pancreatic, rectal, and esophageal cancer have shown no differences in survival outcomes, morbidity, and complete cytoreduction rates between MIS and open surgery.13–15 In early-stage uterine cancer, the LACE and LAP2 trial demonstrated noninferiority of MIS compared to open surgery.16–18 Although prospective data on the feasibility of MIS in ovarian cancer cytoreductive surgery are lacking, a meta-analysis of 6 retrospective studies found no difference in overall survival (OS), cytoreduction rates, or complications between groups undergoing interval cytoreduction surgery.19 In patients with recurrent platinum-sensitive disease, a retrospective study found no difference in recurrence-free survival between surgical approaches.20 However, in cervical cancer, a randomized trial comparing MIS to open radical hysterectomy ended accrual early due to lower rates of disease-free survival and OS in the MIS group.21 Given the lack of data on MIS in recurrent AGCT, this retrospective cohort study aimed to determine whether surgical approach at recurrence influences survival outcomes.
Materials and methods
Case selection
This is a retrospective cohort study of patients with recurrent AGCT enrolled in the MD Anderson Rare Gynecologic Malignancy Registry as of April 2024. All patients were enrolled in an institutional review board (IRB)–approved Rare Gynecologic Malignancy Registry (protocol #PA17–0586). This registry collects data from 2 affiliated institutions, MD Anderson Cancer Center and Lyndon B. Johnson General Hospital. Many of the patients seen in this registry had prior treatments and surgeries at outside institutions and were seen at our 2 affiliated institutions for consultation or additional care. Therefore, most surgeries took place at outside institutions. All patients provided written informed consent for the tumor registry or had a waiver of informed consent if they had not been seen at the institutions for at least 3 years or were deceased. This registry collects a wide variety of data with pathologists at MD Anderson confirming the diagnosis of a rare tumor in at least one specimen. The use of registry data for these specific analyses was separately approved by the IRB (protocol #2020–1156).
Patients were included if they had a diagnosis of AGCT, at least one documented recurrence, and underwent secondary cytoreductive surgery. Exclusions included synchronous non-AGCT malignancy (except ductal carcinoma in situ of the breast, basal cell carcinoma, or squamous cell carcinoma of the skin) within 3 years of first AGCT recurrence, surgeries performed before 2000, non-intraabdominal surgeries, tumor pathology indicated >10% of a non-AGCT component, or if an operative report or detailed clinical documentation of surgery was not available. A cutoff of January 1, 2000, was chosen, given the limited performance of MIS prior to this date. This study adheres to the Declaration of Helsinki.
Data collection
Study data were managed using REDCap tools hosted at MD Anderson.22,23 Clinical data included demographics, stage, tumor histology, treatment history, recurrence history, and vital status. Residual tumor at the time of cytoreductive surgery was collected from individual operative reports, R0 indicates complete resection of tumor, R1 indicates microscopic (≤1 cm) residual tumor, and R2 indicates macroscopic (>1 cm) residual tumor. A complexity score adapted from ovarian cancer primary debulking surgery24 was used (Supplemental Table). If a patient had multiple procedures in the same category, they only received the allotted points once for that procedure. For example, if a surgery included both a pelvic and para-aortic lymph node dissection, only 1 point would be allotted. Tomographic imaging results prior to planned surgery were reviewed. Disease was defined as multisite if more than one tumor was present on preoperative imaging. Disease was defined as extrapelvic if the disease was not confined to the bladder, rectum, uterus, adnexa, pelvic sidewall, or pelvic lymph nodes.
Statistical analyses
Progression-free survival 2 (PFS2) was defined from first recurrence to second recurrence or death. OS was defined from the date of first recurrence to death or last contact. Kaplan-Meier (KM) and Cox proportional hazards regression evaluated survival outcomes and covariates, including surgical approach, year, and disease extent. Differences were considered statistically significant at P value <.05. Analyses were performed using R,25 primarily as-treated with a subset analyzed by intention-to-treat for MIS to open conversions.
Results
Patient population
Figure 1 demonstrates the study flow diagram. Of 485 patients with AGCTs in the registry, 256 lacked documented recurrence, 40 did not have surgery at first recurrence, 38 had no available operative reports, and 26 patients had surgery before January 1, 2000. Of the remaining 125 patients, 17 patients were excluded: 9 due to synchronous cancers, 3 with >10% of additional components, 3 with recurrences not amenable to open surgery or MIS, a recurrence in the hip bone and 2 recurrences in the lung, and 2 patients with an unusual surgical history at first recurrence. One patient had surgery done by a general surgeon with minimally invasive biopsy and aspiration of a retroperitoneal mass, then adjuvant chemotherapy, followed later by cytoreductive surgery. Another patient had 3 debulking surgeries performed within 2 months.
FIGURE 1.
Study diagram
*Subsequent staging surgery was not considered as multiple surgeries.
AGCT, adult-type granulosa cell tumor; MDACC, MD Anderson Cancer Center.
The remaining 108 patients were included; 78 (72%) had open surgery and 30 (28%) had MIS performed at first recurrence. Table 1 demonstrates the patient demographics. In the MIS group, 16 (53%) underwent laparoscopy and 14 (47%) underwent a robotic approach. Patients undergoing recurrence surgery with an MIS approach were younger (median age 42 vs 49, P=.03). Recurrent surgeries were more often completed using MIS after 2010, (P=.002).
TABLE 1.
Comparison of select demographic and baseline clinical factors between the open surgery and MIS groups
| Characteristicsa | Open surgery at first recurrence (n=78) | MIS at first recurrence (n=30) | P valueb |
|---|---|---|---|
| Age at the time of diagnosis | .13 | ||
| Median (IQR) | 42 (35–53) | 39 (32–48) | |
| Age at time of recurrence | .03 | ||
| Median (IQR) | 49 (41–59) | 42 (37–52) | |
| N (%) | N (%) | ||
| Initial stage | .31 | ||
| I | 42 (72) | 21 (81) | |
| II | 10 (17) | 5 (19) | |
| III | 6 (10) | 0 | |
| Unknown | 20 (26) | 4 (13) | |
| Race | .80 | ||
| Asian | 4 (5) | 3 (10) | |
| White | 55 (71) | 19 (63) | |
| Black/African American | 11 (14) | 5 (17) | |
| Other | 7 (9) | 2 (7) | |
| Surgery mode at diagnosis | <.001 | ||
| Open approach | 48 (62) | 8 (27) | |
| MIS approach | 26 (33) | 21 (70) | |
| Unknown | 4 (5) | 1 (3) | |
| Chemotherapy in upfront setting | 24 (31) | 7 (23) | .4 |
| Year of recurrent surgery | .002 | ||
| Prior to 2010 | 29 (37) | 2 (7) | |
| 2010 and after | 49 (63) | 28 (93) |
IQR, interquartile range; MIS, minimally invasive surgery.
If values were unknown, they were excluded from statistical analysis;
Wilcoxon rank sum test; Fisher’s exact test.
Surgical outcomes
Of patients who underwent MIS at the time of recurrence, 70% had an MIS cytoreduction at diagnosis of AGCT (Table 1). This was significantly higher compared to patients who underwent an open approach at the time of recurrence; only 33% of these patients had MIS cytoreduction at diagnosis (P=.0009). There was no significant difference in receipt of adjuvant chemotherapy at either diagnosis (P=.4) or first recurrence (P=.26) between the MIS and open group (Tables 1 and 2). Similarly, there was no significant difference in receipt of adjuvant endocrine therapy at the time of recurrence between the 2 surgical groups (P=.98, Table 2). Patients with either multisite disease or extrapelvic disease were more likely to undergo an open approach at the time of recurrence compared to those with a single site (P<.001) or only pelvic disease (P=.02) (Table 2).
TABLE 2.
Comparison of treatment approaches and perioperative factors between the open surgery and MIS surgery groups
| Characteristicsa | Evaluable patients | Open surgery at first recurrence | MIS surgery at first recurrence | P valueb |
|---|---|---|---|---|
| N (%) | N (%) | |||
| Imaging disease volume | 79 | <.001 | ||
| Multisite disease | 40 (73) | 7 (29) | ||
| Single-site disease | 15 (27) | 17 (71) | ||
| Imaging disease site | 78 | .02 | ||
| Extrapelvic disease | 21 (39) | 3 (13) | ||
| Pelvic disease only | 33 (61) | 21 (87) | ||
| Surgical complexity score | 108 | .004 | ||
| Low | 49 (63) | 28 (93) | ||
| Intermediate | 26 (33) | 2 (7) | ||
| High | 3 (4) | 0 | ||
| Cytoreduction status of recurrent surgery | 92 | .68 | ||
| R0 | 57 (85) | 22 (88) | ||
| R1 | 8 (12) | 3 (12) | ||
| R2 | 2 (3) | 0 | ||
| Adjuvant therapy after secondary cytoreduction | 108 | |||
| Chemotherapy | 45 (58) | 13 (43) | .26 | |
| Endocrine therapy | 24 (31) | 10 (33) | .98 |
MIS, minimally invasive surgery.
If values were unknown, they were excluded from statistical analysis;
Fisher’s exact test; Pearson’s chi-squared test.
The surgical complexity score was higher in the open group compared to the MIS group (P=.004, Table 2). In the open group, 33% of surgeries were considered to have been intermediate complexity and 4% high complexity, compared to 7% and 0% in the MIS group, respectively. There was no significant difference in the achievement of complete cytoreduction between both groups at the time of primary surgery, with 95% (35/37) in the open group vs 100% (19/19) in the MIS group (P=.31). Similarly, there was no significant difference in the achievement of complete cytoreduction at the time of recurrence surgery, with 85% (57/67) achieving R0 in the open group and 88% (22/25) in the MIS group (P=.68) (Table 2). Of note, cytoreductive residual disease data was missing for 57% of primary surgeries and 15% of first recurrence surgeries.
There were 11 patients who had their surgery converted from MIS to open during their secondary cytoreduction; they were included in the laparotomy group. Reasons for conversion include surgical complications (3/11, 27%) and surgical feasibility (7/11, 73%). Surgical complications included significant bleeding, bladder injury, and diaphragmatic injury leading to entry into the chest. Surgical feasibility concerns included dense adhesions and extent of disease. Comparisons of clinical variables between the planned MIS group and the converted MIS group are described in Table 3. In contrast to patients who underwent a successful MIS, there was no significant difference in complexity between groups (P=.11), achievement of complete cytoreduction (P>.9), or surgical approach at the time of diagnosis (P=.07). Patients who were converted from MIS to open had higher rates of multifocal disease compared to patients who underwent successful MIS (P=.04), but no significant difference in rates of extrapelvic disease (P=.56).
TABLE 3.
Comparison of treatment approaches and perioperative factors between the open surgery and the MIS group that was converted to open surgery
| Characteristica | Evaluable patients | Completed MIS at first recurrence | MIS converted to open at first recurrence | P valueb |
|---|---|---|---|---|
| N (%) | N (%) | |||
| Surgery mode at diagnosis | 40 | .07 | ||
| Open approach | 8 (28) | 7 (64) | ||
| MIS approach | 21 (72) | 4 (46) | ||
| Chemotherapy in upfront setting | 41 | 7 (23) | 5 (45) | .25 |
| Imaging disease volume | 32 | .04 | ||
| Multisite disease | 7 (29) | 6 (75) | ||
| Single-site disease | 17 (71) | 2 (25) | ||
| Imaging disease site | 31 | .56 | ||
| Extrapelvic disease | 3 (13) | 2 (29) | ||
| Pelvic disease only | 21 (87) | 5 (71) | ||
| Surgical complexity score | 41 | .11 | ||
| Low | 28 (93) | 8 (73) | ||
| Intermediate | 2 (7) | 3 (27) | ||
| High | 0 | 0 | ||
| Cytoreduction status of recurrent surgery | 34 | >.9 | ||
| R0 | 22 (88) | 8 (89) | ||
| R1 | 3 (12) | 1 (11) | ||
| Adjuvant therapy after secondary cytoreduction | 41 | |||
| Chemotherapy | 13 (43) | 5 (45) | >.9 | |
| Endocrine therapy | 10 (33) | 7 (64) | .17 |
MIS, minimally invasive surgery.
If values were unknown, they were excluded from statistical analysis;
Fisher’s exact test; Pearson’s Chi-squared test.
Of the 108 patients in this study, 74 (69%) had a documented second recurrence in the rare tumor registry. Sixty-eight patients were evaluable, given the availability of an operative report or imaging, for either port site or incisional metastasis at their second recurrence. Of the evaluable group, 56 (82%) had undergone an open approach and 12 (18%) a MIS approach at the time of first recurrence. Port site metastasis subsequently occurred in 1/12 (8.3%) patients of the MIS group, and incisional metastasis occurred in 4/56 (7.4%) of the open surgery group (P=.89).
Survival outcomes
There was no significant difference in PFS2 when comparing MIS to the open approach at the time of first progression (P=.42). Figure 2, A demonstrates the KM curve for PFS2. The median time for PFS2 was 26 months for the open approach compared to 21 months for the MIS approach at the time of recurrence (hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.44–1.41, P=.42). Figure 2, B demonstrates the KM curve for OS. Similarly, there was no difference in OS when comparing the 2 groups, with a median OS time of 166 months in the open group compared to 94 months in the MIS group (HR 0.33, 95% CI 0.04–2.99; P=.27). The numerically longer OS time in the open group can be partially explained by the longer median follow-up time, 187 months compared to 123 months.
FIGURE 2.
Progression-free and overall survival after first recurrence by route of secondary cytoreductive surgery
A, KM of progression-free survival after first recurrence comparing MIS and open surgical groups. B, KM of OS from time of first recurrence to either censorship or death comparing MIS and open surgical groups.
KM, Kaplan-Meier; MIS, minimally invasive surgery; OS, overall survival.
Multivariable Cox proportional hazards analysis was conducted for PFS2 (Table 4). Single-site vs multisite disease was included in the model as it seemed to distinguish between the completed MIS group and the converted to open MIS group (Table 3). After adjusting for age, mode of surgery, year of surgery, and extent of disease, no significant association between the route of surgery and PFS2 was observed. There was no significant difference in OS between open and MIS groups across all subgroups analyzed. This included single-site disease (P=.3; n=32; 15 open, 17 MIS), multisite disease (P=.3; n=47; 40 open, 7 MIS), pelvic disease (P=.1; n=54; 33 open, 21 MIS), and extrapelvic disease (P=.5; n=24; 21 open, 3 MIS).
TABLE 4.
Multivariable analysis for PFS2 comparing open vs MIS approach, n=108
| Characteristica | HR | 95% CI | P value |
|---|---|---|---|
| Age at recurrence | 0.99 | 0.98–1.02 | >.9 |
| Secondary surgery mode | |||
| Open approach | Ref | Ref | |
| MIS approach | 0.92 | 0.46–1.83 | >.8 |
| Imaging disease volume | |||
| Multisite | Ref | Ref | |
| Single site | 0.70 | 0.36–1.35 | .29 |
| Unknown | 1.05 | 0.59–1.89 | .87 |
| Year | |||
| Prior to 2010 | 0.72 | 0.41–1.26 | .25 |
| 2010 and after | Ref | Ref |
CI, confidence interval; HR, hazard ratio; MIS, minimally invasive surgery; PFS2, Progression-free survival 2; Ref, reference.
If values were unknown, they were excluded from statistical analysis.
Principal findings
In patients with AGCT undergoing secondary cytoreductive surgery for first recurrence, an open surgical approach did not achieve superior outcomes compared to surgery via a minimally invasive approach. This remains consistent when adjusting for factors including age, year of surgery, and disease burden. Factors that demonstrated a difference in surgical approach included age at the time of recurrence, initial surgical approach at the time of diagnosis, and extent of disease on preoperative imaging. Patients diagnosed with recurrence at a younger age were more likely to undergo MIS at the time of recurrence. In addition, a MIS approach at the time of initial AGCT diagnosis was associated with higher rates of MIS at the time of recurrence. Cosmetic concerns and consideration of possible adhesions could explain these 2 findings.
Disease burden and distribution play a role in selecting patients for an open surgical approach. In this study, patients undergoing an open surgical approach at the time of recurrence were more likely to have multisite disease and extrapelvic disease on imaging, which translated to higher surgical complexity scores. Patients who required conversion from MIS to an open approach had similar surgical complexity scores and cytoreduction outcomes when compared to patients with a planned open approach or those who underwent a successful MIS approach. A key concern with MIS in the setting of recurrent malignancy is the rate of port site or incisional metastases. In this study, there was no difference in port site or incisional metastasis at the time of the second recurrence when comparing patients undergoing open versus MIS for secondary cytoreductive surgery.
Results in the context of what is known
AGCTs are often diagnosed incidentally after surgery performed for an adnexal mass. Due to this, proper staging is only sometimes completed, and patients may require additional staging surgery. A comparison of open versus MIS restaging of patients with incompletely staged GCTs found no significant difference in terms of the percentage of patients who were upstaged, survival outcomes, or surgical complications.26 Another study looking at an open versus MIS approach for stage 1 AGCT with patients desiring fertility found no difference in disease-free survival between groups.27 However, another study looking at stage 1 sex-cord stromal tumors found that the recurrence rate after initial surgery was higher in patients undergoing initial cytoreduction via a MIS approach.28 A Cochrane review of 5 retrospective studies, including 535 patients with AGCT, found that at diagnosis, approach to surgery including MIS versus open, performing lymphadenectomy, and adjuvant chemotherapy or radiation therapy were not associated with significant differences in survival outcomes.29
Prior literature has shown that at the time of diagnosis, there is overall no difference in survival outcomes when comparing surgical approaches. Notably, the majority of these studies involved stage I AGCTs in the primary setting. A case series of 3 patients with AGCT undergoing robotic debulking surgery for recurrence found that complete cytoreduction could be achieved and reported no intra- or postoperative complications.30 However, none of these studies analyzed the surgical approach at the time of first recurrence. This study focused on outcomes for AGCT with initial stage I to III in the recurrent setting. While surgery at the time of first and second recurrence has been associated with improved survival outcomes,3 there is little known about the safety and feasibility of an open compared to a MIS approach.
Clinical implications
While there are data looking at the mode of surgery at the time of recurrence in epithelial ovarian cancer, there is a paucity of data in AGCT. Results show that the mode of surgery, whether an open or MIS approach, is not associated with changes in PFS2 or OS. Given the observational nature of this study with an inherent risk for selection bias, these findings need to be interpreted with caution. Laparoscopic and robotic surgeries are associated with shorter lengths of stay, less blood loss, and faster time to recovery. When feasible, based on prior surgical history and imaging findings, a minimally invasive approach may be considered in recurrent AGCT, recognizing the need for further prospective studies to validate these findings.
Research implications
While this paper demonstrates no difference in survival outcomes between the 2 surgical approaches in recurrent AGCT, there were no available data on postoperative outcomes in the rare tumor registry. Further research could evaluate whether a difference in cost, morbidity, and patient-reported outcomes is observed between the 2 surgical groups. In addition to further clinical outcomes, additional research is needed to establish criteria to help surgeons determine which patients with recurrent AGCTare the best candidates for an MIS approach. Considerations for such a criterion could include prior surgeries, medical comorbidities, imaging findings, or potentially using a standardized laparoscopic assessment technique.31 Finally, given that serial cytoreductive surgery at the time of AGCT recurrence has been associated with improved survival outcomes, retrospective studies could be performed evaluating the mode of surgery at each recurrence.
Strengths and limitations
A strength of this study is the rare tumor registry, which has over 400 patients with AGCT. The database has long-term follow-up, with median follow-up being 7 years for patients who are alive. Given the rarity of AGCT, prospective surgical trials are challenging to complete, and this study provides detailed information on surgical outcomes in AGCTs.
As this study is retrospective, inherent limitations do exist. The study is limited by the data available in the medical record, and misclassification bias is possible. Additionally, selection bias may have influenced patient selection for the surgical approach, and potential confounding variables may not have been assessed. Operative reports were used to determine cytoreduction status and are at risk for surgeon bias and possibly misclassification due to the inability to see small remaining tumors during MIS procedures. Temporal changes in practice may also affect outcomes as robotic and laparoscopic surgery have become more accessible and surgeon comfort has increased with time.
This research was unable to assess morbidity, cost, and length of stay associated with each mode of surgery, given these data are not collected in the database. A shortcoming of these data is that many of the patients have surgeries completed at an institution outside of MD Anderson Cancer Center. Many patients are referred for a second opinion after multiple recurrences. Therefore, there are often incomplete records, many of which do not include postoperative courses. However, data can be extrapolated from a significant, phase 3 randomized control trial comparing MIS to open approaches in ovarian cancer, which demonstrates higher postoperative complications and blood loss in the open approach group.20,32 Patients were more likely to have MIS at the time of recurrence after the year 2010, possibly explained by the improved technology and access to perform laparoscopic and robotic approaches. Finally, the multivariable model was limited, given the small numbers in each group.
Conclusions
For patients with a first recurrence of AGCT undergoing planned cytoreductive surgery, open cytoreductive surgery did not achieve superior survival and cytoreductive outcomes compared to MIS. Furthermore, the mode of surgery was not associated with higher rates of either port site or incisional recurrences. However, these findings should be interpreted with caution due to the study’s retrospective nature and sample size, which may limit the generalizability of the results. Future research should focus on the indications for MIS in recurrent AGCT as expertise and technology improve.
Supplementary Material
AJOG at a Glance.
Why was this study conducted?
Treatment of recurrent adult-type granulosa cell tumors (AGCTs) often incorporates cytoreductive surgery, but little is known about associations between surgical approach, cytoreductive success, and survival outcomes.
Key findings
When comparing open to minimally invasive surgical approach, there was no significant difference between progression-free survival (P=.42) and overall survival (P=.27) from the time of first recurrence. There was no significant difference in either port site or incisional recurrences between the 2 groups (P=.89).
What does this add to what is known?
These results support the use of minimally invasive cytoreductive surgery for carefully selected patients with recurrent AGCTs.
Acknowledgments
We would like to thank all the patients who participated in this study.
This research was partly supported by the National Institutes of Health through M.D. Anderson’s Cancer Center Support Grant CA016672. This research was partly supported by Cancer Prevention & Research Institute of Texas grants RR2000045 (R.T.H.). The NIH/NCI supported this work under award number T32 CA101642 (A.L.B.). Additional funding sources include the Jennifer “Jenny” Song Fund for Granulosa Cell Tumor Research, Alisha B. Smith GCT Hope Fund, The University of Texas MD Anderson Cancer Center Ovarian Cancer SPORE (NIH grant CA281701), the American Cancer Society (A.K.S.), the Ovarian Cancer Research Alliance (A.K.S.), and the Frank McGraw Memorial Chair in Cancer Research (A.K.S.). These funders above had no role in the study’s design, in the collection, analysis, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.
Footnotes
CRediT authorship contribution statement
Allison L. Brodsky: Writing – original draft, Methodology, Formal analysis, Data curation, Conceptualization. Alejandra Flores Legarreta: Writing – review & editing, Methodology, Data curation. Jeffrey A. How: Writing – review & editing, Methodology, Conceptualization. Veena Vuttaradhi: Writing – review & editing. Anil K. Sood: Writing – review & editing. Lois M. Ramondetta: Writing – review & editing. David M. Gershenson: Writing – review & editing. R. Tyler Hillman: Writing – review & editing, Writing – original draft, Supervision, Methodology, Formal analysis, Conceptualization.
A.K.S. is a consultant for Kiyatec, Merck, GSK, Onexo, ImmunoGen, Iylon, and AstraZeneca. D.M.G is a consultant for Verastem and a shareholder in Johnson & Johnson, Bristol Myers Squibb, and Procter & Gamble. R.T.H. reports a past sponsored research agreement with Sumitomo Pharma, Inc. A.L.B., A.F.L., J.A.H., V.V., and L.M.R report no conflict of interest.
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