Is Cardiopulmonary Exercise Testing Predictive of Surgical Complications in Patients Undergoing Surgery for Ovarian Cancer?

Preoperative cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capability. In other intra-abdominal surgical specialties, CPET outcomes are predictive of operative morbidity. However, in ovarian cancer surgery, its predictive value remains unknown. In this study, we evaluated the association between CPET performance and surgical morbidity in ovarian cancer patients. Secondly, we assessed the association between CPET performance and other surgical outcomes (i.e., hospital stay, readmission and residual disease). This was a retrospective cohort study of patients undergoing primary surgery for ovarian cancer between 2020 and 2023. CPET performance included peak oxygen uptake (VO2 max), ventilatory efficiency (VE/VO2) and anaerobic threshold. Outcomes were operative morbidity and included intra- and postoperative complications (Clavien-Dindo), hospital stay, readmission within 30 days and residual disease. A total of 142 patients were included. A lower VO2 peak and a higher VE/VCO2 were both associated with the occurrence of postoperative complications, and a poorer anaerobic threshold was associated with more transfusions. VE/VCO2 remained significantly associated after multivariate analysis (p = 0.035). None of the CPET outcomes were associated with length of stay, readmission or residual disease. In conclusion, VE/VCO2 was significantly associated with an increased risk of all-cause postoperative complications in ovarian cancer patients undergoing primary surgery.

The origin of serous ovarian cancer may be found in the uterus: a novel hypothesis.

Since 1971 the incessant ovulation theory by Fathalla is widely accepted as theory for ovarian carcinogenesis, supported mainly by epidemiological findings. However, this theory cannot explain the protective effect of hysterectomy and tubal ligation on the incidence of ovarian cancer. Furthermore, never a precursor lesion has been identified in the ovary itself. Although recently the fallopian tube has been proposed as possible site of origin, there are reasons to believe that a precursor lesion for ovarian and pelvic serous carcinoma is located within the uterus. Uterine serous papillary carcinoma (UPSC) resembles serous ovarian and pelvic carcinoma in behavior and prognosis. Its precursor lesion endometrial intraepithelial carcinoma (EIC) is non-invasive and often multifocal in origin. Importantly, these premalignant cells have a loosely cohesive nature and are able to spread to intraperitoneal surfaces easily, thereby often found on the surface of ovaries or in the fallopian tube. We hypothesize that EIC is a precursor lesion of serous ovarian carcinoma, originating in the uterus and spreading into the intraperitoneal cavity via a mechanism as is accepted for endometriosis. To illustrate this, some cases of serous ovarian carcinoma with concordant EIC in the endometrium as only precursor lesions are presented. A paradigm shift with respect to the origin of ovarian cancer from the ovary to the endometrium could have enormous consequences for primary and secondary preventive strategies to decrease the mortality from this disease.