human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE Most cases of epithelial ovarian cancer ( EOC ) are diagnosed in an advanced stage . When the disease has spread intra-abdominally , complete surgical tumor debulking is the single most important prognostic factor . Neoadjuvant chemotherapy ( NACT ) before surgery can cause fibrosis and adhesions in the peritoneal cavity and may interfere with the perioperative evaluation of tumor spread . In this prospect i ve study , we evaluated whether perioperative visual assessment of tumor dissemination is similar in patients undergoing primary and interval surgery for EOC . METHODS Systematic visual evaluation of tumor spread was performed at the start of primary surgery/diagnostic laparoscopy  ( n=39 ) or interval surgery ( n=16 ) . Peritoneal cavity was divided into 22 anatomical regions . The carefully documented results of the visual assessment were compared with the histopathological analysis of 220 biopsies from primary and 92 biopsies from interval surgery . RESULTS In primary surgery , perioperative visual estimation of tumor spread showed 98 % sensitivity , 76 % specificity and 95 % accuracy compared to histopathology . The corresponding figures after NACT were 86 % , 76 % and 84 % , respectively . The difference in sensitivity and accuracy in primary and interval operations was statistically significant ( p<0.001 ) . CONCLUSIONS In advanced EOC , microscopically carcinomatous areas have a benign visual appearance more often after NACT than at primary surgery . NACT may interfere with the perioperative visual evaluation of tumor spread and thus lead to incomplete resection of tumor in potentially resectable areas Purpose The aim of this study was to investigate whether preoperative laparoscopic evaluation of the dissemination of disease may have an independent impact on survival in advanced epithelial ovarian cancer ( AEOC ) . Methods All AEOC women were su bmi tted to staging laparoscopy before receiving primary debulking surgery ( PDS ) or neoadjuvant chemotherapy ( NACT ) . All study women received a laparoscopic score ( predictive index value [ PIV ] ) and were stratified into three groups based on volume of disease : high tumor load ( HTL ) for PIV ≥8 , intermediate tumor load ( ITL ) for PIV equal to 6 and 4 , and low tumor load ( LTL ) for PIV < 4 . Surgical and survival outcome were evaluated by univariate and multivariate analysis . Results Among 348 consecutive patients , almost half ( 48.0 % ) had an HTL . Among 165 cases receiving PDS , residual tumor ( RT ) was as follows : no gross residual in 102 patients ( 61.8 % ) ; RT ≤1 cm in 48 patients ( 29.1 % ) and RT > 1 cm in 15 cases ( 9.1 % ) . When stratifying the whole population according to laparoscopic tumor load , the median progression-free survival ( PFS ) was 33 months for LTL , 18 months for ITL , and 14 months for HTL ( p = 0.0001 ) . The median overall survival ( OS ) with respect to laparoscopic PIV was not reached for LTL , whereas it was 47 months for ITL and 33 months for HTL , respectively ( p = 0.0001 ) . At multivariate analysis , tumor load stratified by PIV retained an independent prognostic value on PFS and OS , together with RT and performance status . Conclusions RT remains an important prognostic factor in patients with AEOC , but tumor dissemination can play a role in determining prognosis in these women OBJECTIVE The purpose of this study was to vali date the performance of a laparoscopy-based model to predict optimal cytoreduction in advanced ovarian cancer patients . STUDY DESIGN In a consecutive prospect i ve series of 113 advanced ovarian cancer patients , the presence of omental cake , peritoneal and diaphragmatic extensive carcinosis , mesenteric retraction , bowel and stomach infiltration , spleen and /or liver superficial metastasis were investigated by laparoscopy . By summing the scores relative to all parameters , a laparoscopic assessment for each patient ( total predictive index value = PIV ) has been calculated . Sensitivity , specificity , positive predictive value ( PPV ) , negative predictive value ( NPV ) , and accuracy have been calculated for each PIV . RESULTS The overall accuracy rate of the laparoscopic procedure ranged between 77.3 and 100 % . At a PIV > /= 8 the probability of optimally resecting the disease at laparotomy is equal to 0 , and the rate of unnecessary exploratory laparotomy is 40.5 % . CONCLUSION The proposed laparoscopic model appears a reliable and flexible tool to predict optimal cytoreduction in advanced ovarian cancer BACKGROUND The international st and ard of care for women with suspected advanced ovarian cancer is surgical debulking followed by platinum-based chemotherapy . We aim ed to establish whether use of platinum-based primary chemotherapy followed by delayed surgery was an effective and safe alternative treatment regimen . METHODS In this phase 3 , non-inferiority , r and omised , controlled trial ( CHORUS ) undertaken in 87 hospitals in the UK and New Zeal and , we enrolled women with suspected stage III or IV ovarian cancer . We r and omly assigned women ( 1:1 ) either to undergo primary surgery followed by six cycles of chemotherapy , or to three cycles of primary chemotherapy , then surgery , followed by three more cycles of completion chemotherapy . Each 3-week cycle consisted of carboplatin AUC5 or AUC6 plus paclitaxel 175 mg/m(2 ) , or an alternative carboplatin combination regimen , or carboplatin monotherapy . We did the r and om assignment by use of a minimisation method with a r and om element , and stratified participants according to the r and omising centre , largest radiological tumour size , clinical stage , and prespecified chemotherapy regimen . Patients and investigators were not masked to group assignment . The primary outcome measure was overall survival . Primary analyses were done in the intention-to-treat population . To establish non-inferiority , the upper bound of a one-sided 90 % CI for the hazard ratio ( HR ) had to be less than 1.18 . This trial is registered , number IS RCT N74802813 , and is closed to new participants . FINDINGS Between March 1 , 2004 , and Aug 30 , 2010 , we r and omly assigned 552 women to treatment . Of the 550 women who were eligible , 276 were assigned to primary surgery and 274 to primary chemotherapy . All were included in the intention-to-treat analysis ; 251 assigned to primary surgery and 253 to primary chemotherapy were included in the per- protocol analysis . As of May 31 , 2014 , 451 deaths had occurred : 231 in the primary -surgery group versus 220 in the primary -chemotherapy group . Median overall survival was 22.6 months in the primary -surgery group versus 24.1 months in primary chemotherapy . The HR for death was 0.87 in favour of primary chemotherapy , with the upper bound of the one-sided 90 % CI 0.98 ( 95 % CI 0.72 - 1.05 ) . Grade 3 or 4 postoperative adverse events and deaths within 28 days after surgery were more common in the primary -surgery group than in the primary -chemotherapy group ( 60 [ 24 % ] of 252 women vs 30 [ 14 % ] of 209 , p=0.0007 , and 14 women [ 6 % ] vs 1 woman [ < 1 % ] , p=0.001 ) . The most common grade 3 or 4 postoperative adverse event was haemorrhage in both groups ( 8 women [ 3 % ] in the primary -surgery group vs 14 [ 6 % ] in the primary -chemotherapy group ) . 110 ( 49 % ) of 225 women receiving primary surgery and 102 ( 40 % ) of 253 receiving primary chemotherapy had a grade 3 or 4 chemotherapy related toxic effect ( p=0.0654 ) , mostly uncomplicated neutropenia ( 20 % and 16 % , respectively ) . One fatal toxic effect , neutropenic sepsis , occurred in the primary -chemotherapy group . INTERPRETATION In women with stage III or IV ovarian cancer , survival with primary chemotherapy is non-inferior to primary surgery . In this study population , giving primary chemotherapy before surgery is an acceptable st and ard of care for women with advanced ovarian cancer . FUNDING Cancer Research UK and the Royal College of Obstetricians and Gynaecologists Following the recent publication of the r and omized study in stages IIIC and IV ovarian cancer of the European Organisation for Treatment and Research —Gynaecological Cancer Group ( EORTC-GCG ) and the National Cancer Institute of Canada ( NCIC ) Clinical Trials Group [ 1 ] , a lot of controversy on the role of neoadjuvant chemotherapy and primary debulking in advanced ovarian cancer emerged [ 2–5 ] . At the recent Gynecologic Cancer InterGroup ( GCIG ) consensus conference a majority of 21 out of 23 member groups supported the statement : “ Delayed primary surgery after neoadjuvant chemotherapy is an option for selected patients with stage IIIC or IV ovarian cancer as included in the EORTC55971 ” [ 6 ] . However , two member groups ( the Arbeitsgemeinschaft Gynaekologische Onkologie [ AGO ] Study Group Germany and the AGO-Austria ) voted for the minority statement “ Neoadjuvant chemotherapy can not be regarded as adequate routine therapy of advanced ovarian cancer and should be limited to selected patients with very advanced International Federation ofGynecology and Obstetrics stage IIIC or IV disease and contraindications against upfront debulking surgery or tumor dissemination , implying no chance for complete resection . ” The latter was also the official statement of the German Society of Gynecologic Oncology [ 7 ] . The authors discussed the role of neoadjuvant chemotherapy in advanced ovarian cancer on many conferences . However , the authors believe it is important to summarize in this paper in which groups of patients we agree that primary debulking should be the preferred treatment strategy and in which patients will probably not benefit from upfront surgery and alternative strategies as neoadjuvant chemotherapy followed by interval debulking should be preferred . Furthermore , we summarize in which groups of patients with advanced ovarian cancer we disagree on the preferred treatment policy . The opinions expressed in this paper are solely the opinion of the authors and not of the Cooperative groups or Societies the authors are member of Background Triage of patients with ovarian cancer to primary debulking surgery ( PDS ) or neoadjuvant chemotherapy ( NACT )  is challenging . In Denmark , the use of NACT has increased , but substantial differences in the use of NACT or PDS exist among centers . We aim ed to characterize the differences between intended and actual first-line treatments in addition to the differences in the triage process among the centers and to evaluate the different diagnostic modalities and the clinical aspects ’ influence in the triage process . Material s and Methods From 4 centers , forms containing data about the diagnostic process and intended treatment were prospect ively collected and merged with data from the Danish Gynecological Cancer Data base and medical records . Results Of the 671 completed forms , 540 patients had stage IIIC or IV epithelial ovarian cancer . Of the 238 ( 44 % ) referred to PDS  , 91 % received PDS and 4 % never had debulking surgery . Of the 288 patients ( 53 % ) referred to NACT  , 44 % were never debulked . Fourteen patients ( 3 % ) were referred to palliative treatment . The use of different imaging modalities , diagnostic laparoscopy , and laparotomy varied significantly among the centers . Diagnostic surgical procedures were considered to be most influential in the triage process . Regardless of the intended first-line treatment or center , the tumor size and dissemination was the most influential clinical aspect . Conclusions In Denmark , substantial differences exist between intended and actual first-line treatments as well as in the diagnostic process and use of NACT , calling for further discussion on diagnostic strategy and therapeutically approach for patients with advanced ovarian cancer OBJECTIVES Ovarian cancers are usually diagnosed at an advanced stage . The extent of the disease before surgery partly determines the ability to perform a complete cytoreduction . The peritoneal cancer index ( PCI ) is used to evaluate peritoneal carcinomatosis and has been vali date d in ovarian cancer and correlated with resectability . The aim of our study was to assess the feasibility of single-port laparoscopy ( SPL ) for suspicion of advanced ovarian cancer and to describe the ability to calculate the PCI score at the time of laparoscopy . STUDY DESIGN Between February 2011 and January 2013 , 33 patients underwent SPL for suspected advanced ovarian cancer . Individual records for all patients were prospect ively review ed and analyzed . For each patient , we determined the PCI score . RESULTS 33 patients underwent initial SPL  , 85 % had increased carcinological markers and 67 % a radiological suspicion of peritoneal carcinomatosis . The median operative time was 90min . During SPL , 76 % of patients underwent ascites evacuation ; all patients had peritoneal cytology and peritoneal biopsies . Only 3 patients experienced perioperative complications . Two open conversions were recorded . Quotation of the PCI score was possible for all patients . Eigh 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE Most cases of epithelial ovarian cancer ( EOC ) are diagnosed in an advanced stage . When the disease has spread intra-abdominally , complete surgical tumor debulking is the single most important prognostic factor . Neoadjuvant chemotherapy ( NACT ) before surgery can cause fibrosis and adhesions in the peritoneal cavity and may interfere with the perioperative evaluation of tumor spread . In this prospect i ve study , we evaluated whether perioperative visual assessment of tumor dissemination is similar in patients undergoing primary and interval surgery for EOC . METHODS Systematic visual evaluation of tumor spread was performed at the start of primary surgery/diagnostic laparoscopy  ( n=39 ) or interval surgery ( n=16 ) . Peritoneal cavity was divided into 22 anatomical regions . The carefully documented results of the visual assessment were compared with the histopathological analysis of 220 biopsies from primary and 92 biopsies from interval surgery . RESULTS In primary surgery , perioperative visual estimation of tumor spread showed 98 % sensitivity , 76 % specificity and 95 % accuracy compared to histopathology . The corresponding figures after NACT were 86 % , 76 % and 84 % , respectively . The difference in sensitivity and accuracy in primary and interval operations was statistically significant ( p<0.001 ) . CONCLUSIONS In advanced EOC , microscopically carcinomatous areas have a benign visual appearance more often after NACT than at primary surgery . NACT may interfere with the perioperative visual evaluation of tumor spread and thus lead to incomplete resection of tumor in potentially resectable areas Purpose The aim of this study was to investigate whether preoperative laparoscopic evaluation of the dissemination of disease may have an independent impact on survival in advanced epithelial ovarian cancer ( AEOC ) . Methods All AEOC women were su bmi tted to staging laparoscopy before receiving primary debulking surgery ( PDS ) or neoadjuvant chemotherapy ( NACT ) . All study women received a laparoscopic score ( predictive index value [ PIV ] ) and were stratified into three groups based on volume of disease : high tumor load ( HTL ) for PIV ≥8 , intermediate tumor load ( ITL ) for PIV equal to 6 and 4 , and low tumor load ( LTL ) for PIV < 4 . Surgical and survival outcome were evaluated by univariate and multivariate analysis . Results Among 348 consecutive patients , almost half ( 48.0 % ) had an HTL . Among 165 cases receiving PDS , residual tumor ( RT ) was as follows : no gross residual in 102 patients ( 61.8 % ) ; RT ≤1 cm in 48 patients ( 29.1 % ) and RT > 1 cm in 15 cases ( 9.1 % ) . When stratifying the whole population according to laparoscopic tumor load , the median progression-free survival ( PFS ) was 33 months for LTL , 18 months for ITL , and 14 months for HTL ( p = 0.0001 ) . The median overall survival ( OS ) with respect to laparoscopic PIV was not reached for LTL , whereas it was 47 months for ITL and 33 months for HTL , respectively ( p = 0.0001 ) . At multivariate analysis , tumor load stratified by PIV retained an independent prognostic value on PFS and OS , together with RT and performance status . Conclusions RT remains an important prognostic factor in patients with AEOC , but tumor dissemination can play a role in determining prognosis in these women OBJECTIVE The purpose of this study was to vali date the performance of a laparoscopy-based model to predict optimal cytoreduction in advanced ovarian cancer patients . STUDY DESIGN In a consecutive prospect i ve series of 113 advanced ovarian cancer patients , the presence of omental cake , peritoneal and diaphragmatic extensive carcinosis , mesenteric retraction , bowel and stomach infiltration , spleen and /or liver superficial metastasis were investigated by laparoscopy . By summing the scores relative to all parameters , a laparoscopic assessment for each patient ( total predictive index value = PIV ) has been calculated . Sensitivity , specificity , positive predictive value ( PPV ) , negative predictive value ( NPV ) , and accuracy have been calculated for each PIV . RESULTS The overall accuracy rate of the laparoscopic procedure ranged between 77.3 and 100 % . At a PIV > /= 8 the probability of optimally resecting the disease at laparotomy is equal to 0 , and the rate of unnecessary exploratory laparotomy is 40.5 % . CONCLUSION The proposed laparoscopic model appears a reliable and flexible tool to predict optimal cytoreduction in advanced ovarian cancer BACKGROUND The international st and ard of care for women with suspected advanced ovarian cancer is surgical debulking followed by platinum-based chemotherapy . We aim ed to establish whether use of platinum-based primary chemotherapy followed by delayed surgery was an effective and safe alternative treatment regimen . METHODS In this phase 3 , non-inferiority , r and omised , controlled trial ( CHORUS ) undertaken in 87 hospitals in the UK and New Zeal and , we enrolled women with suspected stage III or IV ovarian cancer . We r and omly assigned women ( 1:1 ) either to undergo primary surgery followed by six cycles of chemotherapy , or to three cycles of primary chemotherapy , then surgery , followed by three more cycles of completion chemotherapy . Each 3-week cycle consisted of carboplatin AUC5 or AUC6 plus paclitaxel 175 mg/m(2 ) , or an alternative carboplatin combination regimen , or carboplatin monotherapy . We did the r and om assignment by use of a minimisation method with a r and om element , and stratified participants according to the r and omising centre , largest radiological tumour size , clinical stage , and prespecified chemotherapy regimen . Patients and investigators were not masked to group assignment . The primary outcome measure was overall survival . Primary analyses were done in the intention-to-treat population . To establish non-inferiority , the upper bound of a one-sided 90 % CI for the hazard ratio ( HR ) had to be less than 1.18 . This trial is registered , number IS RCT N74802813 , and is closed to new participants . FINDINGS Between March 1 , 2004 , and Aug 30 , 2010 , we r and omly assigned 552 women to treatment . Of the 550 women who were eligible , 276 were assigned to primary surgery and 274 to primary chemotherapy . All were included in the intention-to-treat analysis ; 251 assigned to primary surgery and 253 to primary chemotherapy were included in the per- protocol analysis . As of May 31 , 2014 , 451 deaths had occurred : 231 in the primary -surgery group versus 220 in the primary -chemotherapy group . Median overall survival was 22.6 months in the primary -surgery group versus 24.1 months in primary chemotherapy . The HR for death was 0.87 in favour of primary chemotherapy , with the upper bound of the one-sided 90 % CI 0.98 ( 95 % CI 0.72 - 1.05 ) . Grade 3 or 4 postoperative adverse events and deaths within 28 days after surgery were more common in the primary -surgery group than in the primary -chemotherapy group ( 60 [ 24 % ] of 252 women vs 30 [ 14 % ] of 209 , p=0.0007 , and 14 women [ 6 % ] vs 1 woman [ < 1 % ] , p=0.001 ) . The most common grade 3 or 4 postoperative adverse event was haemorrhage in both groups ( 8 women [ 3 % ] in the primary -surgery group vs 14 [ 6 % ] in the primary -chemotherapy group ) . 110 ( 49 % ) of 225 women receiving primary surgery and 102 ( 40 % ) of 253 receiving primary chemotherapy had a grade 3 or 4 chemotherapy related toxic effect ( p=0.0654 ) , mostly uncomplicated neutropenia ( 20 % and 16 % , respectively ) . One fatal toxic effect , neutropenic sepsis , occurred in the primary -chemotherapy group . INTERPRETATION In women with stage III or IV ovarian cancer , survival with primary chemotherapy is non-inferior to primary surgery . In this study population , giving primary chemotherapy before surgery is an acceptable st and ard of care for women with advanced ovarian cancer . FUNDING Cancer Research UK and the Royal College of Obstetricians and Gynaecologists Following the recent publication of the r and omized study in stages IIIC and IV ovarian cancer of the European Organisation for Treatment and Research —Gynaecological Cancer Group ( EORTC-GCG ) and the National Cancer Institute of Canada ( NCIC ) Clinical Trials Group [ 1 ] , a lot of controversy on the role of neoadjuvant chemotherapy and primary debulking in advanced ovarian cancer emerged [ 2–5 ] . At the recent Gynecologic Cancer InterGroup ( GCIG ) consensus conference a majority of 21 out of 23 member groups supported the statement : “ Delayed primary surgery after neoadjuvant chemotherapy is an option for selected patients with stage IIIC or IV ovarian cancer as included in the EORTC55971 ” [ 6 ] . However , two member groups ( the Arbeitsgemeinschaft Gynaekologische Onkologie [ AGO ] Study Group Germany and the AGO-Austria ) voted for the minority statement “ Neoadjuvant chemotherapy can not be regarded as adequate routine therapy of advanced ovarian cancer and should be limited to selected patients with very advanced International Federation ofGynecology and Obstetrics stage IIIC or IV disease and contraindications against upfront debulking surgery or tumor dissemination , implying no chance for complete resection . ” The latter was also the official statement of the German Society of Gynecologic Oncology [ 7 ] . The authors discussed the role of neoadjuvant chemotherapy in advanced ovarian cancer on many conferences . However , the authors believe it is important to summarize in this paper in which groups of patients we agree that primary debulking should be the preferred treatment strategy and in which patients will probably not benefit from upfront surgery and alternative strategies as neoadjuvant chemotherapy followed by interval debulking should be preferred . Furthermore , we summarize in which groups of patients with advanced ovarian cancer we disagree on the preferred treatment policy . The opinions expressed in this paper are solely the opinion of the authors and not of the Cooperative groups or Societies the authors are member of Background Triage of patients with ovarian cancer to primary debulking surgery ( PDS ) or neoadjuvant chemotherapy ( NACT )  is challenging . In Denmark , the use of NACT has increased , but substantial differences in the use of NACT or PDS exist among centers . We aim ed to characterize the differences between intended and actual first-line treatments in addition to the differences in the triage process among the centers and to evaluate the different diagnostic modalities and the clinical aspects ’ influence in the triage process . Material s and Methods From 4 centers , forms containing data about the diagnostic process and intended treatment were prospect ively collected and merged with data from the Danish Gynecological Cancer Data base and medical records . Results Of the 671 completed forms , 540 patients had stage IIIC or IV epithelial ovarian cancer . Of the 238 ( 44 % ) referred to PDS  , 91 % received PDS and 4 % never had debulking surgery . Of the 288 patients ( 53 % ) referred to NACT  , 44 % were never debulked . Fourteen patients ( 3 % ) were referred to palliative treatment . The use of different imaging modalities , diagnostic laparoscopy , and laparotomy varied significantly among the centers . Diagnostic surgical procedures were considered to be most influential in the triage process . Regardless of the intended first-line treatment or center , the tumor size and dissemination was the most influential clinical aspect . Conclusions In Denmark , substantial differences exist between intended and actual first-line treatments as well as in the diagnostic process and use of NACT , calling for further discussion on diagnostic strategy and therapeutically approach for patients with advanced ovarian cancer OBJECTIVES Ovarian cancers are usually diagnosed at an advanced stage . The extent of the disease before surgery partly determines the ability to perform a complete cytoreduction . The peritoneal cancer index ( PCI ) is used to evaluate peritoneal carcinomatosis and has been vali date d in ovarian cancer and correlated with resectability . The aim of our study was to assess the feasibility of single-port laparoscopy ( SPL ) for suspicion of advanced ovarian cancer and to describe the ability to calculate the PCI score at the time of laparoscopy . STUDY DESIGN Between February 2011 and January 2013 , 33 patients underwent SPL for suspected advanced ovarian cancer . Individual records for all patients were prospect ively review ed and analyzed . For each patient , we determined the PCI score . RESULTS 33 patients underwent initial SPL  , 85 % had increased carcinological markers and 67 % a radiological suspicion of peritoneal carcinomatosis . The median operative time was 90min . During SPL , 76 % of patients underwent ascites evacuation ; all patients had peritoneal cytology and peritoneal biopsies . Only 3 patients experienced perioperative complications . Two open conversions were recorded . Quotation of the PCI score was possible for all patients . Eigh 
    Output:
    