Survival outcomes comparing minimally invasive versus open cytoreductive surgery in recurrent adult-type granulosa cell tumors.

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 intra-abdominal. 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: 485 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=0.03). For the open group, 33% of surgeries were considered intermediate complexity and 4% high complexity, compared to 7% and 0% in the MIS group, respectively (p=0.004). There was no difference in achieving optimal cytoreduction, 85% in the open group and 88% in the MIS group (p=0.68). 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=0.27), or progression-free survival after first recurrence, 26 months in the open group compared to 21 months in the minimally invasive group (p=0.42). The difference in progression-free survival after the first recurrence remained non-significant 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=0.89).

Conclusions: 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.