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We thank Fagotti et al. for their interest in our paper describing the patterns and sites of residual disease (RD) in patients with advanced ovarian cancer who have undergone primary debulking surgery (PDS) (Heitz et al., 2016) in an expert referral center. The colleagues compare their own datawith ours even though the patients populations are quite different with all incoming patients being analyzed in our series as opposed to only pre-selected patient cohorts reported in the Rome series. Nevertheless, we appreciate and acknowledge that their continuous surgical training led to an improvement of their complete resection rates and overall surgical quality over the last years. Fagotti et al. focus their discussion mainly around selection criteria for ideal treatment strategies in patients with advanced ovarian cancer. This was however not the main purpose of our analysis. Our aimwas to identify and describe the patterns and sites of residual disease in patients operated in centers where not the skill of the surgical team is the limit but rather the anatomical and tumor-biological factors.We described the outcome of all incoming patients providing all associated information unbiased and without any preselection. Moreover, the interpretation that we reported 30.3% of patients being not suitable for PDS is inaccurate. Fagotti et al. added together all patients who did not have primary surgery and those who underwent PDS with large residual disease. They missed the statement that half of the 161 patients who did not undergo PDS was due to the reason of having already started neoadjuvant therapy in centers elsewhere. Obviously, we were not involved in the initial decision making process whether or not these patients could have been candidates for PDS. As stated, the rate of patients deemed not suitable for PDS in the cohort of patients that have started treatment in our center was only 10.9%. In fact, PDS was retrospectively not the best choice in 8.5% of the patients due to RD N 1 cm – a pretty low rate compared with other series. Nevertheless, this was sufficient motivation for us to further define selection criteria for PDS without withholding a high chance for (curative) complete resection (ongoing protocol AGO-OVAR 19). Laparoscopy as selection aid had been shown to be beneficial in Rome when complete resection rates were much lower and comparable to ours at the beginning of our learning curve (Harter et al., 2011). However, even with laparoscopy complete resection rates were still lower than in our center without pre-selection – and the same accounted for the cited SCORPION trial in which 13.7% of patients were excluded before randomization due to suspected inoperable disease but still 9.0% and 9.6% in the PDS and interval debulking groups, respectively, were left with RD N 1 cm (Fagotti et al., 2016).

gynecologic oncology reports

Response to the letter of Fagotti et al. regarding the manuscript: “Pattern of and reason for postoperative residual disease in patients with advanced ovarian cancer following upfront radical debulking surgery”