{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,1]],"date-time":"2026-07-01T13:29:16Z","timestamp":1782912556190,"version":"3.54.5"},"reference-count":57,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2023,2,3]],"date-time":"2023-02-03T00:00:00Z","timestamp":1675382400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background: The Peritoneal Carcinomatosis Index (PCI) and the Intra-operative Mapping for Ovarian Cancer (IMO), to a lesser extent, have been universally validated in advanced-stage epithelial ovarian cancer (EOC) to describe the extent of peritoneal dissemination and are proven to be powerful predictors of the surgical outcome with an added sensitivity of assessment at laparotomy of around 70%. This leaves room for improvement because the two-dimensional anatomic scoring model fails to reflect the patient\u2019s real anatomy, as seen by a surgeon. We hypothesized that tumor dissemination in specific anatomic locations can be more predictive of complete cytoreduction (CC0) and survival than PCI and IMO tools in EOC patients. (2) Methods: We analyzed prospectively data collected from 508 patients with FIGO-stage IIIB-IVB EOC who underwent cytoreductive surgery between January 2014 and December 2019 at a UK tertiary center. We adapted the structured ESGO ovarian cancer report to provide detailed information on the patterns of tumor dissemination (cancer anatomic fingerprints). We employed the extreme gradient boost (XGBoost) to model only the variables referring to the EOC disseminated patterns, to create an intra-operative score and judge the predictive power of the score alone for complete cytoreduction (CC0). Receiver operating characteristic (ROC) curves were then used for performance comparison between the new score and the existing PCI and IMO tools. We applied the Shapley additive explanations (SHAP) framework to support the feature selection of the narrated cancer fingerprints and provide global and local explainability. Survival analysis was performed using Kaplan\u2013Meier curves and Cox regression. (3) Results: An intra-operative disease score was developed based on specific weights assigned to the cancer anatomic fingerprints. The scores range from 0 to 24. The XGBoost predicted CC0 resection (area under curve (AUC) = 0.88 CI = 0.854\u20130.913) with high accuracy. Organ-specific dissemination on the small bowel mesentery, large bowel serosa, and diaphragmatic peritoneum were the most crucial features globally. When added to the composite model, the novel score slightly enhanced its predictive value (AUC = 0.91, CI = 0.849\u20130.963). We identified a \u201cturning point\u201d, \u22645, that increased the probability of CC0. Using conventional logistic regression, the new score was superior to the PCI and IMO scores for the prediction of CC0 (AUC = 0.81 vs. 0.73 and 0.67, respectively). In multivariate Cox analysis, a 1-point increase in the new intra-operative score was associated with poorer progression-free (HR: 1.06; 95% CI: 1.03\u20131.09, p &lt; 0.005) and overall survival (HR: 1.04; 95% CI: 1.01\u20131.07), by 4% and 6%, respectively. (4) Conclusions: The presence of cancer disseminated in specific anatomical sites, including small bowel mesentery, large bowel serosa, and diaphragmatic peritoneum, can be more predictive of CC0 and survival than the entire PCI and IMO scores. Early intra-operative assessment of these areas only may reveal whether CC0 is achievable. In contrast to the PCI and IMO scores, the novel score remains predictive of adverse survival outcomes.<\/jats:p>","DOI":"10.3390\/cancers15030966","type":"journal-article","created":{"date-parts":[[2023,2,3]],"date-time":"2023-02-03T03:36:57Z","timestamp":1675395417000},"page":"966","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":23,"title":["Development of a Novel Intra-Operative Score to Record Diseases\u2019 Anatomic Fingerprints (ANAFI Score) for the Prediction of Complete Cytoreduction in Advanced-Stage Ovarian Cancer by Using Machine Learning and Explainable Artificial Intelligence"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4870-7393","authenticated-orcid":false,"given":"Alexandros","family":"Laios","sequence":"first","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4416-8764","authenticated-orcid":false,"given":"Evangelos","family":"Kalampokis","sequence":"additional","affiliation":[{"name":"Information Systems Lab, Department of Business Administration, University of Macedonia, 54636 Thessaloniki, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2677-2709","authenticated-orcid":false,"given":"Racheal","family":"Johnson","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sarika","family":"Munot","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amudha","family":"Thangavelu","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8963-5517","authenticated-orcid":false,"given":"Richard","family":"Hutson","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tim","family":"Broadhead","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Georgios","family":"Theophilou","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"David","family":"Nugent","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0081-674X","authenticated-orcid":false,"given":"Diederick","family":"De Jong","sequence":"additional","affiliation":[{"name":"Department of Gynaecologic Oncology, St James\u2019s University Hospital, Leeds LS9 7TF, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"7","DOI":"10.3322\/caac.21551","article-title":"Cancer statistics, 2019","volume":"69","author":"Siegel","year":"2019","journal-title":"CA A Cancer J. Clin."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"8802","DOI":"10.1200\/JCO.2005.02.1287","article-title":"Does aggressive surgery only benefit patients with less advanced ovarian cancer? Results from an international comparison within the SCOTROC-1 Trial","volume":"23","author":"Crawford","year":"2005","journal-title":"J. Clin. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"26","DOI":"10.1016\/j.ygyno.2009.03.018","article-title":"Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm","volume":"114","author":"Chi","year":"2009","journal-title":"Gynecol. Oncol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1156","DOI":"10.1245\/ASO.2006.08.021","article-title":"A Laparoscopy-Based Score To Predict Surgical Outcome in Patients With Advanced Ovarian Carcinoma: A Pilot Study","volume":"13","author":"Fagotti","year":"2006","journal-title":"Ann. Surg. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1055\/s-2003-41864","article-title":"\u201cIMO\u201d\u2014Intraoperatives Mapping des Ovarialkarzinoms","volume":"125","author":"Sehouli","year":"2003","journal-title":"Zentralbl Gynakol"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"1083","DOI":"10.1016\/j.ygyno.2006.06.028","article-title":"The addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival in patients with stages IIIC\u2013IV epithelial ovarian cancer","volume":"103","author":"Eisenhauer","year":"2006","journal-title":"Gynecol. Oncol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1016\/j.ygyno.2014.04.013","article-title":"2014 FIGO staging for ovarian, fallopian tube and peritoneal cancer","volume":"133","author":"Mutch","year":"2014","journal-title":"Gynecol. Oncol."},{"key":"ref_8","first-page":"2495131","article-title":"Prognostic Relevance of the Peritoneal Surface Disease Severity Score Compared to the Peritoneal Cancer Index for Colorectal Peritoneal Carcinomatosis","volume":"2016","author":"Shen","year":"2016","journal-title":"Int. J. Surg. Oncol."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Sugarbaker, P.H. (1996). Peritoneal Carcinomatosis: Principles of Management, Springer.","DOI":"10.1007\/978-1-4613-1247-5"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1053\/ejso.2002.1380","article-title":"Peritoneal cancer index: A prognostic indicator of survival in advanced ovarian cancer","volume":"29","author":"Tentes","year":"2003","journal-title":"Eur. J. Surg. Oncol. (EJSO)"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1699","DOI":"10.1097\/IGC.0b013e3182a616a7","article-title":"Accuracy and Reproducibility of the Peritoneal Cancer Index in Advanced Ovarian Cancer During Laparoscopy and Laparotomy","volume":"23","author":"Gouy","year":"2013","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"244","DOI":"10.1245\/s10434-020-08649-6","article-title":"The Peritoneal Cancer Index is a Strong Predictor of Incomplete Cytoreductive Surgery in Ovarian Cancer","volume":"28","author":"Lomnytska","year":"2021","journal-title":"Ann. Surg. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2915","DOI":"10.1016\/j.ejso.2021.05.019","article-title":"Peritoneal cancer index predicts severe complications after ovarian cancer surgery","volume":"47","author":"Lomnytska","year":"2021","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1245\/s10434-015-4966-5","article-title":"Computerized System for Staging Peritoneal Surface Malignancies","volume":"23","author":"Sammartino","year":"2016","journal-title":"Ann. Surg. Oncol."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1097\/IGC.0000000000000327","article-title":"Prognostic Significance of Sugarbaker\u2019s Peritoneal Cancer Index for the Operability of Ovarian Carcinoma","volume":"25","author":"Lampe","year":"2015","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/j.ygyno.2016.03.015","article-title":"Pattern of and reason for postoperative residual disease in patients with advanced ovarian cancer following upfront radical debulking surgery","volume":"141","author":"Heitz","year":"2016","journal-title":"Gynecol. Oncol."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Laios, A., Kalampokis, E., Johnson, R., Thangavelu, A., Tarabanis, C., Nugent, D., and De Jong, D. (2022). Explainable Artificial Intelligence for Prediction of Complete Surgical Cytoreduction in Advanced-Stage Epithelial Ovarian Cancer. J. Pers. Med., 12.","DOI":"10.3390\/jpm12040607"},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Chen, T., and Guestrin, C. (2016, January 13\u201317). XGBoost: A Scalable Tree Boosting System. Proceedings of the 22nd ACM SIGKDD International Conference on Knowledge Discovery and Data Mining, San Francisco, CA, USA. KDD \u201916.","DOI":"10.1145\/2939672.2939785"},{"key":"ref_19","unstructured":"Guyon, I., Luxburg, U.V., Bengio, S., Wallach, H., Fergus, R., Vishwanathan, S., and Garnett, R. (2017, January 4\u20139). A Unified Approach to Interpreting Model Predictions. Proceedings of the Advances in Neural Information Processing Systems, Long Beach, CA, USA."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"575","DOI":"10.1016\/j.compbiomed.2011.04.014","article-title":"Development of an advanced database for clinical trials integrated with an electronic patient record system","volume":"41","author":"Newsham","year":"2011","journal-title":"Comput. Biol. Med."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Johnson, R.L., Laios, A., Jackson, D., Nugent, D., Orsi, N.M., Theophilou, G., Thangavelu, A., and de Jong, D. (2021). The Uncertain Benefit of Adjuvant Chemotherapy in Advanced Low-Grade Serous Ovarian Cancer and the Pivotal Role of Surgical Cytoreduction. J. Clin. Med., 10.","DOI":"10.3390\/jcm10245927"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"123","DOI":"10.1016\/j.ejogrb.2017.04.016","article-title":"British Gynaecological Cancer Society (BGCS) epithelial ovarian\/fallopian tube\/primary peritoneal cancer guidelines: Recommendations for practice","volume":"213","author":"Fotopoulou","year":"2017","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"1199","DOI":"10.1136\/ijgc-2021-002951","article-title":"European Society of Gynaecological Oncology guidelines for the peri-operative management of advanced ovarian cancer patients undergoing debulking surgery","volume":"31","author":"Fotopoulou","year":"2021","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"676.e1","DOI":"10.1016\/j.ajog.2007.10.495","article-title":"Relationship among surgical complexity, short-term morbidity, and overall survival in primary surgery for advanced ovarian cancer","volume":"197","author":"Aletti","year":"2007","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1006\/jcss.1997.1504","article-title":"A Decision-Theoretic Generalization of On-Line Learning and an Application to Boosting","volume":"55","author":"Freund","year":"1997","journal-title":"J. Comput. Syst. Sci."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"56","DOI":"10.1038\/s42256-019-0138-9","article-title":"From local explanations to global understanding with explainable AI for trees","volume":"2","author":"Lundberg","year":"2020","journal-title":"Nat. Mach. Intell."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"749","DOI":"10.1038\/s41551-018-0304-0","article-title":"Explainable machine-learning predictions for the prevention of hypoxaemia during surgery","volume":"2","author":"Lundberg","year":"2018","journal-title":"Nat. Biomed. Eng."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Laios, A., Kalampokis, E., Johnson, R., Munot, S., Thangavelu, A., Hutson, R., Broadhead, T., Theophilou, G., Leach, C., and Nugent, D. (2022). Factors Predicting Surgical Effort Using Explainable Artificial Intelligence in Advanced Stage Epithelial Ovarian Cancer. Cancers, 14.","DOI":"10.3390\/cancers14143447"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"100355","DOI":"10.1016\/j.bdr.2022.100355","article-title":"Linked Open Government Data to Predict and Explain House Prices: The Case of Scottish Statistics Portal","volume":"30","author":"Karamanou","year":"2022","journal-title":"Big Data Res."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"105405","DOI":"10.1016\/j.aap.2019.105405","article-title":"Toward safer highways, application of XGBoost and SHAP for real-time accident detection and feature analysis","volume":"136","author":"Parsa","year":"2020","journal-title":"Accid. Anal. Prev."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"115","DOI":"10.21873\/anticanres.15465","article-title":"Scoring Systems of Peritoneal Dissemination for the Prediction of Operative Completeness in Advanced Ovarian Cancer","volume":"42","author":"Hosoya","year":"2022","journal-title":"Anticancer Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"120","DOI":"10.1016\/j.suronc.2019.04.008","article-title":"Can machine learning predict resecability of a peritoneal carcinomatosis?","volume":"29","author":"Maubert","year":"2019","journal-title":"Surg. Oncol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"163","DOI":"10.1016\/j.ejso.2017.11.003","article-title":"MUAPOS working group (multidisciplinary unit of abdominal pelvic oncology surgery). Prognostic value of peritoneal cancer index in primary advanced ovarian cancer","volume":"44","author":"Llueca","year":"2018","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"607","DOI":"10.1007\/s00404-016-4080-3","article-title":"Maximal effort cytoreductive surgery for disseminated ovarian cancer in a UK setting: Challenges and possibilities","volume":"294","author":"Fotopoulou","year":"2016","journal-title":"Arch. Gynecol. Obstet."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1248","DOI":"10.1200\/JCO.2002.20.5.1248","article-title":"Survival Effect of Maximal Cytoreductive Surgery for Advanced Ovarian Carcinoma During the Platinum Era: A Meta-Analysis","volume":"20","author":"Bristow","year":"2002","journal-title":"J. Clin. Oncol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1234","DOI":"10.1002\/cncr.24149","article-title":"Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: A combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials","volume":"115","author":"Reuss","year":"2009","journal-title":"Cancer"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"943","DOI":"10.1056\/NEJMoa0908806","article-title":"Neoadjuvant Chemotherapy or Primary Surgery in Stage IIIC or IV Ovarian Cancer","volume":"363","author":"Vergote","year":"2010","journal-title":"N. Engl. J. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"434","DOI":"10.1245\/s10434-015-4890-8","article-title":"Which Surgical Attitude to Choose in the Context of Non-Resectability of Ovarian Carcinomatosis: Beyond Gross Residual Disease Considerations","volume":"23","author":"Vidal","year":"2016","journal-title":"Ann. Surg. Oncol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"3059","DOI":"10.21873\/anticanres.15089","article-title":"Peri-operative Variables Associated with Prolonged Intensive Care Stay Following Cytoreductive Surgery for Ovarian Cancer","volume":"41","author":"Collins","year":"2021","journal-title":"Anticancer Res."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1097\/IGC.0000000000001173","article-title":"Specific Regions, Rather than the Entire Peritoneal Carcinosis Index, are Predictive of Complete Resection and Survival in Advanced Epithelial Ovarian Cancer","volume":"28","author":"Rosendahl","year":"2018","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1016\/j.ygyno.2015.12.004","article-title":"Diaphragmatic peritonectomy vs. full thickness resection with pleurectomy during Visceral-Peritoneal Debulking (VPD) in 100 consecutive patients with stage IIIC\u2013IV ovarian cancer: A surgical-histological analysis","volume":"140","author":"Ferrari","year":"2016","journal-title":"Gynecol. Oncol."},{"key":"ref_42","doi-asserted-by":"crossref","unstructured":"Tozzi, R., Ferrari, F., Nieuwstad, J., Campanile, R.G., and Soleymani Majd, H. (2020). Tozzi classification of diaphragmatic surgery in patients with stage IIIC\u2013IV ovarian cancer based on surgical findings and complexity. J. Gynecol. Oncol., 31.","DOI":"10.3802\/jgo.2020.31.e14"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1006\/gyno.2001.6312","article-title":"What Are the Current Surgical Objectives, Strategies, and Technical Capabilities of Gynecologic Oncologists Treating Advanced Epithelial Ovarian Cancer?","volume":"82","author":"Eisenkop","year":"2001","journal-title":"Gynecol. Oncol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/j.ygyno.2019.08.025","article-title":"Diagnostic flow-chart to identify bowel involvement in patients with stage IIIC-IV ovarian cancer: Can laparoscopy improve the accuracy of CT scan?","volume":"155","author":"Tozzi","year":"2019","journal-title":"Gynecol. Oncol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"326","DOI":"10.5603\/GP.2016.0002","article-title":"Computed tomography as a predictor of the extent of the disease and surgical outcomes in ovarian cancer","volume":"87","author":"Cerci","year":"2016","journal-title":"Ginekol. Pol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"269","DOI":"10.1016\/j.ygyno.2022.08.022","article-title":"Peroperative extent of peritoneal metastases affects the surgical outcome and survival in advanced ovarian cancer","volume":"167","author":"Engbersen","year":"2022","journal-title":"Gynecol. Oncol."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.ygyno.2007.05.032","article-title":"A new frontier for quality of care in gynecologic oncology surgery: Multi-institutional assessment of short-term outcomes for ovarian cancer using a risk-adjusted model","volume":"107","author":"Aletti","year":"2007","journal-title":"Gynecol. Oncol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1619","DOI":"10.1016\/j.ejso.2019.04.011","article-title":"Prognostic impact of initial tumor load and intraperitoneal disease dissemination patterns in patients with advanced ovarian cancer undergoing complete cytoreductive surgery","volume":"45","author":"Uzan","year":"2019","journal-title":"Eur. J. Surg. Oncol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"1023","DOI":"10.1080\/08941939.2020.1733146","article-title":"Interval Debulking Surgery for Advanced Ovarian Cancer in Elderly Patients (\u226570 y): Does the Age Matter?","volume":"34","author":"Pinelli","year":"2021","journal-title":"J. Investig. Surg."},{"key":"ref_50","unstructured":"Ekmann-Gade, A.W., Schnack, T.H., Seib\u00e6k, L., Noer, M.C., and H\u00f8gdall, C. Impact of surgery and chemotherapy timing on outcomes in older versus younger epithelial ovarian cancer patients: A nationwide Danish cohort study, J. Geriatr. Oncol., in press."},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"58","DOI":"10.1016\/j.ygyno.2019.08.004","article-title":"Using an evidence-based triage algorithm to reduce 90-day mortality after primary debulking surgery for advanced epithelial ovarian cancer","volume":"155","author":"Narasimhulu","year":"2019","journal-title":"Gynecol. Oncol."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"3621","DOI":"10.1200\/JCO.2006.10.2517","article-title":"Prognostic Factors for Stage III Epithelial Ovarian Cancer: A Gynecologic Oncology Group Study","volume":"25","author":"Winter","year":"2007","journal-title":"J. Clin. Oncol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1136\/ijgc-2019-001124","article-title":"Interval debulking surgery is not worth the wait: A National Cancer Database study comparing primary cytoreductive surgery versus neoadjuvant chemotherapy","volume":"30","author":"Lyons","year":"2020","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"480","DOI":"10.1016\/j.ygyno.2006.11.002","article-title":"Delaying the primary surgical effort for advanced ovarian cancer: A systematic review of neoadjuvant chemotherapy and interval cytoreduction","volume":"104","author":"Bristow","year":"2007","journal-title":"Gynecol. Oncol."},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"675","DOI":"10.1097\/IGC.0000000000000967","article-title":"Factors Predicting Use of Neoadjuvant Chemotherapy Compared With Primary Debulking Surgery in Advanced Stage Ovarian Cancer\u2014A National Cancer Database Study","volume":"27","author":"Leiserowitz","year":"2017","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1007\/s11547-020-01170-6","article-title":"Radiological assessment of Peritoneal Cancer Index on preoperative CT in ovarian cancer is related to surgical outcome and survival","volume":"125","author":"Avesani","year":"2020","journal-title":"La Radiol. Medica"},{"key":"ref_57","doi-asserted-by":"crossref","unstructured":"Delgado-Barriga, K., Medina, C., Gomez-Quiles, L., Marco-Domenech, S.F., Escrig, J., and Llueca, A. (2022). CT Enterography for Preoperative Evaluation of Peritoneal Carcinomatosis Index in Advanced Ovarian Cancer. J. Clin. Med., 11.","DOI":"10.3390\/jcm11030476"}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/15\/3\/966\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:22:58Z","timestamp":1760120578000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/15\/3\/966"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,3]]},"references-count":57,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2023,2]]}},"alternative-id":["cancers15030966"],"URL":"https:\/\/doi.org\/10.3390\/cancers15030966","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,3]]}}}