INTRODUCTION: Predicting suboptimal primary debulking and perioperative complications will lead to improved outcomes for patients with advanced ovarian, fallopian tube, and peritoneal cancer. MANUSCRIPT I: A multicenter prospective trial evaluating the ability of preoperative computed tomography (CT) scan and serum CA-125 to predict suboptimal cytoreduction at primary debulking surgery for advanced ovarian, fallopian tube, and peritoneal cancer OBJECTIVE: To assess the ability of preoperative CT scan and CA-125 to predict suboptimal (>1cm residual disease) primary cytoreduction in advanced ovarian, fallopian tube, and peritoneal cancer. METHODS: This was a prospective multicenter trial of patients who underwent primary cytoreduction for stage III-IV ovarian, fallopian tube, and peritoneal cancer. A CT scan of the abdomen/pelvis and serum CA-125 were obtained within 35 and 14 days before surgery, respectively. Four clinical and 20 radiologic criteria were assessed. RESULTS: From 7/2001-12/2012, 350 patients met eligibility criteria. The optimal debulking rate was 75%. On multivariate analysis, three clinical and six radiologic criteria were significantly associated with suboptimal debulking: age ?60 years (p=0.01); CA-125 ?500 U/mL (p<0.001); ASA 3-4 (p<0.001); suprarenal retroperitoneal lymph nodes >1cm (p<0.001); diffuse small bowel adhesions/thickening (p<0.001); and lesions >1cm in the small bowel mesentery (p=0.03), root of the superior mesenteric artery (p=0.003), perisplenic area (p<0.001), and lesser sac (p<0.001). A `predictive value score' was assigned for each criterion, and the suboptimal debulking rates of patients who had a total score of 0, 1-2, 3-4, 5-6, 7-8, and ?9 were 5%, 10%, 17%, 34%, 52%, and 74%, respectively. A prognostic model combining these nine factors had a predictive accuracy of 0.758. CONCLUSIONS: We identified nine criteria associated with suboptimal debulking, and developed a model that was predictive of suboptimal cytoreduction. These results may be helpful in pretreatment patient assessment. MANUSCRIPT II: Predictive value of the age-adjusted charlson comorbidity index on perioperative complications and survival in patients undergoing primary debulking surgery for advanced epithelial ovarian cancer OBJECTIVE: To assess the ability of the age-adjusted Charlson comorbidity index (ACCI) to predict perioperative complications and survival in patients undergoing primary debulking surgery for advanced epithelial ovarian cancer (EOC). METHODS: Data were analyzed for all patients with stage IIIB-IV EOC who underwent primary cytoreduction from 1/2001-1/2010 at our institution. Patients were divided into 3 groups based on an ACCI of 0-1, 2-3, and ?4. Clinical and survival outcomes were assessed and compared. RESULTS: We identified 567 patients; 199 (35%) had an ACCI of 0-1, 271 (48%) had an ACCI of 2-3, and 97 (17%) had an ACCI of ?4. The ACCI was significantly associated with the rate of complete gross resection (0-1=44%, 2-3=32%, and ?4=32%; p=0.02), but was not associated with the rate of minor (47% vs 47% vs 43%, p=0.84) or major (18% vs 19% vs 16%, p=0.8) complications. The ACCI was also significantly associated with progression-free (PFS) and overall survival (OS). Median PFS for patients with an ACCI of 0-1, 2-3, and ?4 was 20.3m, 16m, and 15.4m, respectively (p=0.02). Median OS for patients with an ACCI of 0-1, 2-3, and ?4 was 65.3m, 49.9m, and 42.3m, respectively (p<0.001). On multivariate analysis, the ACCI remained a significant prognostic factor for both PFS (p=0.02) and OS (p<0.001). CONCLUSIONS: The ACCI was not associated with perioperative complications in patients undergoing primary cytoreduction for advanced EOC, but was a significant predictor of PFS and OS. Prospective clinical trials in ovarian cancer should consider stratifying for an age-comorbidity covariate. OVERALL CONCLUSIONS: Nine criteria associated with suboptimal cytoreduction were identified, and a model that was predictive of suboptimal debulking was developed. The ACCI was not associated with perioperative complications, but was a significant prognostic factor for survival outcomes.