Elsevier

Gynecologic Oncology

Volume 106, Issue 3, September 2007, Pages 482-487
Gynecologic Oncology

Cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma

https://doi.org/10.1016/j.ygyno.2007.04.006Get rights and content

Abstract

Objective.

This study aims to identify favorable preoperative characteristics and examine the impact of secondary cytoreductive surgery on survival for patients with recurrent epithelial ovarian carcinoma.

Methods.

Patients who underwent cytoreductive surgery for recurrent epithelial ovarian cancer were identified in our surgical database for the period 1988–2004. Patient charts were reviewed and data collected regarding patient demographics, surgical management, preoperative evaluation, perioperative complications, and oncologic outcome.

Results.

Eighty-five patients met eligibility criteria. Preoperative factors that correlated with improved survival were disease-free interval of greater than 12 months (p < 0.01) and residual disease after primary surgery of < 2 cm (p < 0.02). Other preoperative factors evaluated but not found significant included radiographic findings, physical findings, previous histology, stage, grade, previous chemotherapy, prior recurrence, and serum CA-125 level. Optimal resection to < 1 cm residual disease was achieved in 86% of patients who had secondary cytoreduction. Small bowel and colon resection for cytoreduction occurred in 7% and 51% of patients, respectively. Operative complications occurred in 14% and postoperative complications occurred in 21% of patients. The median survival of patients who were optimally cytoreduced to < 1 cm was 30 months compared to 17 months for patients with residual disease ≥ 1 cm (p < 0.05). Operative factors that were evaluated and did not significantly effect survival were location of recurrence, presence of ascites, and extent of recurrence. Recurrent or progressive disease occurred in 75% of patients during follow-up.

Conclusion.

When selecting patients for secondary cytoreduction, the most significant preoperative factors are disease-free interval and success of a prior cytoreductive effort. Once secondary cytoreductive surgery is attempted, the most important factor for improved survival is optimal cytoreduction. Of equal importance is counseling regarding the significant risk for bowel surgery, colostomy, and complications.

Introduction

Annually there are 22,220 new cases of ovarian cancer in the United States and 16,210 deaths [1]. Despite efforts to develop an effective ovarian cancer screening method, 60% of patients still present with advanced (Stages III–IV) disease [2]. In the setting of primary disease, optimal cytoreductive surgery (< 1–2 cm) and platinum-based chemotherapy have been established as the most important components when treating advanced epithelial ovarian cancer [3], [4], [5], [6], [7]. The theoretic benefit from cytoreductive surgery relates to removing large tumor volumes that have a decreased growth fraction and poor blood supply, thereby improving the efficacy of chemotherapeutic agents [8].

Despite achieving clinical remission after completion of initial treatment, most patients (60%) with advanced epithelial ovarian cancer will ultimately develop recurrent disease [9]. The management of recurrent ovarian cancer is less clear than that of primary disease. Available literature regarding secondary cytoreductive surgery is largely composed of retrospective studies and, more recently, several prospective studies [10], [11], [12]. Several studies have concluded that patients with platinum-resistant disease (recurrent disease within 6 months of completing treatment) do not benefit from secondary cytoreductive surgery [13], [14]. Multiple other preoperative and operative factors have been evaluated to help delineate which patients will benefit from secondary cytoreductive surgery, but clear criteria for selection of patients remain unclear. This study was performed to help delineate factors that would improve survival in patients being evaluated for secondary cytoreduction. In addition, surgical procedures and complications are being reported so that appropriate preoperative counseling of patients can occur. Finally, from these patients for whom cytoreduction is determined to be beneficial, we hope to determine which operative factors influence survival.

Section snippets

Materials and methods

Institutional review board approval was obtained prior to initiating the study. Patients who underwent cytoreduction for recurrent ovarian cancer were identified from our gynecologic oncology surgical database for the period 1988–2004. Selection criteria for secondary cytoreductive surgery during the study interval included a disease-free interval ≥ 6 months, a Gynecologic Oncology Group performance status ≤ 2, radiographic and physical exam findings of an isolated site of recurrence, and absence

Results

During the study period, 85 patients met eligibility criteria. The mean age was 61 years (range 35–87 years). Most patients were Caucasian (96%) and the mean body mass index was 24.6 kg/m2 (range 19–46 kg/m2). Comorbid medical conditions such as hypertension, diabetes, and coronary artery disease were present in 35% of patients. In our population, a personal history of breast and uterine cancer was reported in 10% and 5% of patients, respectively. Twenty percent of patients reported a family

Conclusion

A consensus regarding the management of recurrent epithelial ovarian cancer, especially the role of secondary cytoreductive surgery, has yet to be reached. Much of the research is retrospective in nature and limited to small series [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25], [26], [27], [28], [29], [30].

More recently, several prospective studies have evaluated factors influencing survival in patients undergoing secondary cytoreductive surgery further clarifying and

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