A contemporary analysis of the ability of preoperative serum CA-125 to predict primary cytoreductive outcome in patients with advanced ovarian, tubal and peritoneal carcinoma

Abstract

Objective

We previously reported that preoperative CA-125 may predict primary cytoreductive outcome in patients with stage III ovarian carcinoma (OC). The objective of this study was to perform a contemporary analysis of the ability of CA-125 to predict cytoreductive outcome in advanced OC since our programmatic change in surgical approach that currently incorporates the utilization of extensive upper abdominal procedures, as needed, to achieve maximal cytoreduction.

Methods

We reviewed the records of all patients with advanced ovarian, tubal or peritoneal carcinoma who underwent primary cytoreduction at our institution between 1/01 and 4/05.

Results

The study cohort included 277 patients. Primary disease sites were: ovary, 232 (84%); tubal, 9 (3%); and peritoneum, 36 (13%). Stages were: IIIA, 6 (2%); IIIB, 12 (4%); IIIC, 215 (78%); and IV, 44 (16%). Tumor grades were: grade 1, 6 (2%); grade 2, 30 (11%); grade 3, 233 (84%), and undifferentiated, 8 (3%). Cytoreductive outcomes were: no gross residual disease (RD), 68 (25%); ≤ 1 cm RD, 153 (55%); and > cm RD, 56 (20%). There was no threshold CA-125 level that accurately predicted cytoreductive outcome. However, with CA-125 values > 500 U/mL, 50% (57/113) of patients required extensive upper abdominal surgery to achieve RD ≤ 1 cm, compared to 27% (25/93) for those with CA-125 < 500 U/mL (P = 0.001).

Conclusion

Following our change in surgical paradigm that the incorporated extensive upper abdominal procedures to attain optimal debulking, preoperative CA-125 did not predict the primary cytoreductive outcome of patients with advanced ovarian, tubal, or peritoneal carcinoma. However, with a preoperative CA-125 > 500 U/mL, extensive upper abdominal procedures were necessary in 50% of cases to achieve residual disease ≤ 1 cm. These data may be useful as part of preoperative surgical counseling and planning.

Introduction

At the time of diagnosis, approximately 70% of women with ovarian cancer will have advanced-stage disease [1]. Currently, the standard management for advanced-stage epithelial ovarian cancer is attempted optimal surgical cytoreduction followed by platinum and taxane combination chemotherapy. Several studies have demonstrated that optimal primary cytoreduction improves survival in patients of ovarian cancer [2], [3], [4], [5], [6]. However, suboptimal cytoreduction confers no survival advantage and can increase morbidity as compared to delaying attempts at cytoreduction and treating with initial chemotherapy. Therefore, over the past two decades, significant research has focused on developing accurate and reliable preoperative models and strategies for predicting whether or not optimal cytoreduction can be accomplished. Computed tomography (CT) scans and preoperative CA-125 levels have been the two most studied preoperative modalities for predicting cytoreductive outcome.

In 2000, we reported that preoperative serum CA-125 may predict primary cytoreductive outcome in patients with stage III ovarian carcinoma [7]. Subsequent to that publication, however, we initiated a programmatic change in our primary surgical approach to advanced gynecologic malignancies using a more comprehensive debulking of upper abdominal disease [8]. The use of extensive upper abdominal procedures has led to a significantly increased rate of optimal primary cytoreduction, with improved progression-free and overall survival [8], [9].

The purpose of this study was to re-analyze the ability of preoperative CA-125 to predict primary cytoreductive outcome in patients with advanced ovarian, tubal, or primary peritoneal carcinoma since the incorporation of extensive upper abdominal procedures into our surgical armamentarium.