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Conservative surgery in high-risk epithelial ovarian carcinoma
Conservative Surgery in High-Risk Epithelial Ovarian Carcinoma Francesco Raspagliesi,
MD,*
Rosanna Fontanelli,
MD,*
Dario Paladini,
MD, t
and
Emanuela M. di Re, MD* Background: In epithelial ovarian cancer, conservative surgery has mainly been adopted for stage Ia disease. The aim of this study is to report on a conservative surgieai approach used in selected young patients with ovarian cancer who would usually undergo radical operations. Study Design: From 1980 through 1994, 10 patients with invasive epithelial ovarian cancer and with high-grade or limited extraovarian disease were treated with conservative surgery. The mean age was 22.7 years. The stage was Ia grade 3 ha 2 patients, Ic in 2 patients, IIIa in 2 patients, and IIIc in 4 patients. Eight patients were given adjuvant therapy (radiotherapy in 1 and chemotherapy in 7). Results: All patients were alive and disease-free at a median followup time of 70 months (range 24-138 months). Nine patients were menstruating regularly and three had become pregnant. Conclusions: It seems that in selected patients, conservative operations can be used beyond the worldwide'accepted criterion of stage Ia. This concept deserves additional investigation in larger series. (J Am Coll Surg 1997;185:457-460. © 1997 by the American College of Surgeons) In epithelial ovarian cancer, patients with earlystage disease can e x p e r i e n c e 5-year survival rates as high as 6 2 - 8 5 % (90-95% for stage Ia) (1, 2). Because 41% of these w o m e n are < 35 years old (3), preserving fertility a n d childbearing capacity by sparing the uterus a n d the contralateral ovary (conservative surgery) is desirable in this group o f patients. Several authors have shown the feasibility a n d the safety of such a conservative surgical app r o a c h in this set o f patients (2-6), provided that close followup can be fulfilled. Such fertilitypreserving operations, however, rarely have b e e n r e p o r t e d for y o u n g patients with m o r e advanced Received March 19; 1997; RevisedMay 27, 1997; AcceptedMay 28, 1997. From the *Departmentof GynecologicSurgical Oncology,Istituto Nazionale Tumori, Milan; and the tDepartmentof Gynecologyand Obstetrics, UniversityFedericoII of Naples, Naples, Italy. Correspondence address: Francesco Raspagliesi, MD, Oncologia Chirurgica Ginecologica,Istituto NazionaleTumori, Via Venezian, 1-20133, Milan, Italy. © 1997 by the AmericanCollegeof Surgeons Published by ElsevierScienceInc.
457
stages b u t with very limited spread of disease (7). The aim of this study is to r e p o r t the e x p e r i e n c e of the Istituto T u m o r i of Milan in conservatively treating selected y o u n g patients with ovarian cancer, who would usually u n d e r g o radical operations. We also have critically reevaluated the criteria used until now to select patients for conservative therapy. Methods
At the Istituto T u m o r i of Milan, criteria identifying patients eligible for conservative operations include: y o u n g age, strong desire for future pregnancies, disease probably localized to one ovary (stage Ia), a n d opportunity for close tbllowup. In a preoperative counseling session, these w o m e n are i n f o r m e d of the possible benefits a n d risks o f conservative surgery a n d sign a c o n s e n t form. T h e decision to p e r f o r m a conservative p r o c e d u r e is t h e n reevaluated twice: intraoperatively, on the basis of inspection o f the abdominopelvic cavity and the result f r o m the frozen-section examination on biopsy of the contralateral ovary a n d of suspect peritoneal lesions; a n d after the operation, on the basis o f the final pathology report: In our unit, a conservative o p e r a t i o n includes the following: peritoneal washings for cytology, resection of the ovarian pedicle o f the previously r e m o v e d g o n a d at its proximal (caval or renal) end, wedge resection or biopsies of the contralateral ovary for histologic examination on frozen section, paraaortic a n d pelvic l y m p h a d e n e c t o m y , infracolic o m e n t e c t o m y , a p p e n d e c t o m y , multiple peritoneal biopsies, a n d e n d o m e t r i a l curettage. From 1980 t h r o u g h 1994, 75 patients were admitted to our unit for restaging laparotomy and conservative operations. All o f t h e m h a d h a d incomplete operation elsewhere (unilateral oophorectomy). Before operation, review o f the slides f r o m the previous intervention c o n f i r m e d the diagnosis of invasive epithelial ovarian c a n c e r in all cases. Patients with ovarian tumors of low malign a n t potential have b e e n the subject o f a f o r m e r r e p o r t (8) and were e x c l u d e d f r o m this analysis. Similarly, operative data on the paraaortic and ISSN 1072-7515/97/$17.00 PII S1072-7515(97)00066-5
458 J AM C O L L
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NOVEMBER
1997
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185:457-460
T a b l e 1. B r e a k d o w n o f t h e 10 P a t i e n t s Patient no.
Age (y)
1 2 3 4 5 6 7 8 9 10
21 16 36 23 25 24 17 20 21 26
Histology Muc Undiff Muc Serous Serous Serous Muc Muc Serous Serous
Grade
Stage
Neoplastic localization
Chemotherapy
Menses
pregnancy
Followup, mo
3 3 2 2 2 1 2 1 1 1
Ia Ia Ic Ic 4IIa IIIa IIIc IIIc IIIc IIIc
O n e ovary O n e ovary Peritoneal cytology Peritoneal cytology Peritoneum Peritoneum 1 Paraaortic n o d e 1 External + 1 internal iliac n o d e 10bturator node 1 External iliac node
No No CP CP CAP CP CP CP RT CP
Yes Yes Yes Yes No Yes Yes Yes Yes Yes
Yes None None None -None None None Yes Yes (miscarriage)
138 78 66 66 54 24 42 42 114 76
Muc, mucinous; Undiff, undifferentiated; CP, cisplatinum + cyclophosphamide; CAP, cisplatinum + adriamycin + cyclophosphamide; RT, radiotherapy.
pelvic lymphadenectomy as staging procedure for ovarian cancer have been reported previously (3). Intraoperatively, the conservative approach had to be converted into a standard one (with removal of the contralateral ovary and the uterus) in 31 patients when unexpected neoplastic localizations were found on the contralateral ovary or the peritoneum. Three other patients were reoperated on for diffuse microscopic lymph node or peritoneal involvement, revealed in the final pathology report. In this study, grade and cell type were not considered in the decision-making process. Of the remaining 41 patients who underwent conservative operations, 31 were confirmed to have low-risk (stage Ia, grade 1-2) lesions, and 10 patients were considered high risk because of grading (grade 3) or because of very limited extraovarian spread. Limited extraovarian spread included one of the following: positive peritoneal washing, single embolic lymph node metastasis, or single peritoneal metastatic focus (Table 1). These 10 patients, treated with conservative operations even though they did n o t meet the commonly accepted requirements for this type of approach, represent the subject of this report. Adjuvant therapy was given in stage Ic-III patients. At the end of treatment, all patients underwent strict followup consisting of clinical checkups with CA 125 evaluation at 3-month intervals for 2 years, and then every 6 months. A pelvic ultrasonographic scan was required every 6 months. Results
The mean age of the patients was 22.7 years (range, 16-36 years). The histology was serous carcinoma in five patients, mucinous carcinoma in four patients, and undifferentiated in another patient. Four patients were grad e 1, four were grade 2, and two were grade 3. The International Feder-
ation of Gynecology and Obstetrics stage is shown in Table 1. In all cases, the decision to adhere to the conservative strategy was made with the patient on the basis of the final pathology report. Unexpected findings included grade 3 tumors (patients 1 and 2), positive peritoneal cytology in the absence o f other localizations (patients 3 and 4), single peritoneal metastases (patients 5 and 6), and lymph node metastases (patients 7-10). No additional therapy was given to patients with stage ia, grade 3 tumors. The other eight patients (stages Ic-IIIa-IIIc) underwent adjuvant therapy. Seven patients underwent adjuvant cisplatin-based combination chemotherapy (cisplatin 90 m g / m 2 and cyclophosphamide 600 m g / m 2 every 21 days for five courses; or cisplatin 50 m g / m 2, adriamycin 50 m g / m ,2 and cyclophosphamide 600 m g / m 2 every 21 days for five courses). One stage IIIc patient, treated in 1975, underwent external megavoltage irradiation with shielding of the conserved ovary. At the end of the adjuvant treatment, all seven patients underwent a second-look procedure (laparotomic in four, laparoscopic in three), which showed no persistent or recurrent disease. All patients were alive and disease-free at 24-138 months of followup (median 70 months). No recurrence has been observed in this set of patients to date. Nine patients were regularly menstruating, and three of the five patients who tried to conceive did so. Of the three pregnancies, two went to term and one was a miscarriage. The patient who did not regain menstruation was the only one who received adriamycin (patient no. 5). Discussion
The idea of a conservative approach to early ovarian cancer dates to 1933 (1). Since then, several
Raspagliesi
e t al
studies have shown that a conservative surgical a p p r o a c h to early ovarian cancer is feasible witho u t an u n d u e increase in the relapse rate a n d l o n g t e r m mortality (2-16). Nonetheless, 5-year survival figures for stage Ia range b e t w e e n 65% and 95%. This discrepancy is likely to reflect diff e r e n t surgical staging p r o c e d u r e s rather than real differences in treatment. An aggressive surgical staging p r o c e d u r e allows correct sampling of all peritoneal surfaces a n d m o r e f r e q u e n t disclosure of lymph n o d e or peritoneal subclinical metastases otherwise o v e r l o o k e d in clinical stage I-II cases (14, 17). Additionally, it has b e e n shown that the incidence o f occult bilateral disease in clinical stage I ovarian c a r c i n o m a ranges from 3% to 9% (3, 5, 11, 12, 14). These data d e m o n s t r a t e that t h o r o u g h surgical staging is m a n d a t o r y in patients d e e m e d eligible for conservative operations to ascertain the real pathologic stage (7). A m o n g the criteria used to select the ideal lowrisk patient for a conservative o p e r a t i o n (young age, stage Ia tumor, low grade, and possibility o f close followup), the only o n e that has rarely b e e n challenged is the absence of extraovarian spread (stage Ia), p r o b a b l y because o f the clear separation b e t w e e n early a n d advanced disease. Col o m b o a n d associates (7) r e p o r t e d g o o d results with conservative operations in stage Ia, grade 3 a n d stage Ic patients, a n d c o n c l u d e d their studies by highlighting the basic role played by t h o r o u g h surgical staging in the correct selection o f the true candidates for such an approach. Beginning with the same considerations, we believed that preservation of o n e tumor-free ovary a n d the uterus does n o t a d d to the chances of s u b s e q u e n t peritoneal r e c u r r e n c e in these cases. We d e c i d e d to p e r f o r m the conservative o p e r a t i o n after a t h o r o u g h counseling session in selected patients who are usually c o n s i d e r e d high risk because o f grade 3, positive cytology, or microscopic peritoneal or retroperitoneal involvement. At o u r institution, paraaortic a n d pelvic lympha d e n e c t o m y has b e e n included a m o n g the routine surgical p r o c e d u r e s for ovarian cancer staging since 1970. This has yielded a relatively large numb e r o f patients allotted to stage IIIc o f the International Federation of Gynecology a n d Obstetrics b e c a u s e of r e t r o p e r i t o n e a l lymph n o d e spread associated with scant or absent intraperitoneal 'disease. It has b e e n d e m o n s t r a t e d that the subset o f patients with stage III lesions d u e to retroperitoneal disease experiences 5-year survival rates significantly different from those o f stage III patients with p e r i t o n e a l with or without r e t r o p e r i t o n e a l involvement (3). We d e c i d e d to a d o p t conserva-
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rive p r o c e d u r e s in f o u r such patients because o f y o u n g age a n d c o n s e q u e n t strong desire to retain childbearing capacity. We emphasize that the decision to use the conservative a p p r o a c h was m a d e on the basis of the pathology report, discussed extensively with the patient. The m e d i a n followup time o f 70 m o n t h s (six patients had c o m p l e t e d 5 years and only o n e patient, stage Ilia, h a d < 42 m o n t h s ) a n d the absence o f r e c u r r e n c e s u n d e r l i n e the n e e d for a cautious reappraisal of the c o m m o n l y a c c e p t e d limits o f conservative surgery in ovarian cancer patients. M t h o u g h the prognostic role of lymph n o d e metastasis is still debated, the possibility to preserve fertility in a set of y o u n g patients with tumors at "high risk" for conservative p r o c e d u r e s should be taken into consideration, even t h o u g h only 5 o f the 10 m e n s t r u a t i n g patients a t t e m p t e d conception. In this respect, a n o t h e r p o i n t that deserves investigation is the psychological aspect of the disease, which can b u r d e n the whole reproductive life o f the y o u n g patient long after the e n d Of c h e m o t h e r a p y a n d the second-look p r o c e d u r e t h r o u g h the endless path of followup controls (18). At least in high-risk cases of conservative surgery, it might be well to do the preoperative counseling t o g e t h e r with a psychologist w h o can evaluate the patient a n d h e r familial b a c k g r o u n d . In conclusion, o u r data seem to indicate the possibility, in selected cases, to e x t e n d the b o r d e r s of conservative surgery b e y o n d the worldwide acc e p t e d criterion o f stage Ia. This c o n c e p t deserves further evaluation by m e a n s of controlled clinical trials. References
1. Lynch RC, and Dockerty MB. Spread of uterine and ovarian carcinoma with special reference to role of fallopian tube. 8urg Gynecol Obstet 1945;80:60-65. 2. Kottmeier HL. Surgical management: conservative surgery. In: Gentil F, Junqueira A, eds. UICC Monograph Series No. 11. New York: Springer Verlag; 1968:443-459. 3. di Re F, FontaneUiR, and RaspagliesiF. Pelvicand para aortic lymphadenectomy in cancer of the ovary. Baillieres Clin Obstet G~aecol 1989;3:131-139. 4. Munnel EW. Is conservative therapy ever justified in stage I (Ia) cancer of the ovary?AmJ Obstet Gynecol 1969;103:641653. 5. Williams TJ. Management of ovarian carcinoma in young women. Clin Obstet Gynecol 1976;19:673-682. 6. Piver MS. Multimodality treatment in early ovarian cancer: the U.S. experience. In: Conte PF, Rosco R, Ragni N, Wermoken IB, eds. Multimodal Treatment of Ovarian Cancer. New York: Raven Press; 1989:99-108. 7. Colombo N, Chiari S, Maggioni A, et al. Controversial issues in the management of early epithelial ovarian cancer: conservative surgery and role of adjuvant therapy. GynecolOncol 1994;55:47-51. 8. di Re F, Paladini D, Fontanelli R, et al. Surgical staging for epithelial ovarian tumors of low malignant potential. Int J Gynecol Cancer 1994;4:310-314.
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9. Pikel H, Lahousen M, Stettner H, and Girardi F. The spread of ovarian cancer. Baillieres Clin Obstet Gynaecol 1989;3:312. 10. Di Saia P. Fertility-sparing treatment of patients with ovarian cancer. Compr Ther 1990;16:35-42. 11. Miyazaky T, TomodaY, Ohta M, et al. Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors. Gynecol Oncol 1988;30:329-341. 12. Woodruff JD, and Bie LS. Mucinous tumors of the ovary. Obstet Gynecol 1960;16:699-708. 13. Dembo AJ, and Davy ML. Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol 1990;75: 263-273. 14. Trimbos JB, Schueler A, van de Burg M, et al. Watch and
15, 16~ 17. 18.
wait after careful surgical treatment and staging in welldifferentiated early ovarian cancer. Cancer 1991;67:597602. Menczer J. A trend toward more conservative surgery in gynecologic oncology. Obstet Gyndcol Surv 1996;51:628636. Brown C, HymanJ, Almadrones L, et al. Conservative surgical management of early epithelial ovarian cancer. Proc Annu Meet Am Soc Clin Oncol 1995;14:A766. Rubin SC, and Curtin JP. Surgery for gynecologic malignancies. Curr Opin Oncol 1992;4:923-929. Kornblith AB, Thaler HT, Wong G, et al. Quality of life of women with ovarian cancer. Gynecol Oncol 1995;59:231242.
MD,*
Rosanna Fontanelli,
MD,*
Dario Paladini,
MD, t
and
Emanuela M. di Re, MD* Background: In epithelial ovarian cancer, conservative surgery has mainly been adopted for stage Ia disease. The aim of this study is to report on a conservative surgieai approach used in selected young patients with ovarian cancer who would usually undergo radical operations. Study Design: From 1980 through 1994, 10 patients with invasive epithelial ovarian cancer and with high-grade or limited extraovarian disease were treated with conservative surgery. The mean age was 22.7 years. The stage was Ia grade 3 ha 2 patients, Ic in 2 patients, IIIa in 2 patients, and IIIc in 4 patients. Eight patients were given adjuvant therapy (radiotherapy in 1 and chemotherapy in 7). Results: All patients were alive and disease-free at a median followup time of 70 months (range 24-138 months). Nine patients were menstruating regularly and three had become pregnant. Conclusions: It seems that in selected patients, conservative operations can be used beyond the worldwide'accepted criterion of stage Ia. This concept deserves additional investigation in larger series. (J Am Coll Surg 1997;185:457-460. © 1997 by the American College of Surgeons) In epithelial ovarian cancer, patients with earlystage disease can e x p e r i e n c e 5-year survival rates as high as 6 2 - 8 5 % (90-95% for stage Ia) (1, 2). Because 41% of these w o m e n are < 35 years old (3), preserving fertility a n d childbearing capacity by sparing the uterus a n d the contralateral ovary (conservative surgery) is desirable in this group o f patients. Several authors have shown the feasibility a n d the safety of such a conservative surgical app r o a c h in this set o f patients (2-6), provided that close followup can be fulfilled. Such fertilitypreserving operations, however, rarely have b e e n r e p o r t e d for y o u n g patients with m o r e advanced Received March 19; 1997; RevisedMay 27, 1997; AcceptedMay 28, 1997. From the *Departmentof GynecologicSurgical Oncology,Istituto Nazionale Tumori, Milan; and the tDepartmentof Gynecologyand Obstetrics, UniversityFedericoII of Naples, Naples, Italy. Correspondence address: Francesco Raspagliesi, MD, Oncologia Chirurgica Ginecologica,Istituto NazionaleTumori, Via Venezian, 1-20133, Milan, Italy. © 1997 by the AmericanCollegeof Surgeons Published by ElsevierScienceInc.
457
stages b u t with very limited spread of disease (7). The aim of this study is to r e p o r t the e x p e r i e n c e of the Istituto T u m o r i of Milan in conservatively treating selected y o u n g patients with ovarian cancer, who would usually u n d e r g o radical operations. We also have critically reevaluated the criteria used until now to select patients for conservative therapy. Methods
At the Istituto T u m o r i of Milan, criteria identifying patients eligible for conservative operations include: y o u n g age, strong desire for future pregnancies, disease probably localized to one ovary (stage Ia), a n d opportunity for close tbllowup. In a preoperative counseling session, these w o m e n are i n f o r m e d of the possible benefits a n d risks o f conservative surgery a n d sign a c o n s e n t form. T h e decision to p e r f o r m a conservative p r o c e d u r e is t h e n reevaluated twice: intraoperatively, on the basis of inspection o f the abdominopelvic cavity and the result f r o m the frozen-section examination on biopsy of the contralateral ovary a n d of suspect peritoneal lesions; a n d after the operation, on the basis o f the final pathology report: In our unit, a conservative o p e r a t i o n includes the following: peritoneal washings for cytology, resection of the ovarian pedicle o f the previously r e m o v e d g o n a d at its proximal (caval or renal) end, wedge resection or biopsies of the contralateral ovary for histologic examination on frozen section, paraaortic a n d pelvic l y m p h a d e n e c t o m y , infracolic o m e n t e c t o m y , a p p e n d e c t o m y , multiple peritoneal biopsies, a n d e n d o m e t r i a l curettage. From 1980 t h r o u g h 1994, 75 patients were admitted to our unit for restaging laparotomy and conservative operations. All o f t h e m h a d h a d incomplete operation elsewhere (unilateral oophorectomy). Before operation, review o f the slides f r o m the previous intervention c o n f i r m e d the diagnosis of invasive epithelial ovarian c a n c e r in all cases. Patients with ovarian tumors of low malign a n t potential have b e e n the subject o f a f o r m e r r e p o r t (8) and were e x c l u d e d f r o m this analysis. Similarly, operative data on the paraaortic and ISSN 1072-7515/97/$17.00 PII S1072-7515(97)00066-5
458 J AM C O L L
SURG
NOVEMBER
1997
VOLUME
185:457-460
T a b l e 1. B r e a k d o w n o f t h e 10 P a t i e n t s Patient no.
Age (y)
1 2 3 4 5 6 7 8 9 10
21 16 36 23 25 24 17 20 21 26
Histology Muc Undiff Muc Serous Serous Serous Muc Muc Serous Serous
Grade
Stage
Neoplastic localization
Chemotherapy
Menses
pregnancy
Followup, mo
3 3 2 2 2 1 2 1 1 1
Ia Ia Ic Ic 4IIa IIIa IIIc IIIc IIIc IIIc
O n e ovary O n e ovary Peritoneal cytology Peritoneal cytology Peritoneum Peritoneum 1 Paraaortic n o d e 1 External + 1 internal iliac n o d e 10bturator node 1 External iliac node
No No CP CP CAP CP CP CP RT CP
Yes Yes Yes Yes No Yes Yes Yes Yes Yes
Yes None None None -None None None Yes Yes (miscarriage)
138 78 66 66 54 24 42 42 114 76
Muc, mucinous; Undiff, undifferentiated; CP, cisplatinum + cyclophosphamide; CAP, cisplatinum + adriamycin + cyclophosphamide; RT, radiotherapy.
pelvic lymphadenectomy as staging procedure for ovarian cancer have been reported previously (3). Intraoperatively, the conservative approach had to be converted into a standard one (with removal of the contralateral ovary and the uterus) in 31 patients when unexpected neoplastic localizations were found on the contralateral ovary or the peritoneum. Three other patients were reoperated on for diffuse microscopic lymph node or peritoneal involvement, revealed in the final pathology report. In this study, grade and cell type were not considered in the decision-making process. Of the remaining 41 patients who underwent conservative operations, 31 were confirmed to have low-risk (stage Ia, grade 1-2) lesions, and 10 patients were considered high risk because of grading (grade 3) or because of very limited extraovarian spread. Limited extraovarian spread included one of the following: positive peritoneal washing, single embolic lymph node metastasis, or single peritoneal metastatic focus (Table 1). These 10 patients, treated with conservative operations even though they did n o t meet the commonly accepted requirements for this type of approach, represent the subject of this report. Adjuvant therapy was given in stage Ic-III patients. At the end of treatment, all patients underwent strict followup consisting of clinical checkups with CA 125 evaluation at 3-month intervals for 2 years, and then every 6 months. A pelvic ultrasonographic scan was required every 6 months. Results
The mean age of the patients was 22.7 years (range, 16-36 years). The histology was serous carcinoma in five patients, mucinous carcinoma in four patients, and undifferentiated in another patient. Four patients were grad e 1, four were grade 2, and two were grade 3. The International Feder-
ation of Gynecology and Obstetrics stage is shown in Table 1. In all cases, the decision to adhere to the conservative strategy was made with the patient on the basis of the final pathology report. Unexpected findings included grade 3 tumors (patients 1 and 2), positive peritoneal cytology in the absence o f other localizations (patients 3 and 4), single peritoneal metastases (patients 5 and 6), and lymph node metastases (patients 7-10). No additional therapy was given to patients with stage ia, grade 3 tumors. The other eight patients (stages Ic-IIIa-IIIc) underwent adjuvant therapy. Seven patients underwent adjuvant cisplatin-based combination chemotherapy (cisplatin 90 m g / m 2 and cyclophosphamide 600 m g / m 2 every 21 days for five courses; or cisplatin 50 m g / m 2, adriamycin 50 m g / m ,2 and cyclophosphamide 600 m g / m 2 every 21 days for five courses). One stage IIIc patient, treated in 1975, underwent external megavoltage irradiation with shielding of the conserved ovary. At the end of the adjuvant treatment, all seven patients underwent a second-look procedure (laparotomic in four, laparoscopic in three), which showed no persistent or recurrent disease. All patients were alive and disease-free at 24-138 months of followup (median 70 months). No recurrence has been observed in this set of patients to date. Nine patients were regularly menstruating, and three of the five patients who tried to conceive did so. Of the three pregnancies, two went to term and one was a miscarriage. The patient who did not regain menstruation was the only one who received adriamycin (patient no. 5). Discussion
The idea of a conservative approach to early ovarian cancer dates to 1933 (1). Since then, several
Raspagliesi
e t al
studies have shown that a conservative surgical a p p r o a c h to early ovarian cancer is feasible witho u t an u n d u e increase in the relapse rate a n d l o n g t e r m mortality (2-16). Nonetheless, 5-year survival figures for stage Ia range b e t w e e n 65% and 95%. This discrepancy is likely to reflect diff e r e n t surgical staging p r o c e d u r e s rather than real differences in treatment. An aggressive surgical staging p r o c e d u r e allows correct sampling of all peritoneal surfaces a n d m o r e f r e q u e n t disclosure of lymph n o d e or peritoneal subclinical metastases otherwise o v e r l o o k e d in clinical stage I-II cases (14, 17). Additionally, it has b e e n shown that the incidence o f occult bilateral disease in clinical stage I ovarian c a r c i n o m a ranges from 3% to 9% (3, 5, 11, 12, 14). These data d e m o n s t r a t e that t h o r o u g h surgical staging is m a n d a t o r y in patients d e e m e d eligible for conservative operations to ascertain the real pathologic stage (7). A m o n g the criteria used to select the ideal lowrisk patient for a conservative o p e r a t i o n (young age, stage Ia tumor, low grade, and possibility o f close followup), the only o n e that has rarely b e e n challenged is the absence of extraovarian spread (stage Ia), p r o b a b l y because o f the clear separation b e t w e e n early a n d advanced disease. Col o m b o a n d associates (7) r e p o r t e d g o o d results with conservative operations in stage Ia, grade 3 a n d stage Ic patients, a n d c o n c l u d e d their studies by highlighting the basic role played by t h o r o u g h surgical staging in the correct selection o f the true candidates for such an approach. Beginning with the same considerations, we believed that preservation of o n e tumor-free ovary a n d the uterus does n o t a d d to the chances of s u b s e q u e n t peritoneal r e c u r r e n c e in these cases. We d e c i d e d to p e r f o r m the conservative o p e r a t i o n after a t h o r o u g h counseling session in selected patients who are usually c o n s i d e r e d high risk because o f grade 3, positive cytology, or microscopic peritoneal or retroperitoneal involvement. At o u r institution, paraaortic a n d pelvic lympha d e n e c t o m y has b e e n included a m o n g the routine surgical p r o c e d u r e s for ovarian cancer staging since 1970. This has yielded a relatively large numb e r o f patients allotted to stage IIIc o f the International Federation of Gynecology a n d Obstetrics b e c a u s e of r e t r o p e r i t o n e a l lymph n o d e spread associated with scant or absent intraperitoneal 'disease. It has b e e n d e m o n s t r a t e d that the subset o f patients with stage III lesions d u e to retroperitoneal disease experiences 5-year survival rates significantly different from those o f stage III patients with p e r i t o n e a l with or without r e t r o p e r i t o n e a l involvement (3). We d e c i d e d to a d o p t conserva-
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rive p r o c e d u r e s in f o u r such patients because o f y o u n g age a n d c o n s e q u e n t strong desire to retain childbearing capacity. We emphasize that the decision to use the conservative a p p r o a c h was m a d e on the basis of the pathology report, discussed extensively with the patient. The m e d i a n followup time o f 70 m o n t h s (six patients had c o m p l e t e d 5 years and only o n e patient, stage Ilia, h a d < 42 m o n t h s ) a n d the absence o f r e c u r r e n c e s u n d e r l i n e the n e e d for a cautious reappraisal of the c o m m o n l y a c c e p t e d limits o f conservative surgery in ovarian cancer patients. M t h o u g h the prognostic role of lymph n o d e metastasis is still debated, the possibility to preserve fertility in a set of y o u n g patients with tumors at "high risk" for conservative p r o c e d u r e s should be taken into consideration, even t h o u g h only 5 o f the 10 m e n s t r u a t i n g patients a t t e m p t e d conception. In this respect, a n o t h e r p o i n t that deserves investigation is the psychological aspect of the disease, which can b u r d e n the whole reproductive life o f the y o u n g patient long after the e n d Of c h e m o t h e r a p y a n d the second-look p r o c e d u r e t h r o u g h the endless path of followup controls (18). At least in high-risk cases of conservative surgery, it might be well to do the preoperative counseling t o g e t h e r with a psychologist w h o can evaluate the patient a n d h e r familial b a c k g r o u n d . In conclusion, o u r data seem to indicate the possibility, in selected cases, to e x t e n d the b o r d e r s of conservative surgery b e y o n d the worldwide acc e p t e d criterion o f stage Ia. This c o n c e p t deserves further evaluation by m e a n s of controlled clinical trials. References
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