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Primary surgical therapy of ovarian cancer: How much and when
GYNECOLOGIC
ONCOLOGY
40, 195-200 (1991)
Primary Surgical Therapy of Ovarian Cancer: How Much and When MARK E. POTTER,M.D., EDWARDE. PARTRIDGE, M.D., KENNETHD. HATCH, M.D., SENG-JAWSOONG, Ph.D., J. MAX AUSTIN, M.D., ANDHUGH M. SHINGLETON, M.D. Division
of Gynecologic
Oncology,
University
of Alabama,
Birmingham,
Alabama 35294, and Southern Gynecologic
Oncology,
PC
Received June 27, 1989
From July 1975 through December1985, 328 patients with ovarian malignancieswere treated. Of these, 302 had epithelial invasivemalignanciesand constitutethe study group. The impact of the operative procedure,findings, and subsequenttreatment is evaluated. Patients who underwent extensivedebulking proceduressuch as bowel resectionand peritonealstripping did not have improved survival comparedwith those patients who did not undergo these proceduresand yet had residual diseaseremaining (P = 0.7 and P = 0.34). Reoperatingpatients felt to be unresectableat the time of referral did not increasesurvival over reoperatingpatients after an attempt at chemotherapeutic reduction (p = 0.34). 0 1991 Academic press,
whether survival was influenced by the timing of the surgical intervention, the extent of the procedures, and the operative findings. MATERIALS AND METHODS
From July 1975 to December 1985, 328 patients with ovarian tumors were.treated at the Division of Gynecologic Oncology, University of Alabama at Birmingham, or Southern Gynecologic Oncology, PC. Three hundred two of these patients had invasive epithelial malignancies and constituted the study group. Patients’ charts were retrospectively evaluated with regard to stage, tumor INTRODUCTION grade, histologic subtype, subsequent treatment utilized, The obstetrician/gynecologist often sees patients for and survival. Staging is based on that described by the the evaluation and treatment of ovarian malignancies. International Federation of Obstetricians and GynecolSince Griffiths’ initial report, the volume of disease left ogists (FIGO). Additionally, two groups of patients were at completion of the primary surgical procedure has been evaluated in a modified fashion. These two subtypes were related to patient survival [l]. Griffith, however, cau- stage II clinical and stage III microscopic. Stage II clinical tioned that this may be a factor of the tumor aggressive- patients had ovarian adhesions to the pelvic sidewall or ness rather than the expertise of the surgeon. It has been surrounding pelvic structures without pathologic involvesuggested that all patients with pelvic massesbe referred ment (current FIG0 stage I). Stage III microscopic pato a gynecologic oncologist to optimally reduce the tumor tients had microscopic involvement in the abdominal cavburden should bowel resection and/or other radical pro- ity or retroperitoneal nodes only. Patients with borderline cedures be necessary [2,3]. In addition the gynecologic malignancy were excluded from evaluation. Operative oncologist is well trained in the staging procedures nec- summaries were utilized to estimate the volume of residessary. The impact of the radical resection, including peri- ual disease and number of disease foci present at the toneal stripping techniques and bowel resections, upon completion of primary surgery, as well as the extent of improved patient survival has not been well defined. Oc- surgical resection performed. Survival curves were calcasionally an ovarian malignancy may be discovered at culated in the method of Kaplan and Maier and differences in survival curves calculated by the log rank (conthe time of laparotomy for an apparent benign indication. servative) method. A stepwise proportional hazards linear The obstetrician/gynecologist is faced with the dilemma module was utilized to evaluate confounding factors. as to whether to complete the procedure to the best of her or his abilities or to refer the patient for reoperation. The patients in this study were treated for ovarian epiRESULTS thelial malignancies at the Division of Gynecologic Oncology, University of Alabama at Birmingham, or through General characteristics of 302 evaluable patients are Southern Gynecologic Oncology, PC, to determine listed in Table 1. Survival by stage is noted in Fig. 1. Of IIIC.
195 0090-8258191 $1.50 Copyright 0 1991 by Academic Press. Inc. All rights of reproduction in any form reserved.
196
POTTER ET AL.
TABLE 1 Characteristics of Patients Treated Stage I II III IV Grade I II III Unknown Histology Serous Mutinous Endometrioid Clear cell Mixed/undifferentiated
20.5% 25.5% 47.7% 6.3% 22.2% 21.9% 40.2% 15.7% 68.2% 8.3% 7.3% 3.6% 12.6%
special note, patients with only adhesions to the pelvic sidewall or pelvic organs without pathologic confirmation of extension (stage II clinical) had survivals similar to those of patients with “stage I” disease. Also of note, however, is that patients with pathologic involvement (FIG0 state II) of the pelvic organs had survivals similar to those of patients with only microscopic involvement outside of the pelvis (stage III microscopic).
One hundred sixty-three patients with stage III and IV disease were treated. Utilizing the stepwise proportional hazards linear model a positive influence upon survival was noted with decreasing age of the patient and decreasing residual disease at the completion of surgery (P = 0.0003 and P = 0.0382, respectively). The influence of residual disease upon patient survival is graphically demonstrated in Fig. 2. Improving survival is achieved in gradual gradations of volume of residual disease, not by leaps and bounds. Hence there is no magic volume of residual disease that portends a better prognosis. Extensive debulking procedures as manifested by peritoneal stripping techniques or bowel resections demonstrated no improvement in survival (Fig. 3). Despite extensive debulking efforts, patients who had bowel resections to achieve no residual disease fared no better than patients who still had residual disease at completion of surgery and yet did not undergo bowel resection (Fig. 4). Forty-three percent of the patients underwent operative intervention by gynecologic oncologists, with 57% having their initial surgical intervention performed by nongynecologic oncologists. Of note this was not of any significant impact in the stepwise logistical model and did not influence volume of residual disease at completion of surgery in this study. Patients with stage III and IV disease were treated with
%
o N=62
-1 -II
-II -111 -Iv
l
\
Cllnkrl Path IIIMkro Gross
N==l6
N=10
FIG. 1. Survival related to stage I vs II clinical P = 0.81; II pathologic vs III microscopic, P = 0.88; II clinical vs III microscopic, P = 0.14; all others, P < 0.05.
PRIMARY
SURGICAL THERAPY
OF OVARlAN
197
CANCER
90-
60.
70.
60 F E 5k-l.
5 z
40 -
30
20 .
-+ N=44
10. N=22
\ 2
1
4
3
survival
N=34
5
7
6
6
9
in Years
FIG. 2. Survival of stage III and IV patients as related to residual disease.
-+Perltoneal
Stripplng
-NoPeritonealStripping 60 .
-Bowel
Resection
70
60 P I f
50.
t 40
30
20
\
10
N=24 1
2
3
4 SurvivaI
5
6
7
6
9
in Years
FIG. 3. Survival of stage III and IV patients related to radicalness of procedure (bowel vs others, P < 0.002).
198
POTTER ET AL.
-No
Rerldurl
-No
Rerldual -Bowel Resection
-+
Residual - Bowel ResectIon Not Done
N=30 N=107
Survival in Years
FIG. 4. Survival of stage III and IV patients as a function of bowel resection and residual disease (no residual vs others, P < 0.008; bowel vs residual, P = 0.55).
platinum-based chemotherapy, other combination chemotherapy, or Alkeran. Survival was not significantly influenced by treatment modality. Median survivals for patients treated with Cytoxan and &platinum (CP); Cytoxan, Adriamycin, and c&platinum (CAP); Cytoxan and Adriamycin (CA); and alkylating agents were 2.3, 3.5, 2.7, and 2.9 years, respectively (P = 0.35). The distribution of residual disease by treatment modality was not shown to be significant (P = 0.191). Twenty-one patients with stage III or IV disease were referred for what was thought to be unresectable carcinoma. Nine patients underwent immediate reoperation and debulking followed by chemotherapy. The other 12 patients underwent chemotherapy first and then subsequent debulking efforts. Survival in both groups were similar as demonstrated in Fig. 5 (P = 0.34). DISCUSSION Many factors influencing survival have been previously evaluated in patients with epithelial ovarian malignancies. The importance of stage and patient age is confirmed in the current series. Maximal operative intervention has been advocated since Griffith initially described the relationship of survival to residual disease after initial operation [ 11. Although the percentage of patients optimally
debulked varies with the series from 18 to 64%, referral to a gynecologic oncologist who can perform radical procedures such as bowel resection and/or peritoneal stripping has been advocated [2,3]. Additionally, patients may be suboptimally staged when the disease is confined to the pelvis. Variable rates of lymph node metastasis have been described in early-stage disease [4-61, confirming the need to adequately evaluate the areas of potential metastases histologically. In the current series, patients were classified as stage II clinical if the tumor was adherent to the pelvic sidewall, even without evidence of pathologic invasion of the tumor capsule. Prior to the most recent FIG0 staging recommendations these patients would have been classified as stage II disease but are now classified as stage I disease. This group of patients in fact has a survival similar to that of patients with freely mobile stage I tumors (Fig. 1). This appears to validate the recent FIG0 change implying that these patients can be treated in a similar fashion. Further studies may add additional insight into this area. Regarding the necessity of evaluation of the upper abdomen in patients with obvious extraovarian pelvic disease, two groups are compared. Patients with gross extraovarian involvement confined to the pelvis (stage II pathologic) were compared to those patients found to
PRIMARY
SURGICAL THERAPY
OF OVARIAN
199
CANCER
-Primary
Rw~wrtbn
-Po81
Chomothorrpy RooPontbn
1
2
3
4 Sunl*rl
FIG.
5.
Inoperable
5
6
7
6
9
In Ywrr
referral patients and the impact of early reoperation (P = 0.34).
have microscopic upper abdominal disease only (stage III quired a bowel resection to achieve such had survival microscopic) (Fig. 1). Although certainly staged differ- similar to that of patients who had residual disease reently the impact of accurate staging upon survival of this maining at the completion of their surgery. This would subset of patients is not demonstrated in this series (P imply that tumor biology is as important as the skill of = 0.70). All patients in these two groups were treated the surgeon. Twenty-one patients referred after laparotomy elsewith chemotherapy. Assuming systemic chemotherapy where underwent reoperation. Patients treated with sevwill be offered as the treatment of choice in these patients, eral courses of chemotherapy prior to debulking survived this would imply that in the presence of obvious extraovarian disease, evaluation for microscopic evaluation in as well as those debulked prior to chemotherapy. Althe upper abdomen is not mandatory in choosing ther- though up to 67% of patients so referred can be optimally apeutic modalities. Certainly for accuracy of staging full debulked [2], no benefit was apparent in this series to evaluation of the upper abdomen histologically is nec- reoperating immediately. Furthermore it has been suggested by some authors that patients who have only a essary. In patients with stage III and IV disease the prognostic partial response should not undergo a debulking proceimportance of age and volume of residual disease at com- dure at all, as survival is not improved with further surgery pletion of initial surgery is again underscored. It should [7,8]. The current series would imply that immediate opbe stressed, however, that there is a gradual improvement eration and neoadjuvant therapy followed by surgical dein survival with decreasing volume of residual disease, bulking are equally efficacious. Unfortunately we are unand not a magic cutoff of volume of disease that clearly able to clarify whether any surgical procedures, in fact, improves prognosis. Extensive debulking procedures in- will improve survival in patients referred because of an cluding bowel resection and peritoneal stripping have “inoperable” cancer. Surgery continues to be an integral part of the evalubeen advocated [2,3]. The benefit of such radical procedures, however, has not been demonstrated in pro- ation and treatment of ovarian cancer. Results of the spective randomized series. In the current series the uti- current study would question the role of uniform bowel lization of bowel resection and radical techniques to resection, especially when residual disease remains at the reduce the tumor burden did not improve survival. Spe- completion of the operative procedure. A role certainly cifically, patients with no gross residual disease who re- exists for bowel resection in the relief of obstructive symp-
200
POTTER ET AL.
toms. Diligent attempts, short of bowel resection, to remove the bulk of the tumor metastases, even if reducing the volume of residual disease by a mere centimeter, may influence survival. Initial chemotherapy and initial surgical debulking appear equally efficacious in those patients referred for “inoperable” ovarian cancer. Further studies may define the optimal timing of surgical intervention in these patients. Additional surgical staging of patients with grossly positive stage II disease does not appear to influence therapeutic decisions as survival in these patients is identical to survival of patients who have only microscopic upper abdominal disease. REFERENCES 1. Griffiths, C. T., Parker, L. M., Fuller, A. F., Jr. Role of cytoreductive surgical treatment in the management of advanced ovarian cancer, Cancer Treat. Rep. 63, 235-240 (1979). 2. Hacker, N. F., Berek, J. S., Lagasse, L. D., Nieherg, R. K., and
Elashoff, R. M. Primary cytoreductive surgery for epithelial ovarian cancer, Obstet. Gynecol. 61, 413-420 (1983). 3. Delgado, G., Oram, D. H., and Petrilii, E. S. Stage III epithelial ovarian cancer: The role of maximal surgical reduction, Gynecol. Oncol. 18, 293-298 (1984). 4, Knapp, R. C., and Friedman, E. A Aortic lymph node metastases in early ovarian cancer, Amer. J. Obstet. Gynecol. 119, 1013-1017 (1974). 5. Burghardt, E., Pickel, H., Lahousen, M., and Stettner, H. Pelvic lymphadenectomy in operative treatment of ovarian cancer, Amer. J. Obstet. Gynecol. 155, 315-319 (1986). ‘. Chen, S. S., and Lee, L. Incidence of para-aortic and pelvic lymph node metastases in opithelial carcinoma of the ovary, Gynecol Oncol. 16, 95-100 (1983). I. Raju, K. S., McKinna, J. A., Barker, G. H., Wiltshaw, E., and Jones, J. M. Second-look operations in the planned management of advanced ovarian carcinoma, Amer. J. Obstet. Gynecol. 144, 650654 (1982). 8, Wiltshaw, E., Raju, K. S., and Dawson, I. The role of cytoreductive surgery in advanced carcinoma of the ovary: An analysis of primary and second surgery, Brit. .I. Obstet. Gynecol. 92, 522-527 (1985).
ONCOLOGY
40, 195-200 (1991)
Primary Surgical Therapy of Ovarian Cancer: How Much and When MARK E. POTTER,M.D., EDWARDE. PARTRIDGE, M.D., KENNETHD. HATCH, M.D., SENG-JAWSOONG, Ph.D., J. MAX AUSTIN, M.D., ANDHUGH M. SHINGLETON, M.D. Division
of Gynecologic
Oncology,
University
of Alabama,
Birmingham,
Alabama 35294, and Southern Gynecologic
Oncology,
PC
Received June 27, 1989
From July 1975 through December1985, 328 patients with ovarian malignancieswere treated. Of these, 302 had epithelial invasivemalignanciesand constitutethe study group. The impact of the operative procedure,findings, and subsequenttreatment is evaluated. Patients who underwent extensivedebulking proceduressuch as bowel resectionand peritonealstripping did not have improved survival comparedwith those patients who did not undergo these proceduresand yet had residual diseaseremaining (P = 0.7 and P = 0.34). Reoperatingpatients felt to be unresectableat the time of referral did not increasesurvival over reoperatingpatients after an attempt at chemotherapeutic reduction (p = 0.34). 0 1991 Academic press,
whether survival was influenced by the timing of the surgical intervention, the extent of the procedures, and the operative findings. MATERIALS AND METHODS
From July 1975 to December 1985, 328 patients with ovarian tumors were.treated at the Division of Gynecologic Oncology, University of Alabama at Birmingham, or Southern Gynecologic Oncology, PC. Three hundred two of these patients had invasive epithelial malignancies and constituted the study group. Patients’ charts were retrospectively evaluated with regard to stage, tumor INTRODUCTION grade, histologic subtype, subsequent treatment utilized, The obstetrician/gynecologist often sees patients for and survival. Staging is based on that described by the the evaluation and treatment of ovarian malignancies. International Federation of Obstetricians and GynecolSince Griffiths’ initial report, the volume of disease left ogists (FIGO). Additionally, two groups of patients were at completion of the primary surgical procedure has been evaluated in a modified fashion. These two subtypes were related to patient survival [l]. Griffith, however, cau- stage II clinical and stage III microscopic. Stage II clinical tioned that this may be a factor of the tumor aggressive- patients had ovarian adhesions to the pelvic sidewall or ness rather than the expertise of the surgeon. It has been surrounding pelvic structures without pathologic involvesuggested that all patients with pelvic massesbe referred ment (current FIG0 stage I). Stage III microscopic pato a gynecologic oncologist to optimally reduce the tumor tients had microscopic involvement in the abdominal cavburden should bowel resection and/or other radical pro- ity or retroperitoneal nodes only. Patients with borderline cedures be necessary [2,3]. In addition the gynecologic malignancy were excluded from evaluation. Operative oncologist is well trained in the staging procedures nec- summaries were utilized to estimate the volume of residessary. The impact of the radical resection, including peri- ual disease and number of disease foci present at the toneal stripping techniques and bowel resections, upon completion of primary surgery, as well as the extent of improved patient survival has not been well defined. Oc- surgical resection performed. Survival curves were calcasionally an ovarian malignancy may be discovered at culated in the method of Kaplan and Maier and differences in survival curves calculated by the log rank (conthe time of laparotomy for an apparent benign indication. servative) method. A stepwise proportional hazards linear The obstetrician/gynecologist is faced with the dilemma module was utilized to evaluate confounding factors. as to whether to complete the procedure to the best of her or his abilities or to refer the patient for reoperation. The patients in this study were treated for ovarian epiRESULTS thelial malignancies at the Division of Gynecologic Oncology, University of Alabama at Birmingham, or through General characteristics of 302 evaluable patients are Southern Gynecologic Oncology, PC, to determine listed in Table 1. Survival by stage is noted in Fig. 1. Of IIIC.
195 0090-8258191 $1.50 Copyright 0 1991 by Academic Press. Inc. All rights of reproduction in any form reserved.
196
POTTER ET AL.
TABLE 1 Characteristics of Patients Treated Stage I II III IV Grade I II III Unknown Histology Serous Mutinous Endometrioid Clear cell Mixed/undifferentiated
20.5% 25.5% 47.7% 6.3% 22.2% 21.9% 40.2% 15.7% 68.2% 8.3% 7.3% 3.6% 12.6%
special note, patients with only adhesions to the pelvic sidewall or pelvic organs without pathologic confirmation of extension (stage II clinical) had survivals similar to those of patients with “stage I” disease. Also of note, however, is that patients with pathologic involvement (FIG0 state II) of the pelvic organs had survivals similar to those of patients with only microscopic involvement outside of the pelvis (stage III microscopic).
One hundred sixty-three patients with stage III and IV disease were treated. Utilizing the stepwise proportional hazards linear model a positive influence upon survival was noted with decreasing age of the patient and decreasing residual disease at the completion of surgery (P = 0.0003 and P = 0.0382, respectively). The influence of residual disease upon patient survival is graphically demonstrated in Fig. 2. Improving survival is achieved in gradual gradations of volume of residual disease, not by leaps and bounds. Hence there is no magic volume of residual disease that portends a better prognosis. Extensive debulking procedures as manifested by peritoneal stripping techniques or bowel resections demonstrated no improvement in survival (Fig. 3). Despite extensive debulking efforts, patients who had bowel resections to achieve no residual disease fared no better than patients who still had residual disease at completion of surgery and yet did not undergo bowel resection (Fig. 4). Forty-three percent of the patients underwent operative intervention by gynecologic oncologists, with 57% having their initial surgical intervention performed by nongynecologic oncologists. Of note this was not of any significant impact in the stepwise logistical model and did not influence volume of residual disease at completion of surgery in this study. Patients with stage III and IV disease were treated with
%
o N=62
-1 -II
-II -111 -Iv
l
\
Cllnkrl Path IIIMkro Gross
N==l6
N=10
FIG. 1. Survival related to stage I vs II clinical P = 0.81; II pathologic vs III microscopic, P = 0.88; II clinical vs III microscopic, P = 0.14; all others, P < 0.05.
PRIMARY
SURGICAL THERAPY
OF OVARlAN
197
CANCER
90-
60.
70.
60 F E 5k-l.
5 z
40 -
30
20 .
-+ N=44
10. N=22
\ 2
1
4
3
survival
N=34
5
7
6
6
9
in Years
FIG. 2. Survival of stage III and IV patients as related to residual disease.
-+Perltoneal
Stripplng
-NoPeritonealStripping 60 .
-Bowel
Resection
70
60 P I f
50.
t 40
30
20
\
10
N=24 1
2
3
4 SurvivaI
5
6
7
6
9
in Years
FIG. 3. Survival of stage III and IV patients related to radicalness of procedure (bowel vs others, P < 0.002).
198
POTTER ET AL.
-No
Rerldurl
-No
Rerldual -Bowel Resection
-+
Residual - Bowel ResectIon Not Done
N=30 N=107
Survival in Years
FIG. 4. Survival of stage III and IV patients as a function of bowel resection and residual disease (no residual vs others, P < 0.008; bowel vs residual, P = 0.55).
platinum-based chemotherapy, other combination chemotherapy, or Alkeran. Survival was not significantly influenced by treatment modality. Median survivals for patients treated with Cytoxan and &platinum (CP); Cytoxan, Adriamycin, and c&platinum (CAP); Cytoxan and Adriamycin (CA); and alkylating agents were 2.3, 3.5, 2.7, and 2.9 years, respectively (P = 0.35). The distribution of residual disease by treatment modality was not shown to be significant (P = 0.191). Twenty-one patients with stage III or IV disease were referred for what was thought to be unresectable carcinoma. Nine patients underwent immediate reoperation and debulking followed by chemotherapy. The other 12 patients underwent chemotherapy first and then subsequent debulking efforts. Survival in both groups were similar as demonstrated in Fig. 5 (P = 0.34). DISCUSSION Many factors influencing survival have been previously evaluated in patients with epithelial ovarian malignancies. The importance of stage and patient age is confirmed in the current series. Maximal operative intervention has been advocated since Griffith initially described the relationship of survival to residual disease after initial operation [ 11. Although the percentage of patients optimally
debulked varies with the series from 18 to 64%, referral to a gynecologic oncologist who can perform radical procedures such as bowel resection and/or peritoneal stripping has been advocated [2,3]. Additionally, patients may be suboptimally staged when the disease is confined to the pelvis. Variable rates of lymph node metastasis have been described in early-stage disease [4-61, confirming the need to adequately evaluate the areas of potential metastases histologically. In the current series, patients were classified as stage II clinical if the tumor was adherent to the pelvic sidewall, even without evidence of pathologic invasion of the tumor capsule. Prior to the most recent FIG0 staging recommendations these patients would have been classified as stage II disease but are now classified as stage I disease. This group of patients in fact has a survival similar to that of patients with freely mobile stage I tumors (Fig. 1). This appears to validate the recent FIG0 change implying that these patients can be treated in a similar fashion. Further studies may add additional insight into this area. Regarding the necessity of evaluation of the upper abdomen in patients with obvious extraovarian pelvic disease, two groups are compared. Patients with gross extraovarian involvement confined to the pelvis (stage II pathologic) were compared to those patients found to
PRIMARY
SURGICAL THERAPY
OF OVARIAN
199
CANCER
-Primary
Rw~wrtbn
-Po81
Chomothorrpy RooPontbn
1
2
3
4 Sunl*rl
FIG.
5.
Inoperable
5
6
7
6
9
In Ywrr
referral patients and the impact of early reoperation (P = 0.34).
have microscopic upper abdominal disease only (stage III quired a bowel resection to achieve such had survival microscopic) (Fig. 1). Although certainly staged differ- similar to that of patients who had residual disease reently the impact of accurate staging upon survival of this maining at the completion of their surgery. This would subset of patients is not demonstrated in this series (P imply that tumor biology is as important as the skill of = 0.70). All patients in these two groups were treated the surgeon. Twenty-one patients referred after laparotomy elsewith chemotherapy. Assuming systemic chemotherapy where underwent reoperation. Patients treated with sevwill be offered as the treatment of choice in these patients, eral courses of chemotherapy prior to debulking survived this would imply that in the presence of obvious extraovarian disease, evaluation for microscopic evaluation in as well as those debulked prior to chemotherapy. Althe upper abdomen is not mandatory in choosing ther- though up to 67% of patients so referred can be optimally apeutic modalities. Certainly for accuracy of staging full debulked [2], no benefit was apparent in this series to evaluation of the upper abdomen histologically is nec- reoperating immediately. Furthermore it has been suggested by some authors that patients who have only a essary. In patients with stage III and IV disease the prognostic partial response should not undergo a debulking proceimportance of age and volume of residual disease at com- dure at all, as survival is not improved with further surgery pletion of initial surgery is again underscored. It should [7,8]. The current series would imply that immediate opbe stressed, however, that there is a gradual improvement eration and neoadjuvant therapy followed by surgical dein survival with decreasing volume of residual disease, bulking are equally efficacious. Unfortunately we are unand not a magic cutoff of volume of disease that clearly able to clarify whether any surgical procedures, in fact, improves prognosis. Extensive debulking procedures in- will improve survival in patients referred because of an cluding bowel resection and peritoneal stripping have “inoperable” cancer. Surgery continues to be an integral part of the evalubeen advocated [2,3]. The benefit of such radical procedures, however, has not been demonstrated in pro- ation and treatment of ovarian cancer. Results of the spective randomized series. In the current series the uti- current study would question the role of uniform bowel lization of bowel resection and radical techniques to resection, especially when residual disease remains at the reduce the tumor burden did not improve survival. Spe- completion of the operative procedure. A role certainly cifically, patients with no gross residual disease who re- exists for bowel resection in the relief of obstructive symp-
200
POTTER ET AL.
toms. Diligent attempts, short of bowel resection, to remove the bulk of the tumor metastases, even if reducing the volume of residual disease by a mere centimeter, may influence survival. Initial chemotherapy and initial surgical debulking appear equally efficacious in those patients referred for “inoperable” ovarian cancer. Further studies may define the optimal timing of surgical intervention in these patients. Additional surgical staging of patients with grossly positive stage II disease does not appear to influence therapeutic decisions as survival in these patients is identical to survival of patients who have only microscopic upper abdominal disease. REFERENCES 1. Griffiths, C. T., Parker, L. M., Fuller, A. F., Jr. Role of cytoreductive surgical treatment in the management of advanced ovarian cancer, Cancer Treat. Rep. 63, 235-240 (1979). 2. Hacker, N. F., Berek, J. S., Lagasse, L. D., Nieherg, R. K., and
Elashoff, R. M. Primary cytoreductive surgery for epithelial ovarian cancer, Obstet. Gynecol. 61, 413-420 (1983). 3. Delgado, G., Oram, D. H., and Petrilii, E. S. Stage III epithelial ovarian cancer: The role of maximal surgical reduction, Gynecol. Oncol. 18, 293-298 (1984). 4, Knapp, R. C., and Friedman, E. A Aortic lymph node metastases in early ovarian cancer, Amer. J. Obstet. Gynecol. 119, 1013-1017 (1974). 5. Burghardt, E., Pickel, H., Lahousen, M., and Stettner, H. Pelvic lymphadenectomy in operative treatment of ovarian cancer, Amer. J. Obstet. Gynecol. 155, 315-319 (1986). ‘. Chen, S. S., and Lee, L. Incidence of para-aortic and pelvic lymph node metastases in opithelial carcinoma of the ovary, Gynecol Oncol. 16, 95-100 (1983). I. Raju, K. S., McKinna, J. A., Barker, G. H., Wiltshaw, E., and Jones, J. M. Second-look operations in the planned management of advanced ovarian carcinoma, Amer. J. Obstet. Gynecol. 144, 650654 (1982). 8, Wiltshaw, E., Raju, K. S., and Dawson, I. The role of cytoreductive surgery in advanced carcinoma of the ovary: An analysis of primary and second surgery, Brit. .I. Obstet. Gynecol. 92, 522-527 (1985).