Surgical treatment of ovarian cancer

GYNECOLOGIC

ONCOLOGY

Surgical

1,

370-378

(1973)

Treatment

of Ovarian FRCS,

C. N. HUDSON,

Cancer

FRCOC

AND

M. Department

CHIR,

FRCS,

FRCOG

of Obstetrics and Gynecology, Royal Hospital of St. Bartholomew, West Smithfield, London EClA 7BE, England Accepted

October

26, 1973

Initial experience with 25 personal cases operated on by a technique of radical oophorectomy is reported. There was one operative death and two fistulae, but no other significant morbidity. The majority of patients were treated with radical postoperative chemotherapy, with early encouraging results. It is suggested that this type of surgery in combination with chemotherapy merits a wider appraisal in the management of those patients with ovarian cancer which has extended locally or metastasised within the pelvis. It may have a place in the management of a few patients with early Stage 3 disease.

Ovarian cancer provides the principle challenge for gynaecological oncology today, nearly as many women dying annually of this disease as of cancer of the body of the uterus and cervix together. Surgery has long been the mainstay of treatment and the standard operation bilateral oophorectomy, with the addition, where appropriate, of total hysterectomy. More extensive procedures such as exenteration have not been favoured (Drukker and Hodgkinson 1971). [2]. Predictably the results of surgical treatment have been uniformly depressing whenever the operation has visibly failed to remove all the tumour, and rather less than half the cases which come to operation permit macroscopic extirpation by the standard technique. When, however, the only visible disease remaining after operation is within the pelvis, postoperative radiotherapy can improve the salvage to some 25% at 3 yr [l]. RADICAL

OOPHORECTOMY

In 1968 a technique of radical oophorectomy was described, with the objective of increasing the operability of malignant tumours fixed in the pelvis [4]. This consists essentially of a retroperitoneal mobilization of the pouch of Douglas as “false capsule” to a fixed tumor, or one which has produced seedling deposits in the cul-de-sac. The uterus is usually removed retrograde in continuity with the tumour mass and the rectum must be mobilized from the hollow of the sacrum (Fig. 1). The dissection is thus completed under direct vision, if necessary incising adherent rectum or other viscera (Figs. 2,3). The rectum is later allowed to fall back into the pelvis denuded of peritoneum. Some of the earlier operations were performed “piece-meal” as the technique evolved, and sometimes it was not necessary to remove both halves 370 Copyright 0 1973 by Academic Press, Inc. All rights of reproduction in any form reserved.

371

/

PERITONEAL %APSULE”

UTERUS, -OVARIAN PEDICLE

.RECTO-SIGMOID VAGINA /

a of the pouch of Douglas if one side was demonstrably clear. The presence of metastatic deposits in the cul-de-sac was regarded as an indication for the procedure rather than the reverse. Justification for an operation of this nature will depend not only on evidence of relative freedom from increased morbidity and improved survival, but also on evidence that adjuvant measures such as radiotherapy or chemotherapy will not produce equally good survival with a lesser surgical procedure. The quality of life of patients with terminal ovarian cancer is very poor and the value of any treatment must be assessed against this background. RESULTS This report is on the first 25 patients operated on by the radical oophorectomy technique, between 1966 and 1972 inclusive. In the majority additional anticancer therapy was used because it was considered naive to suppose that apparently complete surgery could actually eradicate disease with extracapsular extension or even with visible metastases within the surgical field. Chemotherapy was generally used as first choice for such additional treatment, in the belief that cytotoxic drugs had the best chance of success when the viable tumour cell population had been reduced to an absolute minimum by surgery. When visible pelvic disease, usually in lymph nodes close to the major vessels, remainded in spite of surgery, radiotherapy was requested. In addition, radiotherapy was sometimes selected for patients with an endometrioid cancer, or a disgerminoma because these tumours are possibly more radiosensitive; it was used for others also if they were emotionally unsuited to the rigours of intensive chemotherapy. Table I sets out the distribution of operations extended to involve adjacent

372

FIG. la and b. Radical from the rectum.

HUDSON

o6phorectomy.

Pouch

AND

CHIR

of Douglas

and uterus

elevated

before

separation

viscera. In all cases, except one, continuity of these organs has been restored by anastomosis or suture, the exception being the ureter from a nonfunctioning kidney which was deliberately tied off.’ With increasing experience sharp dissection of tumour from the anterior rectal wall has more easily been carried out without entering the lumen of the bowel. In two instances longitudinally incised wounds in the rectum have been sewn up transversely but have leaked, whereas restorative resections with anastomosis have not. On reflection, this is probably due to formation of “dogs’ ears” at the lateral ends of the hole which cause tension on the suture line. It is, therefore, likely to be better to widen a longitudinal ellipse so that this does not occur. Moreover, if the rectal wall has been cut through obliquely the part nearest the hole is 1 In a recent case not included, restored at a later date.

Hartmann’s

operation

has been

performed.

Continuity

may

be

RADICAL

06PHORECTOMY

373

a

likely to be dangerously thin, and it may then be better to resect a short length of rectum rather than repair the hole. Intrapelvic resection and rectal anastomosis (IPRRA) is comparatively easy under these circumstances, as there is a very adequate length of sigmoid which can be brought down without tension. There is no question of high inferior mesentery ligation or anxiety about the adequacy of the blood supply. The lateral ligaments of the rectum do not as a rule require to be divided and the only difficulty is likely to stem from the fact that the inferior stump does not have a serous coat. It is recognised that intraperitoneal anastomoses do have an inherent risk of leakage and if the vagina is open the chance of fistula is increased [5], Hartmann’s operation is a useful alternative if the operator is unhappy about anastomosis, which can be carried out as a second stage if appropriate. One patient only had had a previous full course of radiotherapy following an incomplete unilateral oophorectomy for an endometrioid cancer some 3 yr earlier: The pelvic mass, referred as an inoperable recurrence, turned out to be fresh recrudescence in the remaining ovary and a macroscopically complete operation was possible including the fibrous stump of the previously incomplete operation. In general, however, previous radiotherapy would render the technique very hazardous, and must carry a high risk of fistula formation. In three other cases the abdomen had previously been opened and either closed as inoperable or an incomplete operation had been carried out. One of these turned out to be benign-an infected but grossly adherent “dermoid”

HUDSON

FI( :.2a. Disc high rectovaginal

of rectum fistula.

remaining

attached

AND

CHIR

to the underside

of tumor.

(b) Colpogram

shoa iing

RADICAL

375

OePHORECTOMY

TABLE I RADICAL O~PHORECTOMY 1965-1972 FIG0 STAGES II, Histology (25 cases)

Papilliferous Mutinous Disgerminoma

TNM Stages (23) cases

III,

IV

9 1 1

Endometrioid Undifferentiated Benign

NX

...... Nl.. .... N2 ......

T3...... 5 T4 . . . . 18

MO Mla Mlb Mlc

17 1 5

(15 with proven metastases) Additional (22 cases) Survival (23 cases)

.......... .......... .......... ..........

8 4 2

10 8 5 0

therapy NIL

3

DXR

7

Chemotherapy

Operative death .. .. ... . .. Died of disease. . .. ... . .. Died intercurrent disease . . . Survive disease free . . . . . . .

. 1 . 4 . 2 . 16

.

12 (1 death)

(DXR - 3, Chemotherapy (includes drug death)

- 1)

RADICAL OhPHORECTOMY 25 CASES 1965-1972 Other

organs

incised

Bladder Small bowel Rectosigmoid

5 3 6

Fistulae Rectal

2

or partly

(IPRRA

resected

Ureter Appendix 3)

3 1

Urinary

Nil

cyst. One other tumour appeared malignant at operation, but on section turned out to be a rather unusual multilocular endometrial cyst. During the retrograde removal of the uterus the uterine vessels on the “blind side” sometimes had to be divided without clamping, only to be secured later when the mass had been removed. On two occasions the occasions the ureter was unintentionally servered at this time, but reimplantation into the bladder presented no difficulties. If the bladder dome is opened or partly removed, the resulting access to the ureteric orifices can be used to advantage for the passage of a probe or catheter if identification of the ureter is difficult. Mercuric chloride 1: 1000 has often been used for irrigation of both pelvis and wound before closure. For a time distilled water was used but has since been abandoned. MORBIDITY There has been one operative death and two rectovaginal wise the immediate morbidity has been low and problems

fistulae. Otherof ileus and ob-

FIG. 3. Sagittal diagrams showing the position at laparotomy of a fixed ovarian tumour and the amount of mobility that can be achieved without gross disruption of the tumour bed by retrorectal mobilization.

RADICAL

OijPHORECTOMY

377

struction have been rather less than might have been expected, perhaps because efficient drainage has been maintained by suction through the vault. The one operation death occurred at 4 wk from secondary haemorrhage, the cause being malignant glands infiltrating the common iliac vessels. This patient had also developed a rectovaginal fistula. One other patient developed a high rectovaginal fistula, illustrated by the colpogram (Fig. 2b) at the site whence a disc of rectum had been excised (Fig. 2a). She made an otherwise good recovery and the fistula was closed by high colpocleisis at 3 mo without colostomy, but unfortunately she died some months later following a stroke. In the case of another patient, who died free of disease at 3.5 yr, death was from infection secondary to marrow failure after continuous oral 1Cyclophosphamide - in fact a drug therapy death. The original stage of this patient had been T3 Nx Mla but at postmortem examination there was no evidence of residual malignancy. PROGRESS

OF DISEASE

There have been four deaths from disease so far, in each instance occurring within a few months of operation. Three of these were associated with extensive retroperitoneal lymph node involvement. This leaves 16 survivors whose span ranges from 6 yr to 1 yr, including one patient who also had carcinoma of the endometrium and who is under treatment for a local recurrence 2 yr from operation. This series should be regarded as no more than a pilot study, but the results perhaps should be viewed in the perspective of the natural history of the disease. All these tumours were locally infiltrative (Tg and T,- 21/23) or frankly metastatic (Nl, N2, Mla, or Mlb13/23) and the 2-yr survival of such a group is most unlikely to be better than 30%. Although in several of these patients the histology showed a well-differentiated papilliferous tumour, in each there were proven metastases. In every instance all major metastases were removed, but in several, small scattered deposits no more than a millimeter or two in diameter, were seen in the upper abdomen. It seems that radical chemotherapy usually with Cyclophosphamide, has frequently been able to contain residual tumour foci of this size. DISCUSSION Although this operation has surprisingly little morbidity directly attributable to the procedure, and, in particular, avoids the micturition problems of the Wertheim’s operation, there could be little justification for it if the adjuvant therapy alone, or in association with a lesser operation, can be shown to do as well. This point is rather difficult to establish, as published work on chemotherapy in ovarian cancer chiefly concerns patients with widespread, inoperable or recurrent disease. Radical chemotherapy has not commonly been used as first line adjuvant therapy in Stage 2b disease. A retrospective study in St. Bartholomew’s Hospital recording the survival of patients with locally extensive disease but no extrapelvic metastases (Stage 2b), shows that of those treated by incomplete surgery and radiotherapy nearly all whose disease was not apparently controlled by radiotherapy died within 2 yr,

378

HUDSON

AND

CHIR

regardless of subsequent chemotherapy; the results of radiotherapy are comparable to those of Dalley [61. The inference from the early behaviour of these 23 patients treated by radical oophorectomy is that better results may be forthcoming. It may well be that the early use of radical chemotherapy could be responsible for this trend, but it is logical to suggest that the use of an operative procedure which tends to facilitate maximum tumour clearance is an important factor. It is now possible to recognize limitations and guide lines on the use of this operation, which have hitherto not been clear [3]. The retrorectal mobilization is acceptable for a test of operability but incisions into neighbouring visceraare not justified unless there is to be macroscopic clearance of local disease. The main difficulty will lie with retroperitoneal lymph nodes in the pelvis, particularly those near the great vessels. When this type of spread is suspected preoperative lymphography may be helpful. With the above exception the technique described is not difficult and it would seem that it merits wider appraisal. ACKNOWLEDGMENTS These operations were mainly performed at St. Bartholomew’s and Hackney grateful to the Theatre staffs who accepted the often unannounced escalations am grateful to colleagues in the Association of Obstetricians and Gynaecologist Metropolitan Region who have referred cases for treatment.

Hospitals-I am without demur. I of the North East

REFERENCES 1. 2. 3. 4. 5. 6.

DALLEY, V. Proc. Roy. SOC. Med. 62, 359 (1969). DRUXKER, B. H. AND HODGKINSON, C. P. Amer. J, Ohtet. Gynae. FEROZE, R. M. Ann. Roy. Coil. Surg. Eng. 48, 139 (1971). HUDSON, C. N.]. Ohm. Cynaec. Brit. Cwlth. 75, 1155 (1968). HUDSON, C. N. Ann. Roy. Coil. Surg. Eng. 46,35 (1970). HUDSON, C. N. Unpublished observation (1972).

109,832

(1971).