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The place of surgery in ovarian cancer
Current
OBSTETRICS& GYNAECOLOGY 1 Mini-symposium: Ovarian carcinoma
The place of surgery in ovarian cancer
C. N. Hudson
-
For many years ovarian cancer was the most neglected of gynaecological malignancies, even though it accounted for more deaths than cancers of the cervix and uterine body combined. This scenario did not change until the advent of anti-cancer chemotherapy. Chemotherapy of solid tumours really began within the field of gynaecology with the successful treatment of gestational choriocarcinema’ and single agent alkylating agent therapy was subsequently established as having a place in the management of the common forms of epithelial ovarian cancer, with a useful response in just over one-third of cases and with a small number (approximately 7%) of long survivors amongst women who would otherwise certainly have died of disease.’ Received surgical wisdom at the time was that in all forms of cancer attempted extirpation of metastatic disease was of little value except when metastases were locally contained within an extended operating field. A technique for the application of this principle to locally extensive ovarian cancer was described by the author in 196K3 In this procedure involved peritoneum of the pouch of Douglas is removed in continuity with the ovarian tumour mass and uterus by a retrograde hysterectomy technique devised by Dellepiane.4 It was Griffith2 who pioneered the concept that extending surgical endeavour into the upper abdomen in cases of disseminated ovarian cancer could increase the response rate to systemic chemotherapy even if macroscopic clearance was not attainable. He showed that the response to chemotherapy could be related to the volume of residual disease and, more particularly, to the volume of individual discrete tumour Professor C. Bartholomew’s Currenr rr, 1994
Ohsferrrcs Lonptmn
N. Hudson, Department Hospital, West Smithfield, and
Gynaecology LIK Ltd
Group
(1994)
4. l-13
masses, and went on to demonstrate within the limitations of an uncontrolled study that patients following surgery who went onto chemotherapy with low volume residual disease following surgery did as well as those with an equivalent volume of residual disease left behind with conventional local genital surgery. This gave rise to the unhappy neologism ‘debulking’, which was unfortunately widely adopted as a term to give professional ‘respectability’ to otherwise inappropriate and sub-optimal surgery. It was never Griffiths’ intention to condone sub-total removal of pelvic disease in those cases when complete clearance or optimal cytoreduction of upper abdominal disease is technically possible.” Since the introduction of single alkylating agent therapy two important changes have occurred, namely the use of combination drug therapy and the introduction of cisplatin and allied compounds. Cisplatin was shown to be effective as second line therapy as it was capable of producing a second remission after relapse on first line alkylating agent chemotherapy.’ This led to a vogue for second-look surgery in ovarian cancer.
Second-look surgery
Second-look laparotomy was utilised in the case of incompletely removed ovarian cancer after apparently successful chemotherapy in order to assess whether microscopic foci of (inevaluable) persistent disease could be detected. If the original operation had succeeded in leaving no residual tumour greater than 1 cm and, in addition, had succeeded in removing all macroscopic disease from within the pelvis then there was no clinical or imaging technique which could be used to
of Gynaecology, St. London EClA 7BE, UK
7
8
CURRENT OBSTETRICS AND GYNAECOLOGY
detect either persistent disease or relapse in its early stages. Secondly, postoperative residual disease, ultrasonic or CT scan or disease in the pelvis initially assessable by rectal examination might so regress under radical chemotherapy that it subsequently became inevaluable. For these two indications secondlook surgery was proposed at a set interval after completion of primary radical chemotherapy to assess the completeness of the response and to determine whether any second line therapy might be indicated.* As platinum compounds came to be incorporated in first line chemotherapy for ovarian cancer, and as data in support of whole abdominal radiotherapy for patients relapsing after chemotherapy were not forthcoming, most programmes for diagnostic second-look surgery in advanced disease have now faded. The role of diagnostic second-look surgery in early disease has been extremely controversial. Serial laparoscopy after apparently complete surgery for localised disease is invasive and of limited value. Metastases may appear several years after primary surgery for early ovarian cancer and the practicality and propriety of repeated laparoscopy is now seriously questioned, the alternative being treatment on clinical relapse.
inappropriate over-treatment, so that in such cases the operator should not hesitate to accept a possible need for a two-stage procedure should mature consideration demand it. In general terms, tumours of low potential malignancy carry a much better prognosis. Even with documented extra-ovarian disease (which may or may not be metastatic) 5-year survival is of the order of 85%.” Russell” has attempted to sub-divide the grades of tumours of low potential malignancy and there is little doubt that cloning occurs so that the invasive potential may change with time and also differ between the primary tumour and metastases. In practice, the malignant potential of ovarian neoplasia is a spectrum with a continuum from total benignity to most aggressive malignancy. Histological ‘cut-offs’ are therefore somewhat artificial and the clinician’s response should be based upon a total case assessment, including age and histological type and evidence of spread. Clinicians should be aware that pathologists’ use of the term ‘no evidence of invasion’ has rather different biological implications than when the same term is used, for instance, when describing lesions of the cervix. The importance of conference and dialogue with pathologists cannot be over-emphasised.
Germ cell turnours Combination chemotherapy has revolutionised the management of germ cell tumours. This has extended beyond non-gestational choriocarcinoma to all forms of malignant teratoma, dysgerminoma and yolk sac tumour (endodermal sinus tumour). These have been so successfully treated potential for preservation of reproductive function now exists.’ The role of radical surgery in the management of germ cell tumours has therefore required complete revision in the light of the above developments. Radical surgery has no place in the primary treatment of germ cell malignancy in the early reproductive years. Secondary transformation of a hitherto benign cystic teratoma is however probably the commonest germ cell tumour, lo but occurs in an older age group. This tumour is relatively unresponsive to adjuvant therapy, either radiotherapy or chemotherapy, and surgery will remain the mainstay of treatment; there is little room for conservatism. Likewise, the association of gonadal dysgenasis with malignant germ cell tumour formation needs to be remembered and bilateral gonadectomy of streak gonads may be indicated in any individual who has, even in a mosaic, a Y chromosome. Other pathological considerations
Even in apparent stage III disease, a more conservative approach may be warranted in the case of ovarian tumours of low potential malignancy. The younger the woman the greater the chance of
Well-differentiated epithelial ovarian tumours Some localised invasive tumours may be considered of low grade and well-differentiated on both architectural and cytological grounds. If, after a properly executed staging procedure, there is no clinical or pathological evidence of extra-ovarian spread then the possibility of more conservative management exists.
Preservation of the reproductive potential
Removal of the uterus in the case of localised ovarian cancer is more time honoured than of substantial benefit. Although interconnecting lymphatics between the ovaries have been described across the fundus of the uterus there are no data to suggest that the uterus is a site for early and selective metastases. There is, however, the possibility of concurrent, and unsuspected, endometrial malignancy. The prevalence of such a coincidence is low, of the order of 3%13 and almost always in association with endometrioid ovarian tumours. If uterine conservation is therefore contemplated, it should be with a view to reproduction rather than mere altruism, and the endometrium should be assessed for occult malignancy. Histological material should be available in association with either transvaginal ultrasonic scanning of the uterus or hysteroscopy.
THE PLACE OF SURGERY
Preservation of the contralateral ovary
Ovarian cancer is commonly bilateral and the propriety of ovarian conservation needs careful examination. Cancer may occur in the second ovary, either synchronously or metachronously. It is the possible presence of a metastasis in an apparently normal contralateral ovary that is a matter for concern when a conservative approach is being contemplated. Although not ideal, a full thickness slice biopsy would detect most occult metastases. It is essential that the best tubal surgery techniques are employed with minimal handling, meticulous haemostasis and the use of very fine nonirritant sutures for the repair as adnexal surgery carries with it a risk of infertility. In addition, there are histopathological considerations. The risk of bilateral disease is increased with high grade poorly differentiated malignancy, and with certain histological types. Bilateral disease is encountered more commonly with serous papillary tumours; rather less so with endometrioid tumours and least with mutinous. At or after the menopause all ovarian neoplasia, whether benign or malignant, should be treated by bilateral oophorectomy. In the reproductive years conservation of a contralateral ovary should only be permitted for serous papillary tumours until further reproductive ambitions have been achieved. At that stage residual oophorectomy should be carried out. In the case of endometrioid tumours. after reproduction is complete hysterectomy and residual oophorectomy should probably be carried out so that hormone replacement therapy can be used without qualm. There is small risk in retaining the ovary after reproduction in a woman who has had a mutinous tumour and the desirability for its removal at the time of, say, sterilization should be discussed with her.
Gonadal stromal tumours These uncommon tumours are another group in which the histopathology is particularly germane to the surgical procedures undertaken. There are two classes: the granulosa/theca cell tumours and the Sertoli/Leydig cell tumours, correctly referred to as androblastoma. Any of these tumours may be malignant. The theta cell component is almost always benign and tumours consisting only of theta cells (thecoma) are, therefore, most unlikely to be malignant. Granulosa cell tumours should always be regarded as potentially malignant, but the actual biological behaviour is very difficult to predict from the histological appearance. A precise diagnosis is important; gonadal stromal tumours tend to recur sporadically at extended intervals and, therefore, aggressive management of individual metastases may well be rewarding, including repeated surgery. Data on chemotherapy are largely anecdotal and such therapy may only be indicated once surgery has
IN OVARIAN
CANCER
9
failed to contain the disease. Metastases have been reported up to 25 years from the removal of the primary tumour.
Other tumours Secondary carcinoma, metastatic from some extragenital, perhaps unsuspected, primary is perhaps the most common remaining form of malignancy to be encountered by a surgeon. If such is encountered there is little theoretical benefit to be obtained from removal of the uterus, but both ovaries should certainly be removed, even if the second does not appear to the naked eye to be involved. The management of an unsuspected gastrointestinal primary needs some consideration. The presence of ovarian metastases ipso facto means that the disease has spread beyond the embrace of local surgery. Limited resection of a colonic cancer with anastomosis is certainly justified as prophylaxis against the development of obstruction. If an unsuspected tumour were found in the upper rectum it would be poor palliation to raise a colostomy in the absence of symptoms. Proper restorative resection and/or radiotherapy would be the correct management. If the unsuspected primary is found to be in the stomach there is a case for at least a partial gastrectomy, even if there is spread elsewhere in the abdomen. Useful remissions with metastatic disease may be obtained with appropriate chemotherapy. Malignancy of the pancreas is not really suited to ad hoc surgical extirpation. Early carcinoma of the breast can spread to the ovaries even when a miniature primary is not clinically detectable. This is a source of great diagnostic anxiety to the clinician and the pathologist and an expectant approach using tamoxifen in the post menopausal patient may be indicated.
Other rare tumours The ovary exhibits a greater range of neoplastic types than any other organ in the body. The non-functional stromal tumour, the fibroma, is of importance as a source of diagnostic confusion to the unwary clinician as it may present with pleural effusion and ascites (Meig’s syndrome). There is no other tumour which is as hard to the touch as a true fibroma. Sarcomatous change is described. A benign cystadenofibroma to the naked eye often looks extraordinarily sinister - the histological diagnosis may come as a relief. Brenner tumours are nearly as hard as the pure fibroma; they are often found in association with mutinous cysts and the epithelial element within the tumour may rarely be malignant.
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CURRENT OBSTETRICS AND GYNAECOLOGY
The surgical management of established invasive epithelial ovarian cancer Staging Staging is critical to the informed management of early stage disease. Piver et alI4 has shown how common inadvertent understaging is, particularly with reference to the inferior aspects of the diaphragm. A search for unsuspected macroscopic disease must be thorough and include the pouch of Douglas, the para-colic gutters and the sub-phrenic spaces. Obviously anything suspicious should be biopsied, including peritoneal ‘sand’. In the absence of any visible lesion the role of biopsy is controversial. Blind biopsies of the diaphragm have punctured the adjacent pleura with unwelcome sequelae. Of greater value is probably the use of exfoliative cytology using a brush or spatula. The first histological evidence of extra-ovarian spread may be from the infracolic omentum, particularly if adjacent to the tumour. Any small puddle of peritoneal fluid should always be aspirated for cytology. Only when this is absent is it necessary to instil fluid for washings.
Lymph node sampling Because of the free anastomosis within the broad ligament, lymph drainage from the ovary is in two directions. The gonadal vessels in both sexes arise in close proximity to the renal vessels and indeed on the left side the gonadal vein drains into the left renal vein. The lumbar lymph node station, therefore, is the group of nodes which lie in the angle between the renal vessels and the aorta and inferior vena cava respectively. Access to these is not easy and is probably best obtained by reflecting the caecum and ascending colon medially and upwards. Even so access to nodes in the left reno-caval angle may be difficult. There is little point in sampling other lumbar lymph nodes below this level, unless they are clinically involved, as they do not constitute a primary station for the ovary. The alternative primary station for lymph drainage is the group of the inter-iliac nodes laying beneath and behind the external iliac vein, above the obturator nerve and anterior to the internal iliac vessels. Anatomically these are parietal nodes of the posterior iliac chain and are often referred to by surgeons as the ‘obturator nodes’. It must remain a matter for individual decision in the absence of clinically positive nodes to assess whether a finding of an occult nodal deposit would alter the treatment plan. In stage I cases the incidence of occult involved nodes is of the order of 10%.15 The information is of obvious prognostic significance, but treatment moderation on the basis of that finding alone may not justify the potential morbidity of extensive retroperitoneal surgery.
Incision It is prudent for all elective operations for any pelvic tumour, which could conceivably be malignant ovarian, to be carried out through a vertical incision. The situation will always arise, however, that the diagnosis of unsuspected ovarian malignancy will arise unexpectedly during a laparotomy which has commenced with a standard Pfannenstiel incision. What advice may be given to the surgeon who finds him/herself in this situation? Transverse incisions can be beyond the lateral margin of the rectus abdominis muscles, provided, of course, that the external oblique muscle is split in the direction of its fibres and not across the inguinal ligament. This will give enhanced exposure below the umbilicus and for added upper abdominal access one or other rectus abdominis muscle may safely be divided transversely with the inferior epigastric vessels secured. If there is no clinically obvious disease above the infracolic omentum careful upper abdominal staging is still required. With the aid of good retraction cytological smears of the diaphragm and liver surface may be obtained and inspection of the subphrenic areas may be achieved through the transverse incision with the aid of a laparoscope without, of course, a distending pneumoperitoneum. The liver may be displaced by hand sufficient to allow the inspection. Definitive surgery Strictly localised disease In the post reproductive era the minimum extent of surgery should be bilateral salpingo-oophorectomy. In young patients, however, every effort should be made to conserve at least part of one ovary pending full evaluation of the histology. It is better to accept the need for re-operation than to have over-treated a young woman by an instant decision to clear the pelvis. Should an ovarian cyst have been removed by cyst enucleation (with ovarian conservation) and subsequent histological examination have shown invasive cancer, the obvious advice would be for the affected ovary to be removed as a definitive procedure even if conservation of the uterus and other ovary were contemplated. l6 Hysterectomy adds little to the magnitude of surgery for an ovarian cyst in a post menopausal woman and may, indeed, facilitate clean removal and give exposure to allow safe separation from the adjacent ureter. There is no evidence that removal of the uterus confers any inherent therapeutic advantage in strictly localised ovarian disease. Intermediate disease Extension or metastases beyond the ovary but within the pelvis constitutes stage II disease. Clinically it is virtually impossible to tell whether dense adhesions
THE PLACE OF SURGERY IN OVARIAN CANCER
are due to infiltration or inflammation. In the most recent FIG0 classification if there is no histological evidence of capsular penetration, such cases remain in stage I. In practice, however, the surgical procedure for the removal of fixed ovarian tumours is the same whether the fixity is due to infiltration or inflammatory adhesion. This is the radical oophorectomy operation.” Technique
After high ligation of the ovarian vessels the pelvic contents are mobilised in a retroperitoneal plane which is developed initially behind the rectum and beneath the pouch of Douglas, after high ligation of the ovarian vessels. The peritoneum is incised around the brim of the true pelvis anteriorly, stripping peritoneum off of the bladder if it is involved. Otherwise, the bladder is reflected from the anterior fornix in the routine way and the vagina entered without prior mobilisation of the uterus. The vagina is circumcised to free the cervix, without entering the peritoneal cavity. The rectovaginal space beneath the pouch of Douglas may be entered once Denonvillier’s fascia has been incised so that the pelvic peritoneum can be mobilised as a false capsule to the pelvic mass and uterus, once the uterine vessels have been secured and the ureter traced and freed on either side. The peritoneum which is attached to the front of the rectum may, if only a small segment is attached, be freed by sharp dissection in the muscle layer, or, otherwise, a limited anterior rectal resection is carried out. There is ample distal bowel for cola-rectal anastomosis, which can usually be performed without great difficulty by upper sigmoid mobilisation. Mobilisation of the splenic flexure is only rarely required. At closure a sump drain in the hollow of the sacrum is prudent. Infra-colic omental resection should be carried out with lymphadenectomy as indicated. Advanced disease
If the staging procedure has disclosed extra-pelvic disease full evaluation is required before surgical strategy is determined. Completely resectable disease. In some cases the only macroscopic evidence of extra-pelvic disease is found in the greater omentum. It is very rare for the transverse mesocolon to be involved. Infra-colic and supra-colic omental resection can usually be carried out without intestinal resection. If all upper abdominal disease can be resected then there is little argument that radical pelvic surgery is indicated, including, if necessary, anterior rectal resection. Delayed primary
surgery.
using a radical oophorectomy
If complete extirpation technique is not within
1i
the competence of the operating surgeon it is much better that staging should be documented, histological confirmation obtained and an elective definitive operation carried out by a gynaecological oncologist at the earliest convenient occasion thereafter. The performance of a traditional total hysterectomy and bilateral salpingo-oophorectomy leaving incompletely removed disease in the pelvis is greatly to be deprecated. The limits of operability of ovarian cancer are in the upper abdomen and not in the pelvis. Low volume unresectable
disease. The presence of small nodules or a thin pannus on the surface of the liver, inferior aspect of the diaphragm, lesser omenturn or serosal surface of a substantial segment of bowel usually means that macroscopic clearance is not possible. Optimal cytoreduction may be achieved by the removal of bulky omental disease and if only small nodules will otherwise remain in the upper abdomen radical pelvic surgery is probably justified. Griffiths’ original suggestion of a 2 cm limit for acceptable residual disease is regarded as rather generous. Less than 1 cm is desirable with preferably an upper limit of 0.5 cm. A recent study has suggested a linear correlation between the size of residual tumour nodules and survival. There is some evidence that intestinal surgery to achieve optimal pelvic resection confers no survival advantage. If the radical oophorectomy retroperitoneal technique is utilised the degree of involvement of the anterior rectal wall may be assessed under direct supervision. Sharp dissection without resection may be preferred under such circumstances, but anterior rectal resection may still be the wisest and easiest option in some cases. Unresectable disease: large volume reducible. Grifhths’ contention that patients with bulky upper abdominal disease which can be reduced in volume by surgery to match low volume disease (as above) will fare as well, has been challenged. Hacker has claimed that there is no survival advantage in removing upper abdominal masses greater than 10 cm in diameter.18 In practice this distinction may not be easily made; often the largest abdominal masses are in the omentum, in the form of a plaque or ‘cake’ which is rarely much more than 3 cm thick, but may be three or four times as great in other dimensions. Such plaques may involve the anterior wall of the transverse colon and would be technically irremovable without resection. Plaque disease on the diaphragm and adjacent liver surface is rarely more than 0.5 cm thick, but extends over a wide area. It is difficult to know how to classify this. Retroperitoneal stripping of diaphragmatic plaques has been carried out but the technique is not really applicable to disease on the surface of the liver. Nevertheless extensive surgical procedures have been carried out piecemeal on advanced upper abdominal disease, but have not found universal favour. Argon laser surgery has been utilised.
12 CURRENT OBSTETRICS AND GYNAECOLOGY Unresectable disease: stage IV disease (liver and pleura). Major involvement of the small bowel and
mesentery, liver porta hepatis and lesser omentum the limits of operability. generally constitute Splenectomy on occasions may be justified but there are sequelae which may increase morbidity by enhancing infection risk during subsequent chemotherapy. The value of radical surgery in stage IV disease has been challenged, and alternative strategies may be considered. Palliative oophorectomy and epiploectomy followed by radical chemotherapy. Removal of the main tumour
masses from the ovaries and greater omentum is of some therapeutic value without any pretence that the procedures contribute to the potential success of subsequent chemotherapy. The benefits from such a simplistic procedure are psychological (with the removal of obvious masses perceived as malignant), and physical, by possible reduction in ascites and possible postponement of pressure and obstructive symptoms. These are worthwhile objectives even were chemotherapy not available. The short-term benefits of palliative surgery and palliative chemotherapy (often single agent non-epilating alkylating therapy) should not be decried. Interval surgery
Interval surgery (in contrast to ‘delayed primary surgery’, which may be interpolated in the middle of a course of chemotherapy) implies that definitive surgery is postponed until the end of a course of radical chemotherapy. Disease deemed inoperable at first laparotomy is only likely to become operable if there has been a major response to chemotherapy. Ovarian tumours may have so shrunk as to render the ovaries normal to the naked eye. Their removal with the uterus is, therefore, technically easy, but there is no evidence that interval surgery confers any survival advantage. Unless a significant remission is obtained on chemotherapy interval surgery is not indicated. It may, therefore, be considered that some women are thereby spared unsuccessful surgical intervention, but nevertheless derived the benefits of surgical palliation. Therapeutic ‘second-look’ surgery Partial remission. If a full course of chemotherapy has only achieved partial remission, surgery has little influence on the prognosis even though technical operability may have been achieved. Surgery for isolated metastasis
After a period of remission, relapse may be detected by imaging, clinical examination or by tumour markers. Tissue diagnosis is essential before second line therapy. If the recurrence is operable, further
surgery may be commended as providing the optimum pre-conditions for further chemotherapy. This is particularly the case with gonadal stromal tumours and those with low biological activity. Surgery for complications
Intestinal obstruction presents a therapeutic dilemma. Multiple site obstruction may well be made worse by laparotomy with an attendant risk of intestinal injury and faecal fistula. Terminal ileal obstruction is, however, common and its relief by resection or enteral anastomosis (ileo-transverse colostomy) is palliative. It is important to establish patency of the distal bowel before operating on such cases. Creation of an artificial stoma is the presence of advancing intra-abdominal malignancy is rarely in the best interest of the patient and the institution of parenteral feeding is usually considered to be prolonging the act of dying. Compassion and judgement are required in full measure in managing these difficult cases. Discussion If invariably effective chemotherapy were available there would be no role for radical surgery. This, however, is not the case. The zenith of ultra radical surgery for advanced malignant disease has probably passed. Data are difficult to obtain, as the value of radical surgery has never been tested in a randomised study. Meta-analysis to evaluate the role of surgery has been predictably unconvincing as the term ‘debulking’ means all things to all men, and many have applied the term ‘radical’ to a standard bilateral oophorectomy with hysterectomy when coupled with an omental resection. Radical oophorectomy within the pelvis is technically usually rather easier than a Wertheims radical hysterectomy. For the average gynaecologist, however, the operation may be somewhat daunting by virtue of the need to operate in an unfamiliar retroperitoneal and recta-rectal plane. The principal deterrent, however, is the occasional need to complete the procedure by anterior rectal resection and anastomosis, for which assistance may be necessary. There is a temptation therefore to rationalise away the desirability of complete removal of pelvic tumour - ‘debulking’ is good enough. With more advanced disease it is a matter of fine judgement to determine how extensive surgery should be if at the conclusion of the procedure there will still be residual disease. Removal of the main tumour masses (both ovaries and the omentum) is certainly palliative, and allows the woman to be in the best state to undertake a course of radical chemotherapy. Doing anything more than this short of complete clearance or virtually complete clearance (no disease greater than 0.5 cm) is of no proven value, and is better avoided.
THE PLACE OF SURGERY IN OVARIAN CANCER
Conclusion Palliative surgery is better than biopsy and closure in very advanced disease. Radical surgery is indicated if complete clearance is achievable or at least only minimal residual disease is left. Intermediate surgery (debulking) provides the worst of both worlds and should be consigned to history. References 1. Li MC. Effect of Methotrexate
2.
3. 4.
5.
6.
therapy upon choriocarcinoma and chorioadenoma. Proc Sot Exp Biol Med 1956; 93: 361 Masterson JG, Lenson JH. The role of chemotherapy in the treatment of gynecologic malignancy. Amer J Obstet Gynec 1956; 93: 1102 Hudson CN. A radical operation for fixed ovarian tumour. Obstet Gyneacol 1968; 75: 115 Dellepiane G. In: Wood C, Walters WAW, eds. Fifth World Congress of Gynaecology and Obstetrics. Sydney: Butterworth 1968 GritIiths CT. Surgical resection of tumour bulk in the primary treatment of ovarian carcinoma. Symposium on ovarian cancer. Nat Cancer Inst Monog 1975; 42: 101-104 Tobias JS, GrifIiths CT. Management of ovarian carcinoma; current concepts and future prospects. New Eng J Med 1976; 294: 819-823 (Pt I) 877-882 (Pt II)
13
7. Wiltshaw E. A review of clinical experience with cisplatinum dia. dichloride. Biochemic 1978: 60: 925-9 8. Smart GE, Farquharson DM. Second-look surgery ~ a review. In: Hudson CN, ed. Ovarian Cancer. Oxford: Oxford University Press, 1985 p 322-333 9. Hudson CN, Davy M. Germ cell tumours in younger patients. Aust NZ J Obstet Gynaec 1984; 24: 143-146 10. Curling OM, Potsides P, Hudson CN. Malignant change in benign cystic teratoma of the ovary. Brit J Obstet Gynaec 1979; 86: 3999402 11. Fox H, Langley FA. Tumours of the ovary. London: Heimnann 1976 12. Russell P. The pathological assessment of ovarian neoplasia II. The proliferating ‘epithelial’ tumours. Pathology 1979; 11: 5-26 13. Curling OM, Hudson CN. Endometrioid carcinoma of the ovary. Brit J Obstet Gynaec 1975; 82: 405 14. Piver MS, Barlow JJ, Lele SB. Continued controversies in the diagnosis and treatment of ovarian carcinoma. Obstet Gynec 1978; 52: 100 15. Knapp RC. Friedman EA. Aortic lymphnode metastases in early ovarian cancer. Amer J Obstet Gynec 1974; 119: 1013 16. McCartney AJ, Hudson CN. Surgical treatment of localised disease; conservative and radical. In: Hudson CN. ed. Ovarian cancer. Oxford: Oxford University Press 1985. p 190 17. Hudson CN, Shepherd JH. Surgery for carcinoma of the ovary. In: Coppleson M, ed. Gynecologic oncology. Edinburgh: Churchill Livingstone 1992, p 1313 18. Hacker NF, Bench JS, Lagasse LD, et al. Primary cytoreductive surgery for epithelial ovarian cancer. Obstet Gynecol 1983; 61: 413-20
OBSTETRICS& GYNAECOLOGY 1 Mini-symposium: Ovarian carcinoma
The place of surgery in ovarian cancer
C. N. Hudson
-
For many years ovarian cancer was the most neglected of gynaecological malignancies, even though it accounted for more deaths than cancers of the cervix and uterine body combined. This scenario did not change until the advent of anti-cancer chemotherapy. Chemotherapy of solid tumours really began within the field of gynaecology with the successful treatment of gestational choriocarcinema’ and single agent alkylating agent therapy was subsequently established as having a place in the management of the common forms of epithelial ovarian cancer, with a useful response in just over one-third of cases and with a small number (approximately 7%) of long survivors amongst women who would otherwise certainly have died of disease.’ Received surgical wisdom at the time was that in all forms of cancer attempted extirpation of metastatic disease was of little value except when metastases were locally contained within an extended operating field. A technique for the application of this principle to locally extensive ovarian cancer was described by the author in 196K3 In this procedure involved peritoneum of the pouch of Douglas is removed in continuity with the ovarian tumour mass and uterus by a retrograde hysterectomy technique devised by Dellepiane.4 It was Griffith2 who pioneered the concept that extending surgical endeavour into the upper abdomen in cases of disseminated ovarian cancer could increase the response rate to systemic chemotherapy even if macroscopic clearance was not attainable. He showed that the response to chemotherapy could be related to the volume of residual disease and, more particularly, to the volume of individual discrete tumour Professor C. Bartholomew’s Currenr rr, 1994
Ohsferrrcs Lonptmn
N. Hudson, Department Hospital, West Smithfield, and
Gynaecology LIK Ltd
Group
(1994)
4. l-13
masses, and went on to demonstrate within the limitations of an uncontrolled study that patients following surgery who went onto chemotherapy with low volume residual disease following surgery did as well as those with an equivalent volume of residual disease left behind with conventional local genital surgery. This gave rise to the unhappy neologism ‘debulking’, which was unfortunately widely adopted as a term to give professional ‘respectability’ to otherwise inappropriate and sub-optimal surgery. It was never Griffiths’ intention to condone sub-total removal of pelvic disease in those cases when complete clearance or optimal cytoreduction of upper abdominal disease is technically possible.” Since the introduction of single alkylating agent therapy two important changes have occurred, namely the use of combination drug therapy and the introduction of cisplatin and allied compounds. Cisplatin was shown to be effective as second line therapy as it was capable of producing a second remission after relapse on first line alkylating agent chemotherapy.’ This led to a vogue for second-look surgery in ovarian cancer.
Second-look surgery
Second-look laparotomy was utilised in the case of incompletely removed ovarian cancer after apparently successful chemotherapy in order to assess whether microscopic foci of (inevaluable) persistent disease could be detected. If the original operation had succeeded in leaving no residual tumour greater than 1 cm and, in addition, had succeeded in removing all macroscopic disease from within the pelvis then there was no clinical or imaging technique which could be used to
of Gynaecology, St. London EClA 7BE, UK
7
8
CURRENT OBSTETRICS AND GYNAECOLOGY
detect either persistent disease or relapse in its early stages. Secondly, postoperative residual disease, ultrasonic or CT scan or disease in the pelvis initially assessable by rectal examination might so regress under radical chemotherapy that it subsequently became inevaluable. For these two indications secondlook surgery was proposed at a set interval after completion of primary radical chemotherapy to assess the completeness of the response and to determine whether any second line therapy might be indicated.* As platinum compounds came to be incorporated in first line chemotherapy for ovarian cancer, and as data in support of whole abdominal radiotherapy for patients relapsing after chemotherapy were not forthcoming, most programmes for diagnostic second-look surgery in advanced disease have now faded. The role of diagnostic second-look surgery in early disease has been extremely controversial. Serial laparoscopy after apparently complete surgery for localised disease is invasive and of limited value. Metastases may appear several years after primary surgery for early ovarian cancer and the practicality and propriety of repeated laparoscopy is now seriously questioned, the alternative being treatment on clinical relapse.
inappropriate over-treatment, so that in such cases the operator should not hesitate to accept a possible need for a two-stage procedure should mature consideration demand it. In general terms, tumours of low potential malignancy carry a much better prognosis. Even with documented extra-ovarian disease (which may or may not be metastatic) 5-year survival is of the order of 85%.” Russell” has attempted to sub-divide the grades of tumours of low potential malignancy and there is little doubt that cloning occurs so that the invasive potential may change with time and also differ between the primary tumour and metastases. In practice, the malignant potential of ovarian neoplasia is a spectrum with a continuum from total benignity to most aggressive malignancy. Histological ‘cut-offs’ are therefore somewhat artificial and the clinician’s response should be based upon a total case assessment, including age and histological type and evidence of spread. Clinicians should be aware that pathologists’ use of the term ‘no evidence of invasion’ has rather different biological implications than when the same term is used, for instance, when describing lesions of the cervix. The importance of conference and dialogue with pathologists cannot be over-emphasised.
Germ cell turnours Combination chemotherapy has revolutionised the management of germ cell tumours. This has extended beyond non-gestational choriocarcinoma to all forms of malignant teratoma, dysgerminoma and yolk sac tumour (endodermal sinus tumour). These have been so successfully treated potential for preservation of reproductive function now exists.’ The role of radical surgery in the management of germ cell tumours has therefore required complete revision in the light of the above developments. Radical surgery has no place in the primary treatment of germ cell malignancy in the early reproductive years. Secondary transformation of a hitherto benign cystic teratoma is however probably the commonest germ cell tumour, lo but occurs in an older age group. This tumour is relatively unresponsive to adjuvant therapy, either radiotherapy or chemotherapy, and surgery will remain the mainstay of treatment; there is little room for conservatism. Likewise, the association of gonadal dysgenasis with malignant germ cell tumour formation needs to be remembered and bilateral gonadectomy of streak gonads may be indicated in any individual who has, even in a mosaic, a Y chromosome. Other pathological considerations
Even in apparent stage III disease, a more conservative approach may be warranted in the case of ovarian tumours of low potential malignancy. The younger the woman the greater the chance of
Well-differentiated epithelial ovarian tumours Some localised invasive tumours may be considered of low grade and well-differentiated on both architectural and cytological grounds. If, after a properly executed staging procedure, there is no clinical or pathological evidence of extra-ovarian spread then the possibility of more conservative management exists.
Preservation of the reproductive potential
Removal of the uterus in the case of localised ovarian cancer is more time honoured than of substantial benefit. Although interconnecting lymphatics between the ovaries have been described across the fundus of the uterus there are no data to suggest that the uterus is a site for early and selective metastases. There is, however, the possibility of concurrent, and unsuspected, endometrial malignancy. The prevalence of such a coincidence is low, of the order of 3%13 and almost always in association with endometrioid ovarian tumours. If uterine conservation is therefore contemplated, it should be with a view to reproduction rather than mere altruism, and the endometrium should be assessed for occult malignancy. Histological material should be available in association with either transvaginal ultrasonic scanning of the uterus or hysteroscopy.
THE PLACE OF SURGERY
Preservation of the contralateral ovary
Ovarian cancer is commonly bilateral and the propriety of ovarian conservation needs careful examination. Cancer may occur in the second ovary, either synchronously or metachronously. It is the possible presence of a metastasis in an apparently normal contralateral ovary that is a matter for concern when a conservative approach is being contemplated. Although not ideal, a full thickness slice biopsy would detect most occult metastases. It is essential that the best tubal surgery techniques are employed with minimal handling, meticulous haemostasis and the use of very fine nonirritant sutures for the repair as adnexal surgery carries with it a risk of infertility. In addition, there are histopathological considerations. The risk of bilateral disease is increased with high grade poorly differentiated malignancy, and with certain histological types. Bilateral disease is encountered more commonly with serous papillary tumours; rather less so with endometrioid tumours and least with mutinous. At or after the menopause all ovarian neoplasia, whether benign or malignant, should be treated by bilateral oophorectomy. In the reproductive years conservation of a contralateral ovary should only be permitted for serous papillary tumours until further reproductive ambitions have been achieved. At that stage residual oophorectomy should be carried out. In the case of endometrioid tumours. after reproduction is complete hysterectomy and residual oophorectomy should probably be carried out so that hormone replacement therapy can be used without qualm. There is small risk in retaining the ovary after reproduction in a woman who has had a mutinous tumour and the desirability for its removal at the time of, say, sterilization should be discussed with her.
Gonadal stromal tumours These uncommon tumours are another group in which the histopathology is particularly germane to the surgical procedures undertaken. There are two classes: the granulosa/theca cell tumours and the Sertoli/Leydig cell tumours, correctly referred to as androblastoma. Any of these tumours may be malignant. The theta cell component is almost always benign and tumours consisting only of theta cells (thecoma) are, therefore, most unlikely to be malignant. Granulosa cell tumours should always be regarded as potentially malignant, but the actual biological behaviour is very difficult to predict from the histological appearance. A precise diagnosis is important; gonadal stromal tumours tend to recur sporadically at extended intervals and, therefore, aggressive management of individual metastases may well be rewarding, including repeated surgery. Data on chemotherapy are largely anecdotal and such therapy may only be indicated once surgery has
IN OVARIAN
CANCER
9
failed to contain the disease. Metastases have been reported up to 25 years from the removal of the primary tumour.
Other tumours Secondary carcinoma, metastatic from some extragenital, perhaps unsuspected, primary is perhaps the most common remaining form of malignancy to be encountered by a surgeon. If such is encountered there is little theoretical benefit to be obtained from removal of the uterus, but both ovaries should certainly be removed, even if the second does not appear to the naked eye to be involved. The management of an unsuspected gastrointestinal primary needs some consideration. The presence of ovarian metastases ipso facto means that the disease has spread beyond the embrace of local surgery. Limited resection of a colonic cancer with anastomosis is certainly justified as prophylaxis against the development of obstruction. If an unsuspected tumour were found in the upper rectum it would be poor palliation to raise a colostomy in the absence of symptoms. Proper restorative resection and/or radiotherapy would be the correct management. If the unsuspected primary is found to be in the stomach there is a case for at least a partial gastrectomy, even if there is spread elsewhere in the abdomen. Useful remissions with metastatic disease may be obtained with appropriate chemotherapy. Malignancy of the pancreas is not really suited to ad hoc surgical extirpation. Early carcinoma of the breast can spread to the ovaries even when a miniature primary is not clinically detectable. This is a source of great diagnostic anxiety to the clinician and the pathologist and an expectant approach using tamoxifen in the post menopausal patient may be indicated.
Other rare tumours The ovary exhibits a greater range of neoplastic types than any other organ in the body. The non-functional stromal tumour, the fibroma, is of importance as a source of diagnostic confusion to the unwary clinician as it may present with pleural effusion and ascites (Meig’s syndrome). There is no other tumour which is as hard to the touch as a true fibroma. Sarcomatous change is described. A benign cystadenofibroma to the naked eye often looks extraordinarily sinister - the histological diagnosis may come as a relief. Brenner tumours are nearly as hard as the pure fibroma; they are often found in association with mutinous cysts and the epithelial element within the tumour may rarely be malignant.
10
CURRENT OBSTETRICS AND GYNAECOLOGY
The surgical management of established invasive epithelial ovarian cancer Staging Staging is critical to the informed management of early stage disease. Piver et alI4 has shown how common inadvertent understaging is, particularly with reference to the inferior aspects of the diaphragm. A search for unsuspected macroscopic disease must be thorough and include the pouch of Douglas, the para-colic gutters and the sub-phrenic spaces. Obviously anything suspicious should be biopsied, including peritoneal ‘sand’. In the absence of any visible lesion the role of biopsy is controversial. Blind biopsies of the diaphragm have punctured the adjacent pleura with unwelcome sequelae. Of greater value is probably the use of exfoliative cytology using a brush or spatula. The first histological evidence of extra-ovarian spread may be from the infracolic omentum, particularly if adjacent to the tumour. Any small puddle of peritoneal fluid should always be aspirated for cytology. Only when this is absent is it necessary to instil fluid for washings.
Lymph node sampling Because of the free anastomosis within the broad ligament, lymph drainage from the ovary is in two directions. The gonadal vessels in both sexes arise in close proximity to the renal vessels and indeed on the left side the gonadal vein drains into the left renal vein. The lumbar lymph node station, therefore, is the group of nodes which lie in the angle between the renal vessels and the aorta and inferior vena cava respectively. Access to these is not easy and is probably best obtained by reflecting the caecum and ascending colon medially and upwards. Even so access to nodes in the left reno-caval angle may be difficult. There is little point in sampling other lumbar lymph nodes below this level, unless they are clinically involved, as they do not constitute a primary station for the ovary. The alternative primary station for lymph drainage is the group of the inter-iliac nodes laying beneath and behind the external iliac vein, above the obturator nerve and anterior to the internal iliac vessels. Anatomically these are parietal nodes of the posterior iliac chain and are often referred to by surgeons as the ‘obturator nodes’. It must remain a matter for individual decision in the absence of clinically positive nodes to assess whether a finding of an occult nodal deposit would alter the treatment plan. In stage I cases the incidence of occult involved nodes is of the order of 10%.15 The information is of obvious prognostic significance, but treatment moderation on the basis of that finding alone may not justify the potential morbidity of extensive retroperitoneal surgery.
Incision It is prudent for all elective operations for any pelvic tumour, which could conceivably be malignant ovarian, to be carried out through a vertical incision. The situation will always arise, however, that the diagnosis of unsuspected ovarian malignancy will arise unexpectedly during a laparotomy which has commenced with a standard Pfannenstiel incision. What advice may be given to the surgeon who finds him/herself in this situation? Transverse incisions can be beyond the lateral margin of the rectus abdominis muscles, provided, of course, that the external oblique muscle is split in the direction of its fibres and not across the inguinal ligament. This will give enhanced exposure below the umbilicus and for added upper abdominal access one or other rectus abdominis muscle may safely be divided transversely with the inferior epigastric vessels secured. If there is no clinically obvious disease above the infracolic omentum careful upper abdominal staging is still required. With the aid of good retraction cytological smears of the diaphragm and liver surface may be obtained and inspection of the subphrenic areas may be achieved through the transverse incision with the aid of a laparoscope without, of course, a distending pneumoperitoneum. The liver may be displaced by hand sufficient to allow the inspection. Definitive surgery Strictly localised disease In the post reproductive era the minimum extent of surgery should be bilateral salpingo-oophorectomy. In young patients, however, every effort should be made to conserve at least part of one ovary pending full evaluation of the histology. It is better to accept the need for re-operation than to have over-treated a young woman by an instant decision to clear the pelvis. Should an ovarian cyst have been removed by cyst enucleation (with ovarian conservation) and subsequent histological examination have shown invasive cancer, the obvious advice would be for the affected ovary to be removed as a definitive procedure even if conservation of the uterus and other ovary were contemplated. l6 Hysterectomy adds little to the magnitude of surgery for an ovarian cyst in a post menopausal woman and may, indeed, facilitate clean removal and give exposure to allow safe separation from the adjacent ureter. There is no evidence that removal of the uterus confers any inherent therapeutic advantage in strictly localised ovarian disease. Intermediate disease Extension or metastases beyond the ovary but within the pelvis constitutes stage II disease. Clinically it is virtually impossible to tell whether dense adhesions
THE PLACE OF SURGERY IN OVARIAN CANCER
are due to infiltration or inflammation. In the most recent FIG0 classification if there is no histological evidence of capsular penetration, such cases remain in stage I. In practice, however, the surgical procedure for the removal of fixed ovarian tumours is the same whether the fixity is due to infiltration or inflammatory adhesion. This is the radical oophorectomy operation.” Technique
After high ligation of the ovarian vessels the pelvic contents are mobilised in a retroperitoneal plane which is developed initially behind the rectum and beneath the pouch of Douglas, after high ligation of the ovarian vessels. The peritoneum is incised around the brim of the true pelvis anteriorly, stripping peritoneum off of the bladder if it is involved. Otherwise, the bladder is reflected from the anterior fornix in the routine way and the vagina entered without prior mobilisation of the uterus. The vagina is circumcised to free the cervix, without entering the peritoneal cavity. The rectovaginal space beneath the pouch of Douglas may be entered once Denonvillier’s fascia has been incised so that the pelvic peritoneum can be mobilised as a false capsule to the pelvic mass and uterus, once the uterine vessels have been secured and the ureter traced and freed on either side. The peritoneum which is attached to the front of the rectum may, if only a small segment is attached, be freed by sharp dissection in the muscle layer, or, otherwise, a limited anterior rectal resection is carried out. There is ample distal bowel for cola-rectal anastomosis, which can usually be performed without great difficulty by upper sigmoid mobilisation. Mobilisation of the splenic flexure is only rarely required. At closure a sump drain in the hollow of the sacrum is prudent. Infra-colic omental resection should be carried out with lymphadenectomy as indicated. Advanced disease
If the staging procedure has disclosed extra-pelvic disease full evaluation is required before surgical strategy is determined. Completely resectable disease. In some cases the only macroscopic evidence of extra-pelvic disease is found in the greater omentum. It is very rare for the transverse mesocolon to be involved. Infra-colic and supra-colic omental resection can usually be carried out without intestinal resection. If all upper abdominal disease can be resected then there is little argument that radical pelvic surgery is indicated, including, if necessary, anterior rectal resection. Delayed primary
surgery.
using a radical oophorectomy
If complete extirpation technique is not within
1i
the competence of the operating surgeon it is much better that staging should be documented, histological confirmation obtained and an elective definitive operation carried out by a gynaecological oncologist at the earliest convenient occasion thereafter. The performance of a traditional total hysterectomy and bilateral salpingo-oophorectomy leaving incompletely removed disease in the pelvis is greatly to be deprecated. The limits of operability of ovarian cancer are in the upper abdomen and not in the pelvis. Low volume unresectable
disease. The presence of small nodules or a thin pannus on the surface of the liver, inferior aspect of the diaphragm, lesser omenturn or serosal surface of a substantial segment of bowel usually means that macroscopic clearance is not possible. Optimal cytoreduction may be achieved by the removal of bulky omental disease and if only small nodules will otherwise remain in the upper abdomen radical pelvic surgery is probably justified. Griffiths’ original suggestion of a 2 cm limit for acceptable residual disease is regarded as rather generous. Less than 1 cm is desirable with preferably an upper limit of 0.5 cm. A recent study has suggested a linear correlation between the size of residual tumour nodules and survival. There is some evidence that intestinal surgery to achieve optimal pelvic resection confers no survival advantage. If the radical oophorectomy retroperitoneal technique is utilised the degree of involvement of the anterior rectal wall may be assessed under direct supervision. Sharp dissection without resection may be preferred under such circumstances, but anterior rectal resection may still be the wisest and easiest option in some cases. Unresectable disease: large volume reducible. Grifhths’ contention that patients with bulky upper abdominal disease which can be reduced in volume by surgery to match low volume disease (as above) will fare as well, has been challenged. Hacker has claimed that there is no survival advantage in removing upper abdominal masses greater than 10 cm in diameter.18 In practice this distinction may not be easily made; often the largest abdominal masses are in the omentum, in the form of a plaque or ‘cake’ which is rarely much more than 3 cm thick, but may be three or four times as great in other dimensions. Such plaques may involve the anterior wall of the transverse colon and would be technically irremovable without resection. Plaque disease on the diaphragm and adjacent liver surface is rarely more than 0.5 cm thick, but extends over a wide area. It is difficult to know how to classify this. Retroperitoneal stripping of diaphragmatic plaques has been carried out but the technique is not really applicable to disease on the surface of the liver. Nevertheless extensive surgical procedures have been carried out piecemeal on advanced upper abdominal disease, but have not found universal favour. Argon laser surgery has been utilised.
12 CURRENT OBSTETRICS AND GYNAECOLOGY Unresectable disease: stage IV disease (liver and pleura). Major involvement of the small bowel and
mesentery, liver porta hepatis and lesser omentum the limits of operability. generally constitute Splenectomy on occasions may be justified but there are sequelae which may increase morbidity by enhancing infection risk during subsequent chemotherapy. The value of radical surgery in stage IV disease has been challenged, and alternative strategies may be considered. Palliative oophorectomy and epiploectomy followed by radical chemotherapy. Removal of the main tumour
masses from the ovaries and greater omentum is of some therapeutic value without any pretence that the procedures contribute to the potential success of subsequent chemotherapy. The benefits from such a simplistic procedure are psychological (with the removal of obvious masses perceived as malignant), and physical, by possible reduction in ascites and possible postponement of pressure and obstructive symptoms. These are worthwhile objectives even were chemotherapy not available. The short-term benefits of palliative surgery and palliative chemotherapy (often single agent non-epilating alkylating therapy) should not be decried. Interval surgery
Interval surgery (in contrast to ‘delayed primary surgery’, which may be interpolated in the middle of a course of chemotherapy) implies that definitive surgery is postponed until the end of a course of radical chemotherapy. Disease deemed inoperable at first laparotomy is only likely to become operable if there has been a major response to chemotherapy. Ovarian tumours may have so shrunk as to render the ovaries normal to the naked eye. Their removal with the uterus is, therefore, technically easy, but there is no evidence that interval surgery confers any survival advantage. Unless a significant remission is obtained on chemotherapy interval surgery is not indicated. It may, therefore, be considered that some women are thereby spared unsuccessful surgical intervention, but nevertheless derived the benefits of surgical palliation. Therapeutic ‘second-look’ surgery Partial remission. If a full course of chemotherapy has only achieved partial remission, surgery has little influence on the prognosis even though technical operability may have been achieved. Surgery for isolated metastasis
After a period of remission, relapse may be detected by imaging, clinical examination or by tumour markers. Tissue diagnosis is essential before second line therapy. If the recurrence is operable, further
surgery may be commended as providing the optimum pre-conditions for further chemotherapy. This is particularly the case with gonadal stromal tumours and those with low biological activity. Surgery for complications
Intestinal obstruction presents a therapeutic dilemma. Multiple site obstruction may well be made worse by laparotomy with an attendant risk of intestinal injury and faecal fistula. Terminal ileal obstruction is, however, common and its relief by resection or enteral anastomosis (ileo-transverse colostomy) is palliative. It is important to establish patency of the distal bowel before operating on such cases. Creation of an artificial stoma is the presence of advancing intra-abdominal malignancy is rarely in the best interest of the patient and the institution of parenteral feeding is usually considered to be prolonging the act of dying. Compassion and judgement are required in full measure in managing these difficult cases. Discussion If invariably effective chemotherapy were available there would be no role for radical surgery. This, however, is not the case. The zenith of ultra radical surgery for advanced malignant disease has probably passed. Data are difficult to obtain, as the value of radical surgery has never been tested in a randomised study. Meta-analysis to evaluate the role of surgery has been predictably unconvincing as the term ‘debulking’ means all things to all men, and many have applied the term ‘radical’ to a standard bilateral oophorectomy with hysterectomy when coupled with an omental resection. Radical oophorectomy within the pelvis is technically usually rather easier than a Wertheims radical hysterectomy. For the average gynaecologist, however, the operation may be somewhat daunting by virtue of the need to operate in an unfamiliar retroperitoneal and recta-rectal plane. The principal deterrent, however, is the occasional need to complete the procedure by anterior rectal resection and anastomosis, for which assistance may be necessary. There is a temptation therefore to rationalise away the desirability of complete removal of pelvic tumour - ‘debulking’ is good enough. With more advanced disease it is a matter of fine judgement to determine how extensive surgery should be if at the conclusion of the procedure there will still be residual disease. Removal of the main tumour masses (both ovaries and the omentum) is certainly palliative, and allows the woman to be in the best state to undertake a course of radical chemotherapy. Doing anything more than this short of complete clearance or virtually complete clearance (no disease greater than 0.5 cm) is of no proven value, and is better avoided.
THE PLACE OF SURGERY IN OVARIAN CANCER
Conclusion Palliative surgery is better than biopsy and closure in very advanced disease. Radical surgery is indicated if complete clearance is achievable or at least only minimal residual disease is left. Intermediate surgery (debulking) provides the worst of both worlds and should be consigned to history. References 1. Li MC. Effect of Methotrexate
2.
3. 4.
5.
6.
therapy upon choriocarcinoma and chorioadenoma. Proc Sot Exp Biol Med 1956; 93: 361 Masterson JG, Lenson JH. The role of chemotherapy in the treatment of gynecologic malignancy. Amer J Obstet Gynec 1956; 93: 1102 Hudson CN. A radical operation for fixed ovarian tumour. Obstet Gyneacol 1968; 75: 115 Dellepiane G. In: Wood C, Walters WAW, eds. Fifth World Congress of Gynaecology and Obstetrics. Sydney: Butterworth 1968 GritIiths CT. Surgical resection of tumour bulk in the primary treatment of ovarian carcinoma. Symposium on ovarian cancer. Nat Cancer Inst Monog 1975; 42: 101-104 Tobias JS, GrifIiths CT. Management of ovarian carcinoma; current concepts and future prospects. New Eng J Med 1976; 294: 819-823 (Pt I) 877-882 (Pt II)
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7. Wiltshaw E. A review of clinical experience with cisplatinum dia. dichloride. Biochemic 1978: 60: 925-9 8. Smart GE, Farquharson DM. Second-look surgery ~ a review. In: Hudson CN, ed. Ovarian Cancer. Oxford: Oxford University Press, 1985 p 322-333 9. Hudson CN, Davy M. Germ cell tumours in younger patients. Aust NZ J Obstet Gynaec 1984; 24: 143-146 10. Curling OM, Potsides P, Hudson CN. Malignant change in benign cystic teratoma of the ovary. Brit J Obstet Gynaec 1979; 86: 3999402 11. Fox H, Langley FA. Tumours of the ovary. London: Heimnann 1976 12. Russell P. The pathological assessment of ovarian neoplasia II. The proliferating ‘epithelial’ tumours. Pathology 1979; 11: 5-26 13. Curling OM, Hudson CN. Endometrioid carcinoma of the ovary. Brit J Obstet Gynaec 1975; 82: 405 14. Piver MS, Barlow JJ, Lele SB. Continued controversies in the diagnosis and treatment of ovarian carcinoma. Obstet Gynec 1978; 52: 100 15. Knapp RC. Friedman EA. Aortic lymphnode metastases in early ovarian cancer. Amer J Obstet Gynec 1974; 119: 1013 16. McCartney AJ, Hudson CN. Surgical treatment of localised disease; conservative and radical. In: Hudson CN. ed. Ovarian cancer. Oxford: Oxford University Press 1985. p 190 17. Hudson CN, Shepherd JH. Surgery for carcinoma of the ovary. In: Coppleson M, ed. Gynecologic oncology. Edinburgh: Churchill Livingstone 1992, p 1313 18. Hacker NF, Bench JS, Lagasse LD, et al. Primary cytoreductive surgery for epithelial ovarian cancer. Obstet Gynecol 1983; 61: 413-20