Extent of Disease and Ascites

Several factors regarding the pattern of recurrent disease should be taken into account before reaching a decision on surgical cytoreduction. These include the anatomic sites of recurrence, the number of lesions, the presence of carcinomatosis, and ascites (Box 10-3). Through imaging and physical examination, most of these factors can be assessed. Assessment of carcinomatosis is not always possible on imaging.

DESKTOP investigators evaluated the predictive value of ascites, localization of recurrence to the pelvis or other parts of the abdomen, and preoperative diagnosis of carcinomatosis.21 These and other variables were appraised for their correlation with complete resection of tumor. On univariate analysis with respect to operability, ascites less than 500 mL, recurrent disease limited to the pelvis only, and no radio-logic diagnosis of peritoneal carcinomatosis were predictors of complete resection. Regarding preoperative tumor assessment, they limited further analysis to ascites volume and when included on multivariate analysis, ascites less than 500 mL showed an independent and significant impact on the probability of achieving complete resection without macroscopically visible residual tumor. On multivariate analysis, the presence of ascites also had a negative impact on survival. Chi and associates20 also found the presence of ascites to be a significant factor for survival on univariate but not multivariate analysis.

Localized recurrence of ovarian cancer with a small number of lesions is considered a favorable prognostic factor. It is thought that the likelihood of successful secondary cytoreduction is greater and that postrecurrence survival is superior. Most of the studies in the literature compare a solitary site with multiple sites of recurrence. Gronlund and associates32 noted that a solitary recurrence was associated with the ability to achieve complete tumor resection and that patients who had complete cytoreduction experienced improved overall survival. Munkarah and colleagues28 also evaluated the role of cytoreductive surgery for solitary versus multiple intra-abdomi-nal recurrence sites of ovarian carcinoma. Survival was not evaluated on the basis of recurrent disease sites, but they were able to achieve optimal cytoreduction in a greater percentage of patients with isolated recurrence sites, which resulted in a trend toward improved survival. Zang and associates18 noted improved ability to perform optimal cytoreduction in patients with a solitary lesion and also observed a significant 5-year survival advantage for patients who had one recurrent disease site (49.8%) compared with patients who had multiple recurrent disease sites (5.4%). Gadducci

Box 10-3. Patterns of Recurrence to Be Evaluated

• Anatomic sites of recurrence

• Number of lesions

• Presence of carcinomatosis

• Ascites and associates33 reported a median survival of 40 months for patients who had an isolated, solitary recurrence versus 19 months for patients who had multiple recurrence sites. Other studies, including an evaluation of isolated lymph nodal recurrences, have also demonstrated notable survival benefits for secondary cytoreductive surgery in patients who have a single site of recurrence.14,27,34-36

To evaluate a wider spectrum of patients, Chi and associates20 demonstrated that patients with a single site of recurrence had a median survival of 60 months compared with 42 months for patients with multiple sites of recurrence and 28 months for patients with carcinomatosis (Fig. 10-3).

Salani and colleagues22 divided a cohort of patients who underwent secondary cytoreduction into two groups with up to five and with more then five sites of recurrence on preoperative imaging studies. The median survival of 48 months from the time of secondary cytoreductive surgery suggested that patients with less than five lesions on imaging studies in general have a better prognosis.

Larger tumor diameter at the time of recurrence has been shown by some investigators to adversely affect survival, although this varies from 5 to 10 cm depending on the study.9,14,27 Others could not show an association of lesion size with either complete cytoreduction or survival.15,19,30,33,34

Overall, the literature consistently supports the idea that a patient with a long DFI and a solitary lesion less than 5 cm with no ascites or carcinomatosis will benefit from secondary cytoreduction. Unfortunately, the woman with a short DFI, extensive disease involving peritoneal surfaces with carcinomatosis, and ascites was in the majority and not the optimal candidate just mentioned (Fig. 10-4). There is a spectrum of recurrence patterns, and few patients fit into the optimal category slot. Logic should be used in determining the pattern of tumor spread that most likely fits surgical ability for resection. Imaging is an important tool for preoperative assessment and is discussed further.

2-20 Sites of recurrence

Figure 10-3. Number of sites of recurrence and survival after secondary cytoreduction.

Optimal candidate for secondary cytoreduction

Poor candidate for secondary cytoreduction

Optimal candidate for secondary cytoreduction

Poor candidate for secondary cytoreduction

Figure 10-4. Spectrum of patterns of recurrence.

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