Importance of Surgical Staging

A major flaw in most studies of early ovarian cancer is the inconsistency in requirements for surgical staging. The Gynecologic Oncology Group's (GOG) definition of complete surgical staging is listed in Box 8-4. Obviously, gross inspection and palpation of the peritoneal cavity may miss occult or microscopic disease that would

Box 8-4. GOG Requirements for Surgical Staging of Ovarian Carcinoma

Staging Operative Procedures

1. Total hysterectomy with bilateral salpingo-oophorectomy

2. Infracolic omentectomy

3. Aspiration of free peritoneal fluid

4. Peritoneal washings for cytology (abdomen and pelvis)

5. Inspection of all abdominal peritoneal surfaces

6. Peritoneal biopsies from four pelvic locations and bilateral paracolic areas

7. Diaphragm scraping or biopsy

8. Bilateral selective pelvic and aortic lymph node dissections

GOG, Gynecologic Oncology Group.

change the stage of disease from early (stage I or II) to advanced (stage III). Thorough surgical staging procedures upstage the diagnosis in 10% to 30% of cases.11-13 Thus, trials claiming to investigate or treat stages I and II disease without complete surgical staging may be including patients who actually have more advanced disease. Evidence for this is found in an analysis of the observation group in the ACTION trial.9 Of the 222 patients in the observation arm, 75 had undergone optimal surgical staging, 147 nonoptimal staging. The recurrence-free survival following optimal surgical staging was significantly better than following nonoptimal staging (hazard ratio [HR] = 1.82, P = .04). This difference implies that more advanced, occult disease is present in cohorts not having complete surgical staging. Thus, surgical staging could affect outcomes in trials of adjuvant chemotherapy.

The inconsistent surgical staging procedures among trials of early ovarian cancer may be another reason for the range of cancer recurrence rates. The natural recurrence rates for stage I cancer treated by surgery only, depicted in Table 8-1, are mostly from trials that did not include complete surgical staging during the initial operation for most patients. The one trial that required complete surgical staging reported similar low recurrence rates for observation and treatment of low-grade cancers.6

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