Procedures Complications and Outcome of Secondary Cytoreductive Surgery

The benefit of secondary cytoreduction appears to be seen only when optimal cytoreduction is achieved. In the primary setting, optimal cytoreduction is commonly defined as the maximal size of residual tumor measuring 1 cm. Many authors, however, suggest that the greatest benefit is seen if all grossly visible recurrent tumor is resected.14'16'18,19'21,22 The exact size of residual disease that should be considered optimal is still debatable, but we seek to achieve a complete gross resection in the secondary or tertiary setting. If this is not possible, cytoreduction for tumors up to 5 mm may also be of benefit.20 Aggressive surgical attempts that leave residual tumor over 5 mm are not warranted except in the palliative setting.

Repeat laparotomy after extensive primary oncologic surgery and chemotherapy is often challenging. When contemplating surgery, two questions regarding the procedure should be answered in assessing the overall benefits versus risks of secondary cytoreduction:

1. What is the rate of optimal cytoreduction or complete gross resection achieved in most series?

2. What are the complications reported and the morbidity described during and after surgical secondary cytoreduction?

In different publications, the rates of achieving optimal secondary cytoreduction, defined as between no residual and less than 2 cm residual tumor, vary widely. Most series report optimal debulking rates of 40% to 60%.11,12,20,31,33,34 Two series reported optimal rates higher than 80%.23,27 Complete macroscopic tumor resection rates also vary. A few studies reported rates of approximately 40%,19,25,32 whereas others reported no residual macroscopic disease in 80% of patients undergoing secondary cytoreduction.14,15,20 Because of the nonrandomized nature of all series published on this topic, a main confounding factor is patient selection.

Almost all patients with recurrent ovarian cancer have already had their uterus and adnexa removed. To achieve optimal resection or no gross residual disease, often many nongynecologic surgical procedures are required. Several authors have reported the procedures required to achieve optimal residual or no residual disease. These procedures include small and large bowel resections, lymph node dissections, diaphragm stripping/resection, liver resections, and splenectomies.

Morbidity and mortality rates after secondary cytoreduction have been reported to range from 4% to 30% and 0% to 6%, respectively (Table 10-1). In these series, the average blood loss per case was approximately 700 mL with a range of 50 to 3500 mL. Operating time averaged 2.5 to 3.5 hours. Hospital stay was reported to average 9 days, but ranged from 2 days to over 3 months.

Tebes and colleagues23 reported enterotomy as the most frequently occurring intraoperative complication (8.3%). Other complications such as cystotomy, diaphragm injury, and vascular injury were rare in their experience (1%).

Postoperatively, ileus or bowel obstruction was a relatively common complication. Its incidence varies from 2% to 30% and is somewhat dependent on whether a bowel resection was performed.31 Wound infection, fistula formation, renal failure, anasto-motic leak, pneumonia, and acute respiratory distress syndrome have also been reported.

Table 10-1. Median Overall Survival in Months After Secondary Cytoreduction

Number of Patients with Optimal* Suboptimal*

Series N No Gross Residual* (months) (months)

Table 10-1. Median Overall Survival in Months After Secondary Cytoreduction

Number of Patients with Optimal* Suboptimal*

Series N No Gross Residual* (months) (months)

Segna et al12

100

27

9

Lichtenegger et al13

63

24

n/a

17

Eisenkop et al14

106

44

19

Zang et al18

117

61%+

21%+

4.5%+

Ayhan et al19

64

39

19

18

Chi et al20

153

56

27

Harter et al21

267

45

20

20

Salani et al22+

55

50

7.2

Tebes et al23

85

30

17

*ln series in which survival was assessed based on no gross residual tumor, the optimal category includes only optimal but gross residual disease. +5-year overall survival.

tMedian overall survival in the suboptimal category is for any gross residual disease regardless of size.

*ln series in which survival was assessed based on no gross residual tumor, the optimal category includes only optimal but gross residual disease. +5-year overall survival.

tMedian overall survival in the suboptimal category is for any gross residual disease regardless of size.

Figure 10-5. Simple linear regression analysis. Median cohort survival time plotted against the proportion of patients in each cohort undergoing complete cytoreductive surgery for recurrent ovarian cancer. Circle size is proportional to the number of subjects in each study.

Complete resection (%)

Complete resection (%)

Figure 10-5. Simple linear regression analysis. Median cohort survival time plotted against the proportion of patients in each cohort undergoing complete cytoreductive surgery for recurrent ovarian cancer. Circle size is proportional to the number of subjects in each study.

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