Recurrent Disease

Although complete clinical remission can be achieved in many patients with advanced epithelial ovarian cancer using a combination of cytoreductive surgery and chemotherapy, the disease will likely recur and require further intervention. Management of recurrent disease may then involve further chemotherapy, surgery, or radiation. Most of the studies that have examined surgical cytoreduction in recurrent ovarian cancer have demonstrated the technical feasibility of further resection, with optimal debulking in 39% to 87% of patients and demonstrate a survival advantage for those left with minimal residual disease.41-45 Munkarah and Coleman46 recently reviewed the role of secondary cytoreductive surgery in recurrent ovarian cancer. In their analysis of 12 publications, complete resection of the tumor recurrence was one of the most powerful determinants of prolonged survival. Harter and associates47 recently reviewed the results of their DESKTOP-OVAR I exploratory multicenter

Chapter 7 Ovarian Cancer Surgery

t

24 36

Months on study

24 36

Months on study

Elected SLL

Alive

Dead

Total

Accept SLL

130

164

294

Elected no SLL

156

210

366

Figure 7-20. Survival (progression-free survival of less than 6 months removed). Accept second-look laparotomy (SLL) versus elected no SLL. (From Greer BE, Bundy BN, Ozols RF, et al: Implications of second-look laparotomy in the context of optimally resected stage III ovarian cancer: a non-randomized comparison using an explanatory analysis: a Gynecologic Oncology Group study. Gynecol Oncol 99:71-79, 2005, Figure 5.)

trial in Germany aimed at gathering evidence to help formulate a hypothesis for selection criteria and predictive factors for successful cytoreductive surgery in recurrent ovarian cancer. In their review of 267 patients, 87% of whom had a treatment-free interval of more than 6 months, the researchers found that the women with macroscopically completely resected tumors showed a significantly longer survival compared with patients who had any visible residual tumor, with a median survival of 45.2 and 19.7 months, respectively, and a hazard ratio for survival of 3.71 (Fig. 7-21). Multivariate analysis of their data suggest that good performance status, early FIGO stage initially, no residual tumor after first surgery, and the absence of ascites could predict complete resection in 79%. A longer disease-free interval has also been associated with an improved survival outcome. Salani and associates48 identified 55 patients who underwent secondary cytoreductive surgery for recurrent epithelial ovarian cancer at their institution with 12 months or more between initial diagnosis and recurrence, and five recurrence sites or less on preoperative imaging. The median survival for patients with 18 months or more diagnosis-to-recurrence interval was 49 months compared with median survival of 3 months for those patients with a diagnosis-to-recurrence interval less than 18 months (Fig. 7-22). Surgery for recurrent epithelial ovarian carcinoma should therefore be considered for patients with a localized recurrence, an extended disease-free interval of at least 6 to 12 months, and a good performance status. The resection of isolated hepatic and extra-abdominal disease such as solitary lung or CNS lesions also seems to afford a similar survival advantage for the affected patients.49

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