Surgical Staging

The importance of a thorough surgical staging was underscored by McGowan and colleagues57 when they reported in 1983 the stage distribution of 157 patients properly staged in comparison with data from the FIGO annual report of the same period showing a reduction in stage I figures from 28% to 16%, in stage II figures from 17% to 4%, and a reallocation to stage III from 55% to 80% when a thorough staging procedure was adopted. Similarly, Young and colleagues and subsequently Helewa and associates and Buchsbaum and associates showed that an accurate staging procedure resulted in a reallocation to a more advanced disease (stage III) in 31% of early-stage ovarian cancer.58-60 An analysis of surgeon specialty revealed that 97%, 52%, and 35% of gynecologic oncologists, obstetrician-gynecologists, and general surgeons, respectively, performed a comprehensive staging procedure for early-stage disease.57 In addition, Le and colleagues,61 in their retrospective chart review of patients with ovarian cancer macroscopically confined to the ovary at the time of laparotomy, found lack of proper surgical staging to be an important independent factor in predicting recurrence with an odds ratio of 2.62 (Fig. 7-24).

The primary procedure should include an abdominal incision that is adequate to explore the entire abdominal cavity. Care should be taken to remove the adnexal mass intact to prevent rupture, since this may impair prognosis. Any free peritoneal fluid is to be aspirated for cytology. If no free fluid is present, separate peritoneal

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40 60 80 100 Follow-up time (months)

Surgery status

- Unstaged

- Staged

Figure 7-24. Survival status of staged and unstaged patients with early-stage invasive epithelial ovarian cancer treated expectantly. (From Le T, Adolph A, Krepart GV, et al: The benefits of comprehensive surgical staging in the management of early-stage epithelial ovarian carcinoma. Gynecol Oncol 85:351-355, 2002, Figure 1.)

washings should be obtained from the pelvis, paracolic gutters, and infradiaphrag-matic area. These may be submitted separately or as a single specimen. All peritoneal surfaces, including the surface of both diaphragms and the serosa and mesentery of the entire gastrointestinal tract, should be visualized and palpated for evidence of metastatic disease. The omentum should be carefully inspected, and at minimum a biopsy of the omentum must be obtained.

If there is no evidence of disease beyond the ovary or the pelvis, peritoneal biopsies from the cul-de-sac, bladder peritoneum, right and left pelvic sidewalls, right and left paracolic gutters, and the right diaphragm should be carried out along with bilateral pelvic and periaortic lymphadenectomy with high para-aortic lymphadenectomy.

Controversies still exist as far as the extent of lymphadenectomy is concerned and, in particular, whether or not it has any therapeutic value. Benedetti Panici and associates62 reported in the interim analysis of their multicenter, prospective, randomized Italian study comparing the feasibility and morbidity of systematic versus selective lymphadenectomy in early-stage ovarian cancer that the relapse rates for the two groups was comparable (21%). Moreover, even if the percentage of patients found to have retroperitoneal involvement was obviously higher in the "systematic lymphadenectomy" group (14% versus 8%), no differences in disease-free or crude survival were seen. Cass and colleagues63 reviewed 96 patients with disease clinically confined to one ovary. Fifty-four patients had bilateral lymph node sampling performed, 30% of patients with lymph node spread had isolated contralateral metastases, highlighting the need for bilateral pelvic and para-aortic node sampling for accurate staging.

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