The Role of Surgery in the Management of Ovarian Cancer

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Sibley Memorial Hospital's Knowledge is Power lecture series on Ovarian Health. Presented by Jeffrey Y. Lin, M.D., director, Gynecologic Oncology.

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The Role of Surgery in the Management of Ovarian Cancer

  1. 1. Knowledge is Power Ovarian cancer series-2012The Role of Surgery in the Management of Ovarian Cancer Jeffrey Y. Lin, M.D. Director, Gynecologic Oncology Sibley Memorial Hospital
  2. 2. Objectives To learn the role of surgery in the treatment of ovarian cancer To understand when surgery may be beneficial and when it may be harmful
  3. 3. Primary surgery for ovarian cancer Rationale Usually performed as a laparotomy Establish primary cancer diagnosis Stage assignment based on surgico-pathologic findings (distribution of disease) Perform surgical “cytoreduction” of metastatic lesions if present Establishment of intraperitoneal (IP) access for chemotherapy Correct any obstructive problems
  4. 4. Surgical cytoreduction Goal: to remove all gross metastatic disease Technical principles − Use of retroperitoneal spaces − En-bloc resection − Resection of gi and urinary tracts with reconstruction − Resection of peritoneal surfaces − Resection of metastatic lymph nodes
  5. 5. Surgical cytoreduction Laparotomy with vertical incision for good exposure of entire abdomen
  6. 6. Surgical cytoreduction  En-bloc resection  Peritoneal stripping
  7. 7. Surgical cytoreduction subdiaphragmatic resection Recent emphasis on upper abdominal surgery − Omentum − Spleen − Diaphragm − Liver, gall bladder, pancreas
  8. 8. Surgical cytoreduction Completion of pelvic resection
  9. 9. Types of additional surgery Interval cytoreduction Secondary, tertiary cytoreductive surgeries Second-look laparotomy Palliative surgeries, generally for end-stage obstructive diseases − Colostomy − Gastrostomy
  10. 10. Rationale for additional surgery Disease assessment Acquistion of fresh tumor for molecular testing, drug resistance/sensitivity assays, cell culture Opportunity for secondary cytoreduction to improve survival Option for hyperthermic intraperitoneal chemotherapy
  11. 11. Second-look laparotomy Many patients with advanced ovarian cancer will have residual disease after completion of postoperative chemotherapy Second-look laparotomy traditionally has been regarded as the most sensitive test to identify persistent cancer Variations include laparoscopic approach
  12. 12. Problems with second-look laparotomy In women with a negative result, many recur eventually (false negative rate 20-50%, Gynecol Oncolog, Podratz and Cliby, 1994) Moderate morbidity associated with second-look surgery No demonstrable survival benefit Newer tumor markers and PET/CT may offer competitive sensitivity High economic costs
  13. 13. Secondary cytoreduction Salani R, et al, Cancer, 2007 Retrospective analysis of 55 women with recurrent ovarian cancer and secondary CTR in 1997-2005 Selection criteria included CR to chemotherapy, >12 mos from recurrence to initial surgery, 5 or less sites of recurrence Median age was 58 yrs, median tumor free interval was 32 mos Rate of complete CTR was 75%
  14. 14. Secondary cytoreduction Salani (continued) Survival − TFI>18 mos, then 49 mos vs 3 mos − Only 1-2 sites of tumor, then 50 mos vs 12 mos − Complete CTR, then 50 mos vs 7.2 mos − Age did not seem to be a statistically significant factor Morbidity for surgery − EBL 200 cc − Length of stay was 5 days − 1 death from sepsis (1.8%)
  15. 15. Secondary cytoreduction Oksefjell H et al., Annals Oncolog, 2009 Retrospective analysis from Radium Hospital 1985-2000 of 789 women with recurrent ovarian cancer Separation into 3 groups − Chemotherapy only (n=572) − Surgery with localized disease (1-2 lesions) (n=84)_ − Surgery with dessiminated disease (n=133) − Noted whether surgery was also for obstructive disease
  16. 16. Secondary cytoreduction Oksefjell (continued) 49% rate of complete cytoreduction (no macro disease) Most patients with bowel obstruction had dessiminated disease Patients treated solely with chemotherapy tended to have higher stage disease and more were older than 70 yrs Chemotherapy with taxane agent gave the best median survival (MS) of 3.7 yrs
  17. 17. Secondary Surgical Cytoreduction Oksfejell (continued) MS with chemotherapy was 1.1 yrs MS with complete CTR was 4.5 yrs MS with 0-2 cm CTR was 2.3 yrs Subset of chemotherapy (>12 mos TFI) was 2-2.6 Significant prognostic factors were TFI, desseminated disease and age >70 yrs
  18. 18. Interval cytoreduction Vergote I, et al, NEJM, 2010 Randomized prospective trial of the Gynecologic Cancer Intergroup Collaboration of 632 women with stage IIIC/IV ovarian, peritoneal or fallopian tube cancer to either cytoreductive surgery/postoperative chemotherapy or neoadjuvant chemotherapy/interval cytoreduction (CTR) Rate of successful primary CTR (<1 cm) was 42% Neoadjuvant chemotherapy was 3 courses of a platinum-based combination, followed by interval CTR with 3 additional courses of chemotherapy afterwards
  19. 19. Interval cytoreduction Vergote (continued) Survival (median overall) − Primary surgery group was 29 mos − Neoadjuvant group was 30 mos (hazard ratio was 0.98 (CI 0.84-1.13)) Authors conclusion was that either approach was reasonable for bulky advanced disease but that primary surgery was advisable for earlier stage III and less disease
  20. 20. Conclusions Surgery is an important component in the management of ovarian cancer Additional surgeries after primary chemotherapy may be of value While secondary surgical cytoreduction may be well accepted, the context in which it is to be employed is still being developed and its absolute benefit still has not been established by a randomized clinical trial

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