Salvage whole-abdominal radiation therapy after second-look laparotomy or secondary debulking surgery in patients with ovarian cancer

OBJECTIVES: Our aim was to determine the outcomes associated with use of whole-abdominal radiation therapy (WART) in women with ovarian cancer, to identify predictors of response, and to assess associated toxicity. METHODS: From 1981 through 2000, 171 women received WART at our institution after ovarian cancer surgery. Relevant clinical information was extracted through retrospective chart review. RESULTS: One hundred nine patients received WART after positive second-look laparotomy (SLL), and 62 were treated after secondary debulking (SD) for recurrent disease. The median dose to the whole abdomen was 25.5 Gy (range, 1.0-30.5 Gy). Therapy included a pelvic boost in 120 patients (70%) and a para-aortic boost in 21 patients (12%). The planned radiation course was completed in 123 patients (72%). In the SLL group, 5-year survival was 29% with a median follow-up of 98.4 months. The 5-year progression-free survival (PFS) was 41% in those with microscopic disease. There was one treatment-related death (1%). For the SD group, median PFS was 11 months and associated with treatment-related mortality in 5%. Overall, treatment-related small bowel obstruction occurred in 26 patients (15%). CONCLUSIONS: In patients with a positive SLL, WART should be considered only for those with microscopic residual disease. Treatment-related small bowel obstruction can be expected in 15% of these patients. Use of WART for recurrent disease appears to be related to serious bowel toxicity in 5% with an associated short disease-free interval; the therapeutic index of WART may not be acceptable in patients with recurrent disease regardless of the degree of cytoreduction.     

Our experience in the second look laparotomy for ovarian cancer

Our experience in second-look laparotomy for ovarian carcinoma is reported: in seven patients the second-look was negative; in two patients a neoplastic dissemination was found; in three patients we performed a debulking surgery.     

Lymphoceles following second-look laparotomy for ovarian cancer

In patients treated for ovarian cancer it is crucial to distinguish recurrent malignancy from a benign process. Presented herein is a patient who developed bilateral pelvic lymphoceles following a second-look laparotomy for ovarian cancer. Indications for surgical intervention are discussed and the preferred surgical approach is outlined.     

卵巢恶性肿瘤二次剖腹探查术中行腹膜后淋巴结清除术的研究

目的　探讨卵巢恶性肿瘤腹膜后淋巴结清除术的最佳时机和临床价值。方法　回顾性分析了 5 0例二次剖腹探查术 (SLL)中行腹膜后淋巴结清除术的卵巢恶性肿瘤患者的临床资料。结果　患者中位数年龄 49岁 ,其 3年和 5年生存率分别为 72 %和 62 %。SLL阳性率为 40 % ( 2 0 / 5 0 ) ,其中临床分期 [国际妇产科联盟 (FIGO)标准 ]Ⅰ期SLL阳性率为 0 % ( 0 / 15 ) ,Ⅱ期和Ⅲ期分别为 40 %( 4/ 10 )、62 % ( 15 / 2 4) ,Ⅳ期为 1例中 1例。SLL阳性率与临床分期的期别呈正相关 ,其中Ⅰ～Ⅱ期( 16% ,4/ 2 5 )和Ⅲ～Ⅳ期 ( 64 % ,16/ 2 5 )患者SLL阳性率比较 ,差异有极显著性 (P <0 0 1)。腹膜后淋巴结转移率为 3 2 % ( 16/ 5 0 ) ,其中Ⅰ、Ⅱ、Ⅲ期分别为 0 % ( 0 / 15 )、2 0 % ( 2 / 10 )、5 4% ( 13 / 2 4) ,Ⅳ期为 1例中1例。SLL阳性患者中 ,4例 ( 8% )仅盆腹腔内有转移灶 ,淋巴结无转移 ;6例 ( 12 % )仅显微镜下淋巴结转移 ,而无盆腹腔转移灶。SLL中 ,行二次肿瘤细胞减灭术共 2 0例 ,其中术后 13例残留灶直径≤ 0 5cm ,7例残留灶直径 >0 5cm。中位数随访时间 44个月 ( 2 4～ 10 4个月 ) ,至随访截止日SLL阴性者 ( 3 0例 )均无肿瘤复发。结论　腹膜后淋巴结清除术在SLL术中进行比较合理 ,而且对降低SLL阴性患     

A review of second-look laparotomy for ovarian cancer

One hundred twenty-seven patients underwent second-look laparotomies from July 1969 to June 1982. To be included in this report they must have met the following criteria: a documented ovarian neoplasm; previous surgery; adequate chemotherapy for cessation if no disease was found; and no X-ray, chemical, or clinical evidence of disease including an exam under anesthesia. Forty-one percent had residual disease at second-look laparotomy. The original stage and the percentage of tumor debulked at initial surgery were inversely related to the likelihood of finding residual disease. Age, histologic type and grade, and type of chemotherapy did not show a significant relationship with the likelihood of disease persisting. Recurrent tumor was subsequently detected in 16% of patients who had been found to be free of disease at second-look laparotomy. Of thirty stage III and IV patients treated with combinations containing cis-platinum, 10 (33%) had recurrences. This rate of recurrence was significantly greater than the 17.6% recurrence rate in 17 patients with Stage III and IV disease whose chemotherapy consisted of single alkylating agents or with combinations without cis-platinum. Twenty patients underwent a third-look laparotomy after completion of additional chemotherapy. Nine were found to have no residual disease. Two of the nine (22%) subsequently had recurrence of disease. Three of the eleven patients with persistent disease at the time of a third-look laparotomy underwent a fourth-look laparotomy. All were found free of disease and none have recurred. Six (55%) of those with persistent disease at the third-look laparotomy have died despite continued therapy. The ability to successfully treat some patients with persistent disease continues to be a justification for the use of a second-look laparotomy. However, the high rate of recurrence after cessation of treatment following the finding of no residual disease raises the question of whether it is appropriate to discontinue all therapy at this time.     

Role of an early second-look laparotomy in ovarian cancer

Of a group of 68 patients treated with standard polychemotherapy (CAP-5), 52 were evaluated by an early second-look laparotomy, preferably after three cycles of treatment. Of 21 patients with initial tumor residuals smaller than 2 cm, only 5 had residual tumor, and of 31 patients with tumor larger than 2 cm, 27 had residuals, which could be surgically debulked in 9 patients. Surgical evaluation led to termination of treatment in 6 patients with stable disease and to intensification of treatment in 5 younger patients with microscopic or bulky residuals. Thus, the second-look influenced therapeutic decisions and treatment policy in a total of 20 patients. The procedure went without severe complications for the duration of anesthesia; there was no difference between biopsy and debulking, but a larger amount of blood was lost during debulking surgery. Second-look laparotomy is well tolerated but should be performed only in selected cases, depending on the therapeutic options available.     

A comparison of findings at second-look laparotomy with preoperative computed tomography in patients with ovarian cancer

Prior to undergoing second-look laparotomy, 57 patients with ovarian cancer were evaluated with computed axial tomography (CT). All patients were clinically free of disease following chemotherapy. At laparotomy, 25 patients had visible evidence of disease, 9 had microscopic disease only, and 23 were free of cancer. Tumor was correctly identified on CT in 9 of the 25 patients (36%) with macroscopic disease. Tumors smaller than 2 cm in size were not detected by CT. CT suggested disease in 8 of the 32 patients (25%) who were free of macroscopic disease. CT provides useful information when it is abnormal. Fine needle aspiration of suspicious areas can spare some patients laparotomy. However, CT has a significant false-negative rate due to its inability to detect small volume disease. Patients with negative CT will continue to require reexploration and tissue confirmation to assess the need for further therapy.     

Ten-year follow-up of ovarian cancer patients after second-look laparotomy with negative findings

Objective: To determine long-term survival and predictors of recurrence in patients with platinum-treated ovarian cancer who were followed for 10 years after second-look laparotomy with negative findings.Methods: Records were reviewed of 91 consecutive patients with negative findings on second-look laparotomy after platinum-based chemotherapy between January 1978 and January 1987. Statistical analysis used Kaplan-Meier survival curves, Cox proportional hazards, and multiple logistic regression.Results: Mean age of patients was 57 (range 30–79) years. Distribution by stage and grade was as follows: stage I, ten; II, 18; III, 57; IV, six; grade 1, 18; 2, 28; 3, 45. Forty-seven of 91 women had optimal initial cytoreduction. Recurrence-free survival rates for all subjects were 75% at 2 years, 55% at 5 years, and 52% at 10 years. For women with stage I disease, the recurrence-free survival rate was 90% at 2, 5, and 10 years. For women with stage II disease, recurrence-free survival rates were 78, 72, and 66% at 2, 5, and 10 years, respectively. Patients with stage III or IV disease had recurrence-free survival rates of 72, 44, and 40% at 2, 5, and 10 years, respectively. Risk of recurrent disease was related to tumor stage (relative risk [RR] 2.02; 95% confidence interval [CI] 1.2, 3.3; P = .005), grade (RR 2.00; 95% CI 1.3, 3.2; P = .004), and presence of a residual tumor of more than 2 cm at the end of initial surgery (RR 3.19; 95% CI 1.2, 8.5; P = .02).Conclusion: Ovarian cancer patients face an appreciable risk of recurrence in the first 5 years after second-look laparotomy with negative findings after platinum-based chemotherapy, but those who remain disease free at 5 years have excellent long-term survival rates. Tumor stage, grade, and presence of a residual tumor of more than 2 cm after initial surgery are significant predictors of recurrence.     

The role of secondary cytoreductive surgery for recurrent ovarian cancer

OBJECTIVE: The aim of this study was to assess the survival benefit of salvage surgical cytoreduction in patients with recurrent ovarian cancer and compare the surgical outcome with salvage chemotherapy alone. METHODS: Seventy-five patients with recurrent ovarian cancer were reviewed for possible benefits of salvage therapy. Forty-four had salvage surgery and 31 patients had salvage chemotherapy alone for the treatment of gross recurrent disease. All patients had been clinically free of disease more than 6 months from the completion of primary treatment. RESULTS: A macroscopically complete surgical cytoreduction was obtained in 34 (77%) patients. Survival was significantly longer in patients who had salvage surgery compared to those who had salvage chemotherapy alone (P = 0.03). Moreover, survival was significantly longer in patients who were completely cytoreduced compared to those who were not completely cytoreduced and those who were not operated (P = 0.007 and P = 0.005, respectively). CONCLUSIONS: Macroscopically complete surgical cytoreduction significantly improves further survival of recurrent ovarian cancer patients. However, we remain in need to evaluate the debulkability of tumor before surgery to maximize the survival benefit and minimize the number of ineffective surgeries.     

Brain metastasis of ovarian cancer after negative second-look laparotomy

We present a case of ovarian carcinoma that had brain metastasis seven months after having a negative second-look laparotomy and 13 months after the onset of diagnosis. Despite intense multidisciplinary treatment with surgery, chemotherapy and radiotherapy, the patient died seven months after second-look laparotomy.     

The correlation between prognostic factors and outcome of second look laparotomy in ovarian cancer

OBJECTIVES: The objective of this study was to verify the correlation between prognostic factors, positive or negative second look laparotomy (SLL) and 5-year survival in patients with ovarian cancer. MATERIAL: Between 1984 and 1993, 178 patients after primary surgery and first-line chemotherapy with complete clinical response underwent second look laparotomy. The correlation between clinical stage and grade of cancers, residual disease, age of patients in two group of patients: with positive and negative second look laparotomy were evaluated. RESULTS: 95 patients (53%) had positive SLL. The 5-years survival in this group was only 20%. Adverse prognostic factors were: advanced primary stage (IV-0% of 5-years survival), low grade of differentiation (9.1% of 5-years survival) and residual disease > 2cm (9.4% of 5-years survival). The 5-year survival in group with negative SLL was 78.3%. The analysed prognostic factors in this group were insignificant in predicting 5-year survival. CONCLUSIONS: This study confirms that the SLL can provide an important prognostic evaluation in patients without evidence of disease and allows surgical cytoreduction in group with positive SLL (more than 50% of patients). The analyzed prognostic factors in group with negative SLL were insignificant in predicting 5-year survival. The multicenter research for new prognostic factors in this group are required.     

Results of second-look laparotomy in patients with early-stage ovarian carcinoma

One hundred twelve patients with early (FIGO stage I and II) ovarian carcinoma had a second-look laparotomy performed after comprehensive surgical staging and randomization into clinical protocols. Of the 95 patients who were asymptomatic before second-look laparotomy, only 5% had positive findings. In contrast, 53% of the 17 patients with findings that suggested recurrence or bowel obstruction had disease at second-look laparotomy. Overall, only 13% of the entire group of 112 patients had recurrent disease at second-look laparotomy. Asymptomatic patients with early ovarian carcinoma who have undergone careful initial surgical staging followed by appropriate adjuvant therapy can be spared a routine second-look operation.     

Polychemotherapy and second-look laparotomy in the management of the ovarian cancer

Polychemotherapy has proved to be a method of choice in the management of the ovarian cancer. The second-look operation helps exact estimation of the patient's conditions after chemotherapy. Our experience shows that chemotherapy improves the mobility of the malignant neoplasm. As yet we have not decided on the optimal time of reoperation of the residual tumours. For now, we have been performing it after 3-4 trials of the intermittent polychemotherapy. The dilemma has still remained when to stop the treatment of polychemotherapy after positive second-look operation and whether to apply the third-look approach. Our experience suggests that non-differentiated malignant tumours require more aggressive chemotherapy while compared with the differentiated tumours of the same stage.     

Is routine second-look laparotomy for ovarian cancer justified?

Thirty-nine patients with epithelial ovarian malignancy underwent second-look laparotomy (2LL), as part of their plan of management at the Johannesburg University Hospital. Twenty-eight patients (71.8%) were found to have no gross or microscopic evidence of disease. Only 1/12 (8.3%) of patients with initial Stage I disease had evidence of persistent disease and after a median follow-up of 53 months (range 29-77) after 2LL, the remaining 11 remain free of relapse. Second-look laparotomy is regarded as unjustified in this subgroup of patients. Twenty-nine percent of the patients with advanced disease (Stage III and IV) who were disease-free at 2LL subsequently developed recurrent disease and died. In this group 2 additional patients died of nonmalignant disease. All 3 of the patients with original Stage II disease were disease-free at 2LL, but subsequent recurrence developed in 1 patient. On the basis of the findings in this study and evidence in the literature, the practice of submitting patients who are in complete clinical remission to 2LL as part of their management plan is questioned and challenged.     

Influence of secondary cytoreduction at the time of second-look laparotomy on the survival of patients with epithelial ovarian carcinoma

The value of secondary cytoreductive surgery at the time of second-look laparotomy in patients with epithelial ovarian carcinoma is not established. Sixty-seven patients with residual carcinoma found at the time of second-look laparotomy performed at Memorial Sloan-Kettering Cancer Center between December 1, 1978, and May 30, 1986, were evaluated for survival relative to the success of secondary cytoreductive surgery. At second-look laparotomy, 17 patients had microscopic disease, 28 patients had disease less than 2 cm and 22 patients had disease greater than 2 cm. After secondary cytoreductive surgery 33 patients had microscopic disease, 26 patients had disease less than 2 cm, and 7 patients had disease greater than 2 cm (1 unknown). Five-year survival by Kaplan-Meier calculation was 62% for patients found to have microscopic disease at second-look laparotomy and 51% for patients whose disease was rendered microscopic by secondary cytoreductive surgery (P = 0.55). Patients left with gross disease (either less than or greater than 2 cm) had 5-year survivals of less than 10% (P = 0.013 compared with microscopic residual). Secondary cytoreductive surgery at the time of second-look laparotomy in patients with epithelial ovarian carcinoma may result in improved survival of patients who are reduced to microscopic residual disease.     

The role of second-look laparotomy in treatment of epithelial ovarian cancer

Forty-two patients underwent a second-look laparotomy to assess response to systemic chemotherapy for epithelial ovarian cancer. In 20 cases the operation showed no histologic evidence of disease. None of these cases received additional treatment at the time of negative second-look laparotomy. There has only been one recurrence noted in an average follow-up interval of 38.5 months. The remaining 22 cases did have residual carcinoma and 16 have developed progressive carcinoma despite secondary treatment. We found second-look laparotomy to be a safe and reliable assessment tool. However, we could not demonstrate a medical benefit from the procedure.     

The prognostic and therapeutic value of second-look laparotomy in advanced ovarian cancer

Summary. Of 267 patients with ovarian cancer FIGO stages III and IV, 157 underwent second-look laparotomy after combination chemotherapy consisting of cis-platinum and cyclophosphamide with and without doxorubicin. At second-look operation 45% had macroscopic tumour, 15% microscopic tumour, and 40% complete pathological response. Survival 3 years after second look was: complete pathological response 74%; microscopic disease 24%; visible tumour <1 cm 28%; visible tumour >1 cm 17%; negative cytology 59%; and positive cytology 18%. Of the patients with macroscopic tumour, 29% had all visible tumour removed at second look. Three-year survival for these patients was about 45%.     

The prognostic and therapeutic value of second-look laparotomy in advanced ovarian cancer

Of 267 patients with ovarian cancer FIGO stages III and IV, 157 underwent second-look laparotomy after combination chemotherapy consisting of cis-platinum and cyclophosphamide with and without doxorubicin. At second-look operation 45% had macroscopic tumour, 15% microscopic tumour, and 40% complete pathological response. Survival 3 years after second look was: complete pathological response 74%; microscopic disease 24%; visible tumour less than 1 cm 28%; visible tumour greater than 1 cm 17%; negative cytology 59%; and positive cytology 18%. Of the patients with macroscopic tumour, 29% had all visible tumour removed at second look. Three-year survival for these patients was about 45%.