Long-term survival of 106 stage III ovarian cancer patients with minimal residual disease after second-look laparotomy and consolidation radiotherapy

OBJECTIVE: Attempts to increase survival in stage III ovarian cancer patients with minimal residual disease at second-look laparotomy have included consolidation radiotherapy. We present long-term survival of 106 consecutive patients treated between 1983 and 1993 in 4 French institutions for stage III ovarian adenocarcinoma with first-look debulking, cisplatin-based chemotherapy, second-look surgery with a residual disease <1 cm and consolidation radiotherapy. METHODS: Median age was 52 years. Residual disease after first look surgery was <1 cm for 40.5% of patients. Median number of chemotherapy cycles was 6 (range 4-12). Residual disease <1 cm at second-look laparotomy was observed in 79% of the patients, with 33% of patients in complete histologic remission. Residual disease <1 cm was obtained in all patients after tumor excision during second-look surgery. Radiation was performed using a linear accelerator with a whole abdomen dose of 22.5 Gy, an additional 22 Gy pelvic boost for 71 patients, and an additional 12 Gy lombo-aortic boost for 33 patients. RESULTS: Median follow-up was 14 years. Radiation was stopped for acute toxicity in 11 patients. Long-term toxicities included radiation enteritis in 21 patients with 9 patients requiring surgery for bowel obstruction. Four deaths were related to enteritis complications. Overall survival at 5 and 10 years was respectively 53% and 36%. CONCLUSION: This sequential treatment with final consolidation abdominopelvic radiotherapy is an effective treatment for a selected group of stage III ovarian cancer patients with a high intestinal toxicity incidence.     

The prognostic implications of low serum CA 125 levels prior to the second-look operation for stage III and IV epithelial ovarian cancer.

Second-look laparotomy is performed to evaluate response to chemotherapy and to determine the need for additional treatment. The relationship between absolute levels of serum CA 125 less than 35 u/ml and disease status at second-look operation was evaluated in 95 patients with advanced-stage epithelial ovarian cancer. Eighty-six patients had Stage III disease and nine patients had Stage IV cancer. Residual tumor was documented at second-look laparotomy in 52 (55%) of the patients studied. Forty-nine percent of the 82 patients with serum CA 125 values less than 20 u/ml had residual disease. In contrast, 12 of 13 (92%) patients with serum CA 125 values of 20-35 u/ml had residual tumor at second-look laparotomy. All patients with serous cystadenocarcinomas and serum CA 125 values of 20-35 u/ml had residual tumor, and two-thirds of these cases had grossly visible disease. The positive predictive value of a serum CA 125 level of 20-35 u/ml was 0.92. These data suggest that second-look laparotomy should be deferred in patients with advanced-stage ovarian cancer until serum CA 125 values are less than 20 u/ml.     

Prognostic factors for recurrence following negative second-look laparotomy in ovarian cancer patients treated with platinum-based chemotherapy

Prior studies of the risk of recurrence following negative second-look laparotomy have included patients treated with a variety of chemotherapeutic regimens, including nonplatinum regimens. We have examined the long-term outcome and risk factors for recurrence among a homogeneous group of platinum-treated patients. During the years 1978-1987, 91 patients at Memorial Sloan-Kettering Cancer Center had a negative second-look laparotomy following platinum-based chemotherapy for epithelial ovarian cancer. The mean age at diagnosis was 57 years, with a range of 30 to 79. Distribution by stage was as follows: I, 10; II, 18; III, 57; IV, 6. The mean number of cycles of platinum prior to second-look surgery was 6.3. The mean number of biopsies taken at negative second-look laparotomy was 12. Lymph node biopsies were done in 47/91 (52%) of patients. Median follow-up from the date of second-look laparotomy was 54.6 months among survivors. Forty of ninety-one patients (44%) have had recurrence, almost 40% of which were outside the peritoneal cavity. The mean interval from negative second-look laparotomy to recurrence was 24 months (range, 2-70 months). By multivariate analysis the risk of recurrence was significantly related to stage (P = 0.017), histologic grade (P = 0.041), and the amount of tumor remaining after the first operation for ovarian cancer (P = 0.015). Recurrence by stage was as follows: stage I, 1/10 (10%); stage II, 5/18 (28%); stage III, 31/57 (54%); stage IV, 3/6 (50%). Recurrence by grade was as follows: grade 1, 4/18 (22%); grade 2, 11/28 (39%); grade 3, 25/45 (56%). There was no relationship between the risk of recurrence and the number of cycles of platinum, the number of biopsies performed at second-look, or the number of months from primary surgery to second-look. Patients having negative second-look laparotomy following platinum-based chemotherapy for advanced epithelial ovarian cancer have a substantial risk of recurrence, particularly within the first 3 years. Such patients should be offered participation in clinical trials of consolidation therapy directed against both intraperitoneal and extraperitoneal disease.     

Prediction of the presence of ovarian cancer at surgery by an immunochemical panel: CA 125 and copper-to-zinc ratio

Preoperative levels of the trace elements copper and zinc, in addition to the level of the known marker CA 125, were studied in sera of 32 patients undergoing exploratory laparotomy for suspicion of ovarian cancer and in sera of 49 patients with the diagnosis of ovarian cancer prior to second-look operation. Most patients (63/81) had stage III or IV disease. CA 125 levels greater than 35 U/ml, copper levels greater than 1.5 mg/liter, and zinc levels less than 0.9 mg/liter were considered pathologic. An immunochemical panel composed of CA 125 serum level and ratio of copper to zinc (Cu/Zn) (normal less than 1.65) was found to be most sensitive (98%) in predicting the existence of ovarian cancer before laparotomy, and its overall predictability was 89%. In 14 of 14 patients (100%) who had complete primary surgery for ovarian cancer, the panel was correct in predicting no tumor at second-look operation. In 13 of 14 patients (93%) who had incomplete primary surgery but had no clinical evidence of disease prior to second-look operation, the panel was correct in predicting ovarian cancer. In these two groups of patients, second-look operation could have been replaced by the results of the immunochemical panel.     

Abdominopelvic irradiation for stage II-IV ovarian carcinoma patients with limited or no residual disease at second-look laparotomy after completion of cisplatinum-based combination chemotherapy

Abdominopelvic irradiation was given to 18 stage II-IV ovarian carcinoma patients who completed cisplatinum-based combination chemotherapy, were in complete clinical remission, and who underwent second-look laparotomy. The survival as well as the progression-free interval (PFI) was significantly longer in patients with a negative second-look laparotomy than in those with limited residual disease at this operation. Abdominopelvic irradiation was not effective in patients with limited residual disease at second-look laparotomy (3 year survival--34.3% and median PFI from second-look laparotomy--4.8 months). Even in patients with a negative second-look laparotomy the median PFI was only 13 months from this operation and the 3-year survival was 87.5%. The results were similar to other comparable series in which no treatment was administered to patients with a negative second-look laparotomy.     

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     

The effects of CO2 pneumoperitoneum on the survival of women with persistent metastatic ovarian cancer

OBJECTIVES: The effects of CO(2) pneumoperitoneum on the survival of women with metastatic ovarian cancer have not been documented. We sought to describe the survival of women with persistent stage III-IV ovarian cancer as documented by positive second-look laparoscopy or laparotomy and to see whether the laparoscopic approach with CO(2) pneumoperitoneum has a negative effect on overall survival. METHODS: We conducted a retrospective review of all patients with FIGO stage III-IV invasive epithelial ovarian cancer who were found to have persistent disease at second-look surgery. All patients underwent primary surgery followed by intravenous chemotherapy and were clinically without evidence of disease prior to second-look surgery. Second-look laparoscopy began to be utilized regularly in 1994. The selection of the second-look surgical approach depended on the surgeon's discretion. CO(2) pneumoperitoneum was utilized for all laparoscopic cases with the maximum intra-abdominal pressure maintained at 15 mm Hg. Patients received a variety of additional intravenous, intraperitoneal, or oral chemotherapy following positive second-look surgery. RESULTS: Between 6/1/91 and 6/30/02, 289 patients were found to have persistent ovarian/peritoneal cancer at second look. Second-look operations included 131 (45%) transperitoneal laparoscopies and 139 (48%) laparotomies. Nineteen (7%) patients underwent laparoscopy followed immediately by laparotomy. The mean age, stage distribution, histology, grade, and size of residual disease at second look did not differ between the two groups. The median overall survival for patients who underwent laparoscopy, 41.1 months (95% CI, 33.2-58.1), did not significantly differ from that of the laparotomy group, 38.8 months (95% CI, 31.9-44.2) (P = 0.742). CONCLUSIONS: Transperitoneal laparoscopy with CO(2) pneumoperitoneum does not appear to reduce the overall survival of women with persistent metastatic intra-abdominal carcinoma of ovarian/peritoneal origin. The overall survival appears to be independent of the second-look surgical approach.     

Value of lymph node assessment in ovarian cancer: Status of the art at the end of the second millennium

Abstract. di Re F, Baiocchi G. Value of lymph node assessment in ovarian cancer: Status of the art at the end of the second millennium.
Available data on the incidence and the clinical value of lymph node assessment in ovarian cancer are reported. In early ovarian cancer, positive nodes are found in 4–25% of patients. Serous adenocarcinoma and poorly differentiated tumors are characterized by the highest incidence of node metastases. Five-year survival for stage IIIC disease with only retroperitoneal spread is clearly better than for stage IIIC with intraperitoneal dissemination. In advanced ovarian cancer, the rate of node involvement ranges from 55 to 75%. The percentage of positive nodes is significantly related to the amount of residual tumor after cytoreductive surgery, and node status seems to be an important prognostic factor for survival. Although data from retrospective studies advocate a therapeutic effect for systematic lymphadenectomy, results from prospective randomized trials are warranted. After chemotherapy a high percentage of patients (range, 25–77%) are found to have metastatic nodes. In particular, at second-look laparotomy, positive nodes are detected in 17–40% of patients who have no intraperitoneal disease.     

Is it justified to classify patients to Stage IIIC epithelial ovarian cancer based on nodal involvement only?

BACKGROUND: Stage IIIC epithelial ovarian cancer is generally associated with upper abdominal tumor implants of greater than 2 cm and carries a grave prognosis. A subset of patients is upstaged to Stage IIIC because of lymph node metastases, in which prognosis is not well defined. We undertook this study to describe the clinical behavior of occult Stage IIIC. METHODS: All consecutive patients found to have Stage IIIC epithelial ovarian cancer during a 9-year period (1994-2002) were analyzed for surgical procedures, pathology, and disease-free (DFS) and overall survival (OS). RESULTS: Thirty-six patients were upstaged to Stage IIIC by virtue of positive nodes. Nine had small volume upper abdominal disease (IIIA/B before upstaging), 15 had disease limited to the pelvis and 12 had disease confined to the ovaries. 32/36 patients had no gross residual disease at the conclusion of surgery. The 5-year DFS and OS survivals were 52% and 76% respectively, for all patients. We observed no significant difference in outcomes between patients upstaged from IIIA/B versus I-II stage disease. The outcomes were superior to a control group of patients cytoreduced to either no gross RD or RD<1 cm, who had large volume upper abdominal disease at beginning of surgery (p<0.001). CONCLUSIONS: Patients upstaged to Stage IIIC epithelial ovarian cancer for node involvement have an excellent 5-year OS relative to all patients with Stage IIIC disease. These data demonstrate the necessity for stratifying patients classified as having Stage IIIC disease based solely on nodal disease when comparing outcomes. This information is particularly valuable when counseling patients regarding prognosis.     

Advanced papillary adenocarcinoma of unknown origin as tumor previa during late pregnancy

A 41-year-old woman with advanced abdominal adenocarcinoma presented at term pregnancy. The tumor was presented as previa and obstructed the delivery. A cesarean section was performed and a healthy child was born. At surgery diffuse metastatic disease was detected throughout the pelvis and abdomen and was partially resected. Combined chemotherapy consisting of cis-platinum, adriamycin and cytoxan was administered for 5 months. At second-look laparotomy no residual disease was found. We present an unusual presentation of metastatic abdominal undifferentiated carcinoma treated as ovarian cancer.     

The value of second-look operation in patients with advanced epithelial ovarian carcinoma

Summary A second-look operation was performed on 151 patients with stage III and IV epithelial ovarian carcinoma who had responded to primary surgery and chemotherapy. 19% of the 79 patients who appeared clinically to be free of disease had microscopic recurrences and 23% had macroscopic residual disease at a second-look operation. The 5-year survival rate for patients with no histological and for those with microscopic secondaries at second-look operation were 55% and 35% respectively (P=0.45). Only patients with well or moderately well differentiated tumors and a small residual tumor mass at first operation had a good prognosis after a second-look operation even without further chemotherapy. Median survival after secondary debulking was 15 to 17 months and was independent in the radicality of the second-look procedure. Outside of clinical trials second-look laparotomy should therefore only be performed as a diagnostic procedured as a diagnostic procedure in patients with well or moderately well differentiated tumors who are left with a small residual tumor mass at the time of the first operation. Because this is a group of patients in whom chemotherapy can be discontinued after a negative second-look operation.     

Use of second-look laparotomy in the management of patients with ovarian epithelial malignancies

Between June 1976 and January 1986, 94 evaluable patients with stage I-IV disease underwent second-look laparotomy as part of their treatment for ovarian epithelial carcinomas. Stage and residual tumor size after initial debulking surgery demonstrated a significant association with absence of disease at reexploration. Forty-nine patients (52%) had no evidence of disease at second-look laparotomy. Thirty patients (32%) had macroscopic residual tumor, and 15 patients (16%) had microscopic disease at reexploration. Patients with a negative second-look laparotomy had an excellent prognosis; uncorrected 2- and 5-year survival rates exceed 90%. None of the patients with stage I or II disease developed recurrent tumor after a negative second-look laparotomy. However, 7 of the 25 (28%) patients with stage III disease and a negative second-look have demonstrated recurrent carcinomas. Recurrences were documented from 15.4 to 51.7 months after second-look laparotomy and were located within the abdominal cavity. Life table methods demonstrated improved survival for patients with microscopic disease as compared to those with gross tumor at second-look survey. Both groups had similar mean patient ages and tumor stage distributions. Patients with microscopic residual disease had uncorrected 2- and 5-year survival rates of 76 and 64%. The 2-year uncorrected survival rate for patients with gross tumor at second-look laparotomy was 25%. Thirty patients with macroscopic disease at second-look laparotomy underwent a repeat attempt at tumor debulking. Seventeen patients completed second-look surgery with residual disease less than 1 cm in maximum dimensions. Life table methods demonstrated improved survival when residual disease was less than 1 cm. Regardless of residual tumor size after reexploration, patients with gross tumor had a worse survival than those with microscopic disease.     

Correlation of serum and ascitic IL-12 levels with second-look laparotomy results and disease progression in advanced epithelial ovarian cancer patients

Forty-two consecutive patients with advanced epithelial ovarian cancer who underwent primary surgical treatment were evaluated. The control group comprised 21 patients who had undergone surgery associated with benign pathologies. Forty-one patients had stage III disease except one who had stage IV. Optimal debulking (<1 cm) was performed in all the patients who subsequently received chemotherapy. Based on the results of the second-look laparotomy and follow-up, the patients were divided into three groups: the first group had negative second-look laparotomy or no evidence of disease during follow-up (n= 21), the second group had positive second-look laparotomy or progressive disease (n= 21), and the third was the control group (n= 21). Interleukin-12 (IL-12) levels were measured in preoperative serum and intraoperative ascites samples for all the patients. The mean serum IL-12 levels (+/-SD) in serum (S) and ascites (A) were as follows: in the first group, S: 108.44 +/- 76.40 pg/mL and A: 330.93 +/- 125.25 pg/mL; in the second group, S: 51.80 +/- 40.95 pg/mL and A: 206.89 +/- 113.47 pg/mL; and in the control group, S: 36.55 +/- 33.16 pg/mL and A: 93.62 +/- 73.07 pg/mL (P= 0.01). In the patients with advanced ovarian cancer, IL-12 levels in serum and ascites were higher compared to the levels of the controls. Also, there was an inverse relationship between initial serum and ascitic IL-12 levels and disease progression.     

Advanced ovarian cancer patients with no evidence of disease after platinum-based chemotherapy: retrospective analysis of the role of second-look.

From 1981 to 1992, 230 previously chemotherapy-untreated epithelial ovarian cancer patients (Stages IIb-III or IV) received platinum-based polychemotherapy at our Division. In this presentation, time to progression and overall survival rates were retrospectively analyzed in 89 epithelial ovarian cancer patients (stage IIb, c - III or IV) with no clinical evidence of disease (clinical complete remission--CCR--in 26 patients with postsurgical residual tumor > or = 2 cm, and no clinical evidence of disease--NED--in 63 patients with post-surgical residual tumor < 2 cm) after first-line platinum-containing chemotherapy. After at least 6 courses of chemotherapy, 62 patients (group A) were submitted to second-look (SL) laparotomy (n=47) or laparoscopy (n=15); 27 patients (group B) did not undergo second-look surgery because of patient refusal, the surgeon's decision or clinical contro-indications to surgery. Groups A and B were comparable in terms of post-surgical residual tumor (< 2 cm: 71% vs 70%), median Performance Status (WHO: 1) and median age (56 vs 57 yrs). FIGO stage IIb, c was more frequent in group B (26% vs 18%--p=0.004). In 9/18 (50%) patients with clinical CR and in 31/44 (70%) NED patients no residual tumor was confirmed at SL (pathological CR--pCR). After a median follow-up of 10 years (range 5-16 years), 72% (64/89) of patients relapsed and 65% (58/89) died. Survival was significantly longer in patients with pCR (median survival 76 months vs 32, 29 and 16 months for patients with pPR, pNC or pPD, respectively, p=0.0001). Multivariate analysis identifies pCR as the only significant prognostic factor exerting an influence on survival after second-look laparotomy (p=0.0000). This study confirms that the second-look can provide an important prognostic evaluation in patients without evidence of disease after chemotherapy for ovarian cancer stages III-IV.     

Retroperitoneal nodal metastasis in primary and recurrent granulosa cell tumors of the ovary

OBJECTIVE: To describe the incidence of retroperitoneal pelvic or paraaortic lymph node metastasis in patients with primary and recurrent ovarian granulosa cell tumors. METHODS: At Memorial Sloan-Kettering Cancer Center, we conducted a retrospective chart review of all patients with ovarian granulosa cell tumors managed as inpatients from January 1991 to July 2005. The initial date of diagnosis ranged from 1971 to 2005. RESULTS: We identified 68 patients with a median age of 49 years (mean, 47.5 years; range, 19-78 years). Sixty-four (94%) patients had adult type and 4 (6%) had juvenile granulosa cell tumors. Fifty-three (78%) patients had their initial surgery at another institution and 55 (81%) were incompletely surgically staged at diagnosis due to the absence of pelvic and/or aortic lymph node dissection. Patients were assigned an International Federation of Gynecology and Obstetrics (FIGO) stage that included IA, 39; IC, 15; IIB, 3; IIC, 3; IIIC, 1. In 7 patients, the original stage was not assigned. Only 16 (24%) patients had a pelvic lymph node sampling and 13 (19%) also had a paraaortic lymph node sampling at primary surgery or at restaging surgery performed shortly following initial diagnosis; however, in these cases, lymph nodes were negative for metastasis. The median number of pelvic lymph nodes removed was 10 (mean, 11.6 nodes; range, 0-36 nodes). The median number of paraaortic lymph nodes removed was 4 (mean, 6 nodes; range, 0-19 nodes). Nine of 15 (60%) of patients managed initially at our institution were surgically staged compared to 4 of 53 (7.5%) who were managed initially elsewhere (P < 0.001). Thirty-four patients with recurrent granulosa cell tumors were managed during the study, 31 (91%) had adult type granulosa cell tumor, and 3 had juvenile histology. Thirty-three of 34 patients who recurred were incompletely surgically staged at the initial operation. Original "clinical" FIGO stage for patients who recurred included IA, 15; IC, 8; IIB, 1; IIC, 3; IIIC, 1; and in 6 patients, the original stage was not available. The median disease-free interval to first recurrence was 63 months (mean,69.4 months; range, 4-170 months). First recurrence sites included pelvis, 24/34 (70%); pelvis and abdomen, 3 (9%); retroperitoneum only, 2 (6%); pelvis and retroperitoneum, 2 (6%); pelvis/abdomen/retroperitoneum, 1(3%); abdomen only, 1 (3%); and bone, 1 (3%). CONCLUSIONS: Complete surgical staging was performed in approximately 1/5 women with ovarian granulosa cell tumors; however, in those initially surgically staged, no nodal metastasis was identified. Clinical stage IA disease was the most common original diagnosis in women who recurred, and approximately 15% of first recurrences appear to involve the retroperitoneum.     

Second-look laparotomy in the management of gynecologic malignancy

Eighty-four second-look laparotomies performed between June 1972 and March 1981 were reviewed. Sixty-three patients had epithelial carcinoma of the ovary. The other malignancies represented include nonepithelial cancer of the ovary, cancer of the uterine fundus, and adenocarcinoma of the fallopian tube. All patients were without objective evidence of intraperitoneal disease just prior to the laparotomy. In the epithelial ovarian carcinoma group, the outcome of the laparotomy was affected by stage, histologic type, histologic grade, and presence of residual disease after initial tumor-reductive surgery. The type of treatment didn't seem to affect laparotomy outcome. Recurrence after a negative second-look laparotomy was affected by stage and presence of residual disease after initial tumor reduction. The second-look laparotomy remains the most sensitive indicator of persistent disease in epithelial carcinoma of the ovary. Experience with second-look laparotomies in other gynecologic malignancies is increasing.     

Long-term survival in stage III and IV ovarian cancer

Summary A total of 104 unselected, previously untreated patients with invasive stage III or IV ovarian cancer were operated on between 1977 and 1984. Nine patients were lost in follow-up, three died from non-malignant disease. Thirteen of the 92 eligible patients (15%) were observed to survive 5 years or longer. In the 13 long-term survivors, 4 had stage IV disease, 7 positive peritoneal cytology, 3 bowel resection, and 12 residual disease <2 cm after primary surgery. Retroperitoneal lymph nodes were involved in 6/9 cases. The majority of 5-year survivors (69%) received cis-platin-containing combination chemotherapy. 5/7 long-term survivors had positive second-look. At 5 years, life-quality in 9/13 patients who were free of disease, was high. It can be concluded that only patients with optimally resected stage III or IV ovarian cancer have a realistic chance of long-term survival. It is expected that increasing radicality in surgery for ovarian cancer together with platinum-based chemotherapy regimens may improve long-term survival in the future. In addition, further studies of new chemotherapeutic approaches are needed.     

Correlation of platelet count with second-look laparotomy results and disease progression in patients with advanced epithelial ovarian cancer

OBJECTIVE: To evaluate the significance of preoperative platelet counts in advanced epithelial ovarian cancer with respect to second-look laparotomy results and disease progression. METHODS: We prospectively evaluated 37 consecutive patients with advanced epithelial ovarian cancer who underwent primary surgical treatment. In addition to platelet counts, all patients were evaluated with respect to age, gravida, parity, and stage and grade of tumor. Thirty-six patients had stage III, and 1 patient had stage IV disease. Optimal debulking (diameter of residual tumor, less than 1 cm) was performed in all patients who subsequently received adjuvant chemotherapy (platin-paclitaxel). According to second-look laparotomy and follow-up results patients were divided into 2 groups. The first group had negative second-look laparotomy or no evidence of disease during follow-up (n = 20), and the second group had positive second-look laparotomy or progressive disease (n = 17). Sensitivity and specificity values were calculated for different cutoff values of platelet counts with receiver operating characteristic curve analysis. RESULTS: Age, gravida, and parity were not significantly different compared with controls (P >.05). Mean platelet counts were 371 x 109/L and 446 x 109/L in the first and second groups, respectively (P =.03). Different cutoff values of platelet counts for the diagnosis of thrombocytosis were evaluated. A cutoff value of 380 x 109/L had sensitivity 77% and specificity 60% for recurrence, whereas a cutoff value of 400 x 109/L had sensitivity 59% and specificity 65%. Area under the curve (+/- standard error) was 0.72 +/- 0.08 (P =.026). CONCLUSION: In patients with progressive disease and positive second-look laparotomy, preoperative platelet counts were significantly higher compared with patients with no evidence of disease on follow-up.     

Second-look laparoscopy in ovarian cancer

Forty-six patients with epithelial ovarian cancer previously treated with surgery, chemotherapy or external radiation underwent second-look laparoscopy to evaluate management. Twenty of the patients had positive laparoscopic findings and were not subjected to further laparotomy. The frequency of positive findings was related to the stage of the disease. Laparoscopic examination revealed no evidence of cancer in the remaining 26 patients. Three of the patients in this group were found to have additional disease at subsequent laparotomy. The laparoscopic procedures were not associated with major complications. Although second-look laparoscopy cannot replace repeat laparotomy, it does have a role in the follow-up of patients with ovarian cancer.     

The second‐look operation improves survival in suboptimally debulked stage III ovarian cancer patients

In a single-institution retrospective cohort study, 230 patients were treated for stage III primary ovarian cancer and 175 became eligible for second-look operations by virtue of a complete clinical response after primary surgical cytoreduction and platinum-based combination chemotherapy. Of these, 109 underwent a second-look operation. Optimal primary cytoreduction was defined as residual disease < or =1 cm. Median follow-up was 68.3 months. Five-year survival for all the 230 stage III ovarian cancers was 43.4%. Among all eligible patients (n = 175), there was no survival difference (P = 0.67) in those having second look (57.3%, 5-year survival) versus no second look (48.7%). In those patients with optimal primary cytoreduction (n = 118), there was no survival advantage to second look (69% versus 61%, P = 0.7). However, in those with suboptimal primary cytoreduction (n = 47), 5-year survival was 36% in those having second look versus only 13% in those refusing second look (P < 0.05). Multivariate analysis identified second-look surgery as the only significant independent prognostic variable affecting survival (RR = 0.321, P < 0.04). Patients with suboptimal debulking at primary surgery for stage III ovarian cancer appear to achieve a survival benefit from second-look surgical procedures, presumably from the early identification and treatment of residual disease.