Surgical Resection and Reconstruction for Advanced and Recurrent Gynecologic Malignancies

Oliver Zivanovic; Dennis S. Chi

Disclosures

Expert Rev of Obstet Gynecol. 2008;3(5):677-690. 

In This Article

Abstract and Surgical Resection of Advanced Ovarian Cancer

The treatment of gynecologic malignancies entails surgery, systemic therapy and radiation therapy. Depending on the primary disease site and extent of the disease, the treatment strategies are applied alone or in combination. Over the past few decades, specialist knowledge and understanding of the pathophysiology and behavior of gynecologic neoplasms has led to a significant improvement in the relevant treatment modalities. The surgical management of gynecologic malignancies has evolved from the simple hysterectomy to more comprehensive staging procedures that are of pivotal importance for improving and estimating the prognosis and guiding the treatment of affected patients. These sometimes complex procedures encompass radical pelvic and upper abdominal surgery, including the associated urologic and intestinal procedures that are required to adequately resect the neoplasm. In this article, we will review and summarize the literature on the surgical resection and reconstruction of advanced and recurrent gynecologic malignancies with a focus on ovarian, endometrial and cervical cancers.

Primary cytoreductive surgery. Although ovarian cancer is the second most common gynecologic malignancy in the USA, with 21,650 estimated new cases in 2008, it is the most lethal gynecologic cancer with 15,520 estimated deaths.[1] While the stage-specific survival of patients with ovarian cancer is similar to those of other gynecologic malignancies, the overall poor prognosis can be explained by the fact that the majority of patients (60-70%) present at an advanced stage (International Federation of Gynecology and Obstetrics [FIGO] stageIII or IV).[2,3]

The natural history of advanced stageIII and IV ovarian cancer is one of clinical remission after primary cytoreductive surgery and postoperative chemotherapy followed by early or late recurrence in the majority of patients. Aggressive surgical cytoreduction and platinum plus taxane-based chemotherapy have improved the median overall survival from 1year in 1975 (stages II and III)[4] to approximately 5years in 2005 (optimally debulked stageIII).[5] However, the long-term cure rates languish between 20 and 30%.[5,6] The most important prognostic factors are primary surgical outcome and the response to postoperative chemotherapy.

Primary cytoreduction of advanced ovarian cancer. Primary surgical cytoreduction of advanced-stage ovarian cancer, also termed 'tumor debulking', is defined as an attempt to maximally resect all visible and palpable disease. Although this approach is a rare surgical strategy in the field of oncology and is not applicable or justified for the majority of other solid tumors, there is a large body of literature demonstrating a survival benefit for patients who are left with minimal ('optimal') disease after the surgical procedure. It has been known for more than 30years that women with advanced ovarian cancer who initiate systemic chemotherapy with an apparent small volume of residual disease after primary surgery experience a superior outcome compared with patients who cannot be optimally cytoreduced.[4] Since 1975, multiple retrospective studies have demonstrated that the amount of residual disease after cytoreductive surgery inversely correlates with progression-free and overall survival ( Table 1 ).[7,8,9,10,11,12,13,14]

Despite the retrospective evidence that the size of residual tumor after primary surgery is a highly prognostic factor of advanced ovarian cancer, there are no prospective randomized data supporting this concept. In other words, it is debatable whether it is the surgical procedure itself that is responsible for the superior outcome associated with smaller disease or whether the ability to achieve an optimal surgical outcome simply identifies a biologically more favorable patient subgroup.[15] Two prospective trials were initiated to answer that question but were closed due to poor accrual based on the strong bias favoring surgery.[16]

Bristow etal. reported on the survival effect of maximal cyto­reduction for ovarian cancer during the era of platinum-based chemotherapy. They conducted a meta-analysis of 81studies accounting for 6885patients with stageIII and IV ovarian cancer. Maximum cytoreduction was one of the most powerful determinants of survival in their meta-analysis. They further noted that, for a given cohort of patients, each 10% increase in the proportion of patients undergoing maximal cytoreduction resulted in a 5.5% increase in median survival time for that patient cohort.[17]

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