Ovarian Cancer Controversies: Examining the Options After Primary Treatment

, National Cancer Institute

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Second-look Surgery

For some time now, an area of considerable controversy has been the role of second-look laparotomy (SLL) at the conclusion of primary therapy of advanced ovarian cancer. Advocates have promoted second-look surgery as an opportunity to evaluate the patient's response to initial chemotherapy, to perform secondary cytoreduction, and to direct subsequent therapy. Second-look surgery is clearly more accurate than CT scan or CA-125 measurement in determining the presence and extent of persistent disease and avoiding premature termination of therapy. Opponents of this procedure, on the other hand, have argued that second-look surgery potentially can benefit only a small subset of patients.[10]

The NIH Ovarian Cancer Consensus panel has recommended that second-look procedures be reserved for patients in clinical-trial protocols or in cases in which second-look findings might change subsequent management. Until recently, the absence of effective salvage or consolidation therapy for advanced ovarian cancer strengthened the arguments against second-look surgery. Several recent developments, however--such as the introduction of paclitaxel and advances in high-dose chemotherapy--have improved salvage therapy, suggesting that second-look surgery be considered more often.[11]

Second-look surgery may help women and their physicians to decide on further therapy after 6 courses of platin/paclitaxel. The woman with negative findings on the second-look procedure might be spared further therapy, for example, or might be offered a short course of consolidation therapy. Barter and Barnes[12] reported a 23% recurrence rate among 1511 patients with negative findings on second-look surgery from 38 series; these data suggest that even women found to have negative results on a second-look procedure should be considered candidates for some form of consolidation therapy. Patients who have minimal residual disease--for instance, without extensive adhesions--would become potential candidates for intraperitoneal therapy. Patients with minimal residual platinum-sensitive disease might be considered for high-dose chemotherapy trials. Examining this option, in fact, is an aspect of the newly opened intergroup trial, jointly conducted by the GOG, the Eastern Cooperative Oncology Group, and the Southwest Oncology Group (SWOG) (see footnote 1). To be eligible for participation in this trial of high-dose chemotherapy with hematologic support versus consolidation treatment with carboplatin/paclitaxel, subjects must agree to undergo second-look surgery that allows oncologists to identify patients with minimal residual platinum-sensitive disease.

While second-look surgery can help the clinician and the patient with advanced ovarian cancer to choose between further treatment options, it is not indicated in early-stage disease. The GOG[13] reported persistent disease in only 5 of 95 (5.2%) women with stages I and II ovarian cancer who were asymptomatic before second-look surgery.

The second-look surgery should include a careful exploration of the abdomen and pelvis; biopsies of adhesions and previously known sites of disease; peritoneal biopsies from the cul-de-sac, ovarian pedicles, paracolic gutters, diaphragm, and pelvis; and selective sampling of para-aortic and pelvic lymph nodes. Skilled laparoscopic surgeons may be able to gain the same information via minimal access surgery as they can from a more standard laparotomy. More important than the means of surgical approach, however, is the thoroughness of the procedure.

1. Oncology Group Protocol #164, a randomized, controlled intergroup trial of salvage therapy with paclitaxel and carboplatin versus salvage therapy with stem-cell-supported high-dose carboplatin, mitoxantrone, and cyclophosphamide in patients with persistent low volume ovarian cancer and who responded to primary therapy.

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