Journal of Medicine Vol 4 - Amrita Institute of Medical Sciences and ...

Amrita Journal of Medicine
Carcinoma of the Ovary
patients with residual disease of less than 1 cm. It is
shown that a possibly superior chemotherapeutic regimen
containing taxanes cannot compensate for the tumor
left behind after surgery. (19 JSO)
The maximum goal of cytoreductive (debulking) surgery
should be the complete removal of all visible disease
and the minimum is to reduce the tumor to less than 1
cm (optimal debulking). To meet this target one may often
have to go for intestinal resections, rarely splenectomy,
peritoneal excisions including diaphragmatic peritoneum
and genito-urinary tract resections. Surgical procedures,
which impair quality of life, for e.g. ostomies, should be
avoided as far as possible. Precise and more expeditious
removal of widespread peritoneal implants including diaphragmatic
implants is facilitated by the use of Cavitron
ultrasonic surgical aspirator (CUSA) and argon beam laser.
Other modalities used are carbon dioxide laser and
loop electrosurgical excision procedures 5,6 . However in
best hands and best centers, many times the initial laparotomy
turns out to be non therapeutic. The mortality
and the morbidity due to haemorrhage in the presence of
friable growth may be overwhelming. In order to circumvent
this problem and in view of the excellent response
of tumor observed even after the futile initial laparotomy,
the concept of interval laparotomy has come into practice.
There is no randomized trial data published in favour
of interval cytoreduction. However several phase II and
retrospective data showed 3-year survival rate of 50%,
which is comparable to optimal primary debulking. With
neoadjuvant chemotherapy (NAC) 50% complete remission
rate is reported and the complete / optimal resection
is possible in 75% of cases. Our own data shows that
the rate of optimal cytoreduction is 50% for primary surgery
and 88.6% for patients who received NAC 7 . However
it has to be clear that good reduction is not equivalent to
initial small volume disease.
For interval debulking also, just like primary surgery,
one has to be prepared for any extent of surgery to completely
remove the disease to microscopic level. So the
minimum prerequisites for an ovarian cancer laparotomy
are adequate infrastructure with adequate theatre facilities,
dedicated team with adequate expertise and oncology
concept. It has to be ascertained that no facility should
offer surgery for patients with ovarian cancer if adequate
standards of care cannot be met with.
Meticulous and systematic pre-operative evaluation
has to be done to assess the operability and to avoid a
non-therapeutic laparotomy.
THE PREDICTORS OF SURGICAL
OUTCOME ARE:
1. Clinical evaluation: age above 50 years, gross ascites
and fixed large pelvic masses are unfavourable
clinical factors.
2. Abdominal ultrasound: large volume ascites and
hydroureteronephrosis increase the inoperability rates.
3. CT scan: Bristow 2000 selected 13 radiographic features
along with performance status 8 . The important
radiographic criteria considered are number of metastasis,
peritoneal thickening, large ascites, large
metastatic deposits on diaphram, suprarenal nodes,
etc. Each parameter was assigned a numerical value.
They reported that with a predictive index > 4, the
specificity was 85% (inappropriate unexploration
15%) and the sensitivity approached 100% (unnecessary
exploration 0%). According to Dowdy, diffuse
peritoneal thickening and large volume ascites independently
predicted surgical outcome.
4. Diagnostic laparoscopy:
Inoperability criteria in advanced ovarian cancer:-
Absolute
a. Stage 1V disease or
b. Metastasis of more than 1 cm at sites where optimal
cytoreduction is not possible, e.g. at porta
hepatis, around superior mesenteric artery, etc.
Relative
a. Uncountable (100) peritoneal metastases
b. Estimated total metastatic load of >1000gm (both
intra and extraperitoneal)
c. Presence of more than 10gms peritoneal metastatic
plaques
d. Large volume ascites (5L)
e. Those with performance status 2 or 3
The time interval between diagnostic laparoscopy and
definitive surgery or chemotherapy should be as short as
possible.
ROLE OF RETROPERITONEAL LYMPH
NODE DISSECTION (RPLND)
Lymph nodal involvement in ovarian cancer is 20-
40% (40 JSO) in apparently early disease to as high as
70-80% in advanced disease. Early stages LND is recommended
as a part of staging (some studies show improved
survival also) and in advanced disease involved nodes
are removed to attain R0 – R1 status.
ROLE OF HYSTERECTOMY
No studies so far tested the benefit of uninvolved
uterus 9 . However, uterus should not be removed in instances
of suboptimal tumor removal, since in the event
of a subsequent recurrence, the tumor will directly invade
the bladder.
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