Research Article| Volume 103, ISSUE 2, P559-564, November 2006

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What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)?



      Recent studies have suggested that the definition of optimal cytoreduction for advanced EOC should be changed from the current Gynecologic Oncology Group threshold of ≤1 cm residual disease to no gross residual disease owing to improved survival of patients (pts) rendered macroscopically disease-free. The objective of this study was to analyze survival rates at very specific residual disease diameters to determine the optimal goal of primary cytoreduction for bulky stage IIIC EOC.


      A prospectively kept database was used to identify and review the records of all pts with Stage IIIC EOC who underwent primary cytoreductive surgery at our institution between January 1989 and December 2003. To analyze a homogeneous cohort of cases, we excluded pts with stage IIIC disease based on nodal metastasis alone (without bulky abdominal tumor), fallopian tube or primary peritoneal carcinomas, and borderline tumors. Standard statistical analyses were utilized.


      The study cohort included 465 pts. The median age was 60 years (range, 25–87), and the median follow-up was 38 months (range, 1–199). Univariate and multivariate analyses, which included various prognostic factors, identified amount of residual disease as a significant prognostic factor (P < 0.001). Median overall survival in relation to the 5 residual disease categories was: no gross residual, 106 months; gross ≤0.5 cm, 66 months; 0.6–1.0 cm, 48 months; 1–2 cm, 33 months; >2 cm, 34 months. Statistical comparison between the 5 residual disease categories revealed 3 distinct groups with significantly different survival rates (P < 0.01). These 3 groups were: (1) no gross residual; (2) gross ≤1 cm residual; and (3) >1 cm residual. Although the difference in survival did not reach statistical significance, within the gross ≤1 cm residual group, there was a trend toward improved survival in pts left with smaller volume, ≤0.5 cm residual compared with those with 0.6–1.0 cm residual (P = 0.06).


      Our data suggest that removal of all evidence of macroscopic disease is associated with prolonged survival and should be the goal of primary cytoreductive surgery. If complete gross resection is not feasible, however, cytoreduction to as minimal residual tumor as possible should be the focus of cytoreductive efforts, as each incremental decrease in residual disease below 1 cm may be associated with an incremental improvement in overall survival.


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        • Jemal A.
        • Murray T.
        • Ward E.
        • Samuels A.
        • Tiwari R.C.
        • Ghafoor A.
        • et al.
        Cancer statistics, 2005.
        CA Cancer J Clin. 2005; 55: 10-30
      1. Staging Announcement: FIGO Cancer Committee.
        Gynecol Oncol. 1986; 25: 383-385
        • Ozols R.F.
        • Bundym B.N.
        • Greer B.E.
        • et al.
        Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a gynecologic oncology group study.
        J Clin Oncol. 2003; 21: 3194-3200
        • Bristow R.E.
        • Tomacruz R.S.
        • Armstrong D.K.
        • Trimble E.L.
        Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis.
        J Clin Oncol. 2002; 20: 1248-1259
        • Hoskins W.J.
        • McGuire W.P.
        • Brady M.F.
        • et al.
        The effect of diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma.
        Am J Obstet Gynecol. 1994; 170: 974-979
        • Omura G.A.
        • Blessing J.
        • Ehrlich C.
        • et al.
        Long follow-up and prognostic factor analysis in advanced ovarian carcinoma: the gynecologic oncology group experience.
        J Clin Oncol. 1991; 9: 1138-1150
        • Hoskins W.J.
        Epithelial ovarian carcinoma: principles of primary surgery.
        Gynecol Oncol. 1994; 55: S91-S96
        • Makar A.P.
        • Baekelandt M.
        • Trope C.G.
        • et al.
        The prognostic significance of residual disease, FIGO substage, tumor histology, and grade in patients with FIGO stage III ovarian cancer.
        Gynecol Oncol. 1995; 56: 175-180
        • Le T.
        • Krepart G.V.
        • Lotocki R.J.
        • Heywood M.S.
        Does debulking surgery improve survival in biologically aggressive ovarian carcinoma?.
        Gynecol Oncol. 1997; 67: 208-214
        • Eisenkop S.M.
        • Friedman R.L.
        • Wang H.J.
        Complete cytoreductive surgery is feasible and maximizes survival in patients with advanced epithelial ovarian cancer: a prospective study.
        Gynecol Oncol. 1998; 69: 103-108
        • Bristow R.E.
        • Montz F.J.
        Complete surgical cytoreduction of advanced ovarian carcinoma using the argon beam coagulator.
        Gynecol Oncol. 2001; 83: 39-48
        • Eisenkop S.M.
        • Spirtos N.M.
        • Friedman R.L.
        • et al.
        Relative influences of tumor volume before surgery and the cytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study.
        Gynecol Oncol. 2003; 90: 390-396
        • Serov S.F.
        • Scully R.E.
        • Sobin L.H.
        Histologic typing of ovarian tumors.
        in: International histologic classification of tumors. World Health Organization, Geneva1973: 17
        • Chi D.S.
        • Franklin C.C.
        • Levine D.A.
        • et al.
        Improved optimal cytoreduction rates for stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal cancer: a change in surgical approach.
        Gynecol Oncol. 2004; 94: 650-654
        • Kaplan E.L.
        • Meier P.
        Nonparametric estimator from incomplete observations.
        J Am Stat Assoc. 1958; 53: 457-481
        • Mantel N.
        Evaluation of survival data and two new rank order statistics arising in its consideration.
        Cancer Chemo Rep. 1966; 50: 163-170
        • Cox D.R.
        Regression models and life tables.
        J R Stat B. 1972; 34: 187-200
        • Griffiths C.T.
        Surgical resection of tumor bulk in the primary treatment of ovarian carcinoma.
        Natl Cancer Inst Monogr. 1975; 42: 101-104
        • Hoskins W.J.
        • Bundy B.N.
        • Thigpen J.T.
        • et al.
        The influence of cytoreductive surgery on recurrence-free interval and survival in small-volume stage III epithelial ovarian cancer: a gynecologic oncology group study.
        Gynecol Oncol. 1992; 47: 159-166
        • Eisenkop S.M.
        • Spirtos N.M.
        Procedures required to accomplish complete cytoreduction of ovarian cancer: is there a correlation with “biological aggressiveness” and survival?.
        Gynecol Oncol. 2001; 82: 435-441
        • Levine D.A.
        • Bonome T.
        • Olshen A.B.
        • Bogomolniy F.
        • Brady J.
        • Pise-Masison C.
        • et al.
        Gene expression profiling of advanced ovarian cancers to predict the outcome of primary surgical cytoreduction (abstract).
        ASCO Proc. 2004; 23: 454
        • Omura G.
        • Blessing J.
        • Erlich C.
        • et al.
        A randomized trial of cyclophosphamide and doxorubicin with or without cisplatin in advanced ovarian carcinoma.
        Cancer. 1986; 57: 1725-1730
        • Benedetti Panici P.
        • Maggioni A.
        • Hacker N.
        • Landoni F.
        • Ackermann S.
        • Campagnutta E.
        • et al.
        Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial.
        J Natl Cancer Inst. 2005; 97: 560-566
        • Crawford S.C.
        • Vasey P.A.
        • Paul J.
        • Hay A.
        • Davis J.A.
        • Kaye S.B.
        Does aggressive surgery only benefit patients with less advanced ovarian cancer? Results from an international comparison within the SCOTROC-1 trial.
        J Clin Oncol. 2005; 23: 8802-8811
        • Bristow R.E.
        • Smith Sehdev A.E.
        • Kaufman H.S.
        • et al.
        Ablation of metastatic ovarian carcinoma with the argon beam coagulator: pathologic analysis of tumor destruction.
        Gynecol Oncol. 2001; 83: 49-55
        • Rose P.G.
        • Nerenstone S.
        • Brady M.F.
        • et al.
        Secondary surgical cytoreduction for a advanced carcinoma.
        N Engl J Med. 2004; 351: 2489-2497
        • Armstrong D.K.
        • Bundy B.
        • Wenzel L.
        • Huand H.Q.
        • Baergen R.
        • Lele S.
        • et al.
        Intraperitoneal cisplatin and paclitaxel in ovarian cancer.
        N Engl J Med. 2006; 354: 34-43
        • Barakat R.R.
        • Sabbatini P.
        • Bhaskaran D.
        • Revzin M.
        • Smith A.
        • Venkatraman E.
        • et al.
        Intraperitoneal chemotherapy for ovarian carcinoma: results of long-term follow-up.
        J Clin Oncol. 2002; 20: 694-698
        • Rubin S.C.
        • Randall T.C.
        • Armstrong K.A.
        • Chi D.S.
        • Hoskins W.J.
        Ten-year follow-up of ovarian cancer patients after second-look laparotomy with negative findings.
        Obstet Gynecol. 1999; 93: 21-24
      2. McCreath WA, Abu-Rustum NR, Venkatraman ES, Caceres A, Bier R, Huh J, et al. Identification of prognostic factors after positive second look surgery in epithelial ovarian carcinoma. Gynecol Oncol in press.

        • Prefontaine M.
        • Gelfand A.T.
        • Donovan J.T.
        • Powell J.L.
        Reproducibility of tumor measurements in ovarian cancer: a study of interobserver variability.
        Gynecol Oncol. 1994; 55: 87-90
        • Farias-Eisner R.
        • Teng F.
        • Oviveira M.
        • Leuchter R.
        • Karlan B.
        • Lagasse L.D.
        • et al.
        The influence of tumor grade, distribution, and extent of carcinomatosis in minimal residual stage III epithelial ovarian cancer after optimal primary cytoreductive surgery.
        Gynecol Oncol. 1994; 55: 108-110