Recurrent Micropapillary Serous Ovarian Carcinoma: The Role of Secondary Cytoreductive Surgery

Abstract & Commentary

Synopsis: Optimal secondary cytoreductive surgery is feasible in the majority of patients with recurrent micropapillary serous carcinoma of the ovary and is an independent predictor of subsequent survival.

Source: Bristow RE, et al. Cancer. 2002;95:791-800.

Bristow and colleagues present a retrospective report of 26 patients with recurrent micropapillary serous ovarian carcinoma (MPSC) from the Johns Hopkins Hospital. The major purpose of this study was to characterize the clinical outcome of patients with recurrent MPSC and to evaluate the effect of secondary cytoreductive surgery on survival. The median age of the patients at recurrence was 46 years. The mean progression-free interval was 32 months, and 92% of patients had advanced stage disease at the time of the initial diagnosis. Twenty-one patients underwent secondary cytoreductive surgery; tumor debulking was performed in 91% of cases and 52% of patients required intestinal resection. Optimal resection (residual disease < 1 cm) was achieved in 15 patients (71%). Patients undergoing optimal secondary cytoreduction had a median survival time of 61 months from date of disease relapse compared with 26 months for those patients in whom suboptimal residual disease remained (P < .02) and 30 months for nonsurgical patients (P < .01). On multivariate analysis, optimal secondary cytoreduction was found to be the only independent predictor of survival. Salvage chemotherapy produced an objective response in 25% of patients with measurable disease. Bristow et al concluded that optimal secondary cytoreductive surgery is feasible in the majority of patients with recurrent MPSC and is an independent predictor of subsequent survival.

Comment by David M. Gershenson, MD

Within the past few years, Kurman and associates1 from Johns Hopkins have published extensively on so-called micropapillary serous ovarian carcinoma (MPSC). The MPSC pattern is proliferative microscopically and is considered by most gynecologic pathologists to be a subset of serous borderline tumor. However, the pattern is distinct from the typical serous borderline pattern and, in general, is associated with more aggressive behavior—principally, a higher frequency of associated invasive peritoneal implants and a greater risk of relapse. Kurman’s group has suggested that the typical serous borderline pattern is essentially almost always associated with a benign course and should be reclassified as "atypical proliferating tumors." They believe that the micropapillary pattern should actually be an entirely separate category—one almost always associated with a more aggressive course in the advanced stages. The ultimate goal of this group appears to be abandonment of the serous borderline category altogether. However, the vast majority of both gynecologic pathologists and gynecologic oncologists have not embraced this concept; they believe that the biologic behavior of MPSC, while more aggressive than the typical serous borderline tumor pattern, is much closer to it than to invasive ovarian cancer. In fact, extensive data from our group and that of others suggest that the typical pattern in the advanced stages is not infrequently associated with an aggressive clinical course and that not infrequently the 2 patterns are admixed in the same primary tumor. While Bristow et al have split out their series of patients with recurrent MPSC, we would consider these relapsed patients to have invasive low-grade serous carcinoma, as described in a series from our institution that is not dissimilar from Bristow’s series.2 Thus, the controversy continues regarding the optimal classification of serous borderline tumor. By focusing just on the so-called MPSC, Bristow et al promote their philosophy, which, in my opinion, is not supported by fact. However, I do agree entirely with the clinical observations detailed in this nice study; the controversy is focused on nomenclature and classification.

Dr. Gershenson is Professor and Chairman, Department of Gynecology, M.D. Anderson Cancer Center, Houston, Tex.

References

1. Kurman RJ, et al. Cancer. 2002;95:675-676.

2. Crispens MA, et al. Obstet Gynecol. 2002;99:3-10.