Cytoreductive Surgery for the Management of Stage IV Epithelial Ovarian Cancer

ABSTRACTS & COMMENTARY

Synopsis: Stage IV epithelial ovarian cancer patients with less than 2 cm residual disease have a survival advantage over patients with bulky residual disease.

Sources: Liu PC, et al. Gynecol Oncol 1997;64:4-8; Curtin JP, et al. Gynecol Oncol 1997;64:9-12; Mun karah AR, et al. Gynecol Oncol 1997:64:13-17.

In a recent issue of Gynecologic Oncology, three independent groups of investigators focused on the surgical management of patients with stage IV epithelial ovarian cancer. Liu et al treated 47 patients with stage IV disease. Patients were deemed stage IV by virtue of positive pleural effusion (26 patients), and 21 had parenchymal liver involvement or metastatic disease outside the abdomen. Fourteen (30%) were optimally cytoreduced to 2 cm or less residual disease at initial surgery. The median survival of the suboptimally debulked group was 17 months, while median survival in the optimal group was 37 months (P = 0.0295). In the study by Curtin et al, 97 patients with stage IV disease were treated. Forty-one (42%) had malignant pleural effusion, and 20 (21%) had liver metastases. Ninety-two of the 97 patients underwent an initial attempt at cytoreductive surgery. The median survival for the entire group was 21 months. Median survival for optimally debulked patients was 40 months compared to 18 months for patients with bulky residual disease (P = 0.01). In the multivariate analysis, only age less than 65 years and optimal debulking were independent predictors of outcome. In the third study, Munkarah et al reported on 100 patients with stage IV disease who underwent primary surgery. Debulking was optimal in 31 patients, suboptimal in 61, and undetermined in eight. The median survival for optimally debulked patients was 25 months compared to 15 months for suboptimally debulked patients (P < 0.02). In all three studies, the authors concluded that stage IV patients with optimal debulking have a survival advantage over those with suboptimal debulking.

COMMENT BY DAVID M. GERSHENSON, MD

Stage IV accounts for approximately 15-20% of epithelial ovarian cancer. The most common clinical presentation within this category is a cytologically positive pleural effusion. Other types of presentation include parenchymal hepatic involvement or peripheral lymph node involvement (such as a positive supraclavicular node). Unfortunately, less than 5% of stage IV patients are cured with current treatments. These three studies all reach identical conclusions about the impact of initial cytoreductive surgery in this population: patients who are able to be optimally debulked have a better prognosis than those who are not able to be optimally debulked. However, we have the same problem in interpretation of these findings that we have in all such retrospective studies of cytoreductive surgery in patients with advanced ovarian cancer: the relative influences of tumor biology and interventions. For instance, it is possible that those patients who are able to be optimally debulked simply have less infiltrative, less extensive tumors. During the past few years, there has been a growing trend to treat presumed stage IV ovarian cancer patients with chemotherapy prior to surgery—so-called neoadjuvant chemotherapy followed by interval debulking. Typically, three cycles of chemotherapy will be given prior to an initial attempt at surgical debulking. Currently, we do not know whether such an approach is as efficacious as the standard one or even more so. Only a prospective randomized study comparing these two strategies will resolve the issue. Ultimately, I hope that clinical, histopathological, or molecular prognostic factors allow us to individualize our treatment approach to stage IV patients.