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Abstract & Commentary
Synopsis: A complete salvage surgical cytoreduction improves further survival of ovarian cancer patients who recur at least six months after the completion of primary therapy.
Source: Gadducci A, et al. Gynecol Oncol 2000;79: 344-349.
Gadducci and colleagues report a retrospective review of 30 patients with recurrent ovarian cancer who underwent salvage surgical cytoreduction. All had been initially treated by primary surgery and platinum-based chemotherapy and had a period of clinical remission of at least six months. Median time to recurrence was 17.5 months (range, 6-76 months). A macroscopically complete salvage cytoreduction was achieved in 17 (57%) patients, whereas eight patients were left with macroscopic residual disease less than 2 cm and five patients with a larger residuum. Logistic regression showed that the probability of achieving a complete cytoreduction was significantly related to the residual disease after initial surgery but not to International Federation of Gynecology and Obstetrics (FIGO) stage, tumor grade, histologic type, patient age at recurrence, and time to recurrence. Median survival following salvage surgery was 21 months for the whole group. Survival was significantly longer in patients who were completely cytoreduced compared to those who were not (median: 37 vs 19 months; P = 0.04). Moreover, survival was significantly related to time to recurrence (> 17.5 vs < 17.5 months, median: 25 vs 15 months; P = 0.039), number of recurrence sites (single vs multiple, median: 40 vs 19 months; P = 0.009), and residual disease after initial surgery (< 2 cm vs > 2 cm, median: 37 vs 19 months; P = 0.01). Survival was not influenced by patient age, recurrence site with the largest size, FIGO stage, tumor grade, and histologic type. Gadducci et al concluded that complete salvage surgical cytoreduction significantly improves further survival of ovarian cancer patients who recur at least six months after the completion of primary therapy.
Comment by David M. Gershenson, MD
Secondary cytoreduction for ovarian cancer remains a controversial topic. Potential settings for secondary cytoreduction include the following: 1) interval surgery after three cycles of primary chemotherapy (following a suboptimal primary cytoreduction); 2) at second-look surgery; or 3) at the time of recurrence. The present study focuses on the latter indication—secondary cytoreduction at recurrence. There is a growing body of retrospective evidence that the procedure may benefit some patients when performed for recurrence. Generally, a minimum of six months since completion of primary treatment is considered optimal by most experts. Patients who relapse in a shorter time interval are generally "platinum resistant" and should not be considered for such surgery. This study and other previous reports have indicated that the longer the time to recurrence the longer the survival after secondary surgery. Gadducci et al also observed that the number of sites of recurrence and the residual disease after primary cytoreduction had an influence on survival after secondary surgery. Predictably, patients who were completely cytoreduced lived longer. This study, like all previous reports, is limited by the relatively small number of patients and its retrospective nature. The Gynecologic Oncology Group is planning to launch a prospective randomized trial to resolve the issue of efficacy.