Perioperative morbidity and outcome of secondary cytoreduction for recurrent epithelial ovarian cancer.

Abstract

Despite radical surgical and chemotherapeutic treatment of ovarian cancer, the majority of patients develop recurrent disease. Secondary cytoreductive surgery can result in favourable outcome in selected patients, but information regarding feasibility, safety and perioperative outcome of these often complex procedures is limited.
Surgical parameters in patients with recurrent epithelial ovarian cancer selected for secondary cytoreduction were analysed and compared to patients undergoing primary cytoreduction.
In total, 222 patients undergoing radical cytoreduction were analysed (48 patients for relapsed disease and 174 patients at primary diagnosis of advanced ovarian cancer). The range of surgical procedures was similar in both groups. In 48% of secondary cytoreductions 'optimal surgical results' (residual tumour <1 cm) were obtained and 33% of the patients had no residual disease compared to 82% and 58% at primary cytoreduction. There was no significant difference in perioperative complication rates. The duration of surgery was shorter and the number of transfused blood products was smaller at secondary cytoreduction (p < 0.001 and p = 0.001).
Secondary cytoreduction in relapsed ovarian cancer is safe and feasible and perioperative outcome is not inferior compared to primary cytoreduction. Surgery-associated morbidity should represent a minor aspect in the selection and counselling of patients regarding treatment options for recurrent ovarian cancer.

Full text

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Accepted Manuscript
Title: Perioperative morbidity and outcome of secondary cytoreduction for recurrent
epithelial ovarian cancer
Authors: L. Woelber, S. Jung, C. Eulenburg, V. Mueller, J. Schwarz, F. Jaenicke, S.
Mahner
PII:S0748-7983(10)00101-0
DOI:10.1016/j.ejso.2010.04.012
Reference:YEJSO 2961
To appear in:
European Journal of Surgical Oncology
Received Date: 21 July 2009
Accepted Date: 22 April 2010
Please cite this article as: Woelber L, Jung S, Eulenburg C, Mueller V, Schwarz J, Jaenicke F, Mahner
S. Perioperative morbidity and outcome of secondary cytoreduction for recurrent epithelial ovarian
cancer, European Journal of Surgical Oncology (2010), doi: 10.1016/j.ejso.2010.04.012
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
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peer-00599223, version 1 - 9 Jun 2011
Author manuscript, published in "European Journal of Surgical Oncology (EJSO) 36, 6 (2010) 583"
DOI : 10.1016/j.ejso.2010.04.012

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MANUSCRIPT

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ACCEPTED MANUSCRIPT
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Perioperative morbidity and outcome of secondary cytoreduction for recurrent
epithelial ovarian cancer

L. Woelber1, S. Jung1, C. Eulenburg2, V. Mueller1, J. Schwarz1#, F. Jaenicke1, S. Mahner1

1Department of Gynaecology, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany
2Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-
Eppendorf, Hamburg, Germany
#Current address: Department of Gynaecology, Asklepios Klinik Nord – Heidberg, Hamburg,
Germany


Corresponding author:
Dr. Sven Mahner, MD
Department of Gynaecology
University Medical Center Hamburg-Eppendorf
Martinistrasse 52, 20246 Hamburg, Germany
Tel: +49 40 7410 52510
Fax: +49 40 7410 40070
Email: Sven.Mahner@gmx.de


Running head: Cytoreduction in recurrent ovarian cancer

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should represent a minor aspect in the selection and counselling of patients regarding
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Abstract
Background
Despite radical surgical and chemotherapeutic treatment of ovarian cancer, the majority of
patients develop recurrent disease. Secondary cytoreductive surgery can result in favourable
outcome in selected patients, but information regarding feasibility, safety and perioperative
outcome of these often complex procedures is limited.
Methods
Surgical parameters in patients with recurrent epithelial ovarian cancer selected for secondary
cytoreduction were analysed and compared to patients undergoing primary cytoreduction.
Results:
In total, 222 patients undergoing radical cytoreduction were analysed (48 patients for relapsed
disease and 174 patients at primary diagnosis of advanced ovarian cancer). The range of
surgical procedures was similar in both groups. In 48% of secondary cytoreductions ‘optimal
surgical results’ (residual tumour <1cm) were obtained and 33% of the patients had no
residual disease compared to 82% and 58% at primary cytoreduction. There was no
significant difference in perioperative complication rates. The duration of surgery was shorter
and the number of transfused blood products was smaller at secondary cytoreduction
(p<0.001 and p=0.001).
Conclusion:
Secondary cytoreduction in relapsed ovarian cancer is safe and feasible and perioperative
outcome is not inferior compared to primary cytoreduction. Surgery-associated morbidity
treatment options for recurrent ovarian cancer.

Key words: ovarian cancer; progression; relapse; cytoreduction; morbidity
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recurrent ovarian cancer compared to primary surgery.
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Introduction
Ovarian cancer accounts for the highest tumour-related mortality of all gynaecologic
malignancies and is a common cancer in women [1]. There are an estimated number of 14 600
deaths due to this disease each year in the US [2]. Despite radical surgery and adjuvant
systemic chemotherapy, the majority of patients develop recurrent disease and eventually die
of their disease [3]. Although primary cytoreductive surgery is well accepted as the crucial
step of initial therapy and residual tumour after primary surgery is considered the most
important prognostic factor, the use of cytoreductive surgery in the setting of recurrent disease
is defined less clearly. Several retrospective studies suggest a benefit of secondary
cytoreduction but until today, no data from randomized phase 3 trials is available [4,5]. Most
retrospective analyses report improved survival in patients with complete secondary
debulking (no residual tumour), while the role of so-called ‘optimal debulking’ (residual
tumour <1cm) for recurrent disease remains controversial [4-16]. Despite these results,
surgical therapy still plays only a minor role in the treatment of recurrent ovarian cancer in
clinical routine. Besides the lack of conclusive evidence this might also be caused by the
technical complexity of secondary surgery in patients with repetitive abdominal procedures.
Information regarding the feasibility and perioperative outcome of these surgical procedures
is very limited. In most of the published retrospective studies, surgical procedures,
perioperative morbidity and mortality were not reported systematically [11].
We conducted the current study to determine the surgical procedures and complications of
secondary cytoreduction and evaluate the accomplishment of optimal surgical results in
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tumour board consisting of gynaecologic oncologists, medical oncologists, radiologists,
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Patients and Methods
Patients
All patients with advanced primary (stage III and IV) or relapsed epithelial ovarian cancer
who presented for surgery at the University Medical Center Hamburg-Eppendorf between
1996 and 2004 were retrospectively analysed. Patients with ovarian carcinoma of low
malignant potential (borderline tumours) and patients who underwent surgery solely for the
correction of bowel obstruction were excluded from the analysis.
Altogether 222 patients were analysed in this study, including 48 patients with relapsed and
174 patients with primary ovarian cancer. In case of recurrent disease, patients who were
considered to have resectable disease underwent an attempt for secondary cytoreduction. This
was defined as surgery with the intent to resect all visible tumour. If complete tumour
resection was appeared achievable, systematic assessment of the retroperitoneum was
performed during secondary surgeries. In case of enlarged lymph nodes, a radical pelvic-
paraaortic lymphadenectomy was performed only in patients who did not undergo this
procedure during primary surgery. Otherwise only enlarged lymph nodes were excised. All
patients received prophylaxis for thromboembolism with low-molecular weight heparin
(Enoxaparin-Natrium 20 and 40mg) from the day before surgery until at least ten days after
surgery. The decision to attempt secondary cytoreduction was based on the results of clinical
examination, previous therapies and performance status of the patient on an individual basis.
Additional radiologic examinations were performed if necessary, but despite vaginal
ultrasound, no routine test was performed. All cases were discussed at an interdisciplinary
pathologists and surgical oncologists.
Data was retrieved from patients’ records, the tumour registry and death certificates; all
patients were followed from the date of surgery until death or the date of last follow up for
patients who remained alive. Written informed consent was obtained from all patients to
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