Is comprehensive surgical staging needed for thorough evaluation of early-stage ovarian carcinoma?




Objective


Patients with ovarian cancer may have occult metastasis at the time of surgery. Our purpose was to determine the prevalence and sites of occult metastasis in epithelial ovarian cancer grossly confined to the ovary and examine the significance of routine omentectomy and peritoneal biopsies as part of a comprehensive staging procedure.


Study Design


Data were retrospectively abstracted from patients presenting to University of Texas Southwestern Medical Center Hospitals from 1993 through 2009 with ovarian cancer without gross spread beyond the ovary who underwent comprehensive surgical staging.


Results


A total of 86 patients with ovarian cancer grossly confined to the ovary who underwent complete surgical staging were identified. Of patients, 29% were upstaged following comprehensive surgical staging; 6% had metastatic disease in uterus and/or fallopian tubes, 6% in lymph nodes, and 17% in peritoneal, omental, or adhesion biopsies.


Conclusion


Patients with epithelial ovarian cancer should continue to undergo comprehensive surgical staging, since it identifies occult metastasis in a significant number of patients.


Patients with ovarian carcinoma grossly confined to the ovaries have been thought to derive both prognostic and therapeutic benefit from a comprehensive surgical staging. Surgical staging for ovarian cancer is defined by the Gynecology Oncology Group as an exploratory laparotomy, peritoneal washings for cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, bilateral pelvic and paraaortic lymphadenectomy, and peritoneal biopsies. Several studies advocate the use of complete surgical staging to guide treatment recommendations. Young et al found that surgical staging detected microscopic metastatic disease in 30% of patients with cancer grossly confined to the ovaries at exploration, thereby increasing the number of patients who may benefit from adjuvant therapy to reduce the risk of recurrence.




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The inclusion of omentectomy and peritoneal biopsies as part of ovarian cancer staging is based on several retrospective and prospective studies indicating that visual examination and palpation of pelvic and abdominal tissue can not accurately detect occult metastasis. In these studies, only 50% of diaphragmatic and 45% of omental metastases were recognized at laparotomy. Young et al showed that of the patients who were upstaged after complete surgical staging of apparent early-stage ovarian cancer, 77% were upstaged based on subclinical disease found in the upper abdomen. However, these studies failed to specify the number of patients upstaged solely due to the presence of microscopic disease identified in peritoneal biopsies. A recent report stated that systematic peritoneal biopsies and omentectomy added little diagnostic value beyond careful inspection when ovarian cancer is grossly limited to the ovaries. In that report, <4% (8/211) of the patients with pelvic metastasis were upstaged based on microscopic disease found in peritoneal biopsies or omentum.


While the standard surgical treatment in patients with ovarian cancer is laparotomy with comprehensive surgical staging, the laparoscopic approach is utilized more often for the management of early ovarian cancer due to expected reduced morbidity, shorter recovery and hospitalization time, and shorter time to initiation of chemotherapy. Further, given that ultrasound and CA-125 assessment identify malignancies in only 12% of suspicious adnexal masses, the less invasive laparoscopic route is an attractive option for diagnosis and treatment of these patients. Several studies have reported on the feasibility of laparoscopic staging of apparent early-stage ovarian cancer. However, sensitivity is a concern related to this approach, since laparoscopy may not allow thorough inspection of the peritoneum, particularly peritoneum overlying the small bowel mesentery. Therefore, it is important to assess the significance of each component of comprehensive surgical staging.


The aim of this study was to determine the prevalence and sites of occult metastases in ovarian cancers with disease grossly confined to the ovaries and to use these results to assess the relevance of performing routine omentectomy and peritoneal biopsies as part of comprehensive surgical staging in these patients.


Materials and Methods


After institutional review board approval was obtained, we searched the institutional tumor registry to identify all women who presented to University of Texas Southwestern Medical Center and Parkland Hospitals from 1993 through 2009 with epithelial ovarian cancer grossly localized to the ovary. Patient medical records were queried for relevant clinicopathologic data including patient demographics, operative reports, and pathologic data that included tumor histology, grade, and final surgical stage. All patients were surgically staged by gynecologic oncologists. The staging procedure for ovarian cancer as described in the Gynecology Oncology Group surgical procedure manual was used as the standard in our institution.


Women selected for study inclusion were those with cancer limited to the ovary by visual inspection and who had comprehensive staging. All surgeries were performed through a laparotomy incision. Patients with incomplete surgical or pathologic data and those with borderline histology were excluded from the study as well as those patients with synchronous primary cancers. Analysis of baseline characteristics and clinicopathological variables were performed using Student t test and Fisher exact test.




Results


A total of 99 women with invasive epithelial ovarian cancer grossly confined to the ovaries underwent comprehensive surgical staging during the 16-year study period. In 13 patients, adequate clinicopathologic data were not available for analysis and thus, the data from the remaining 86 women were analyzed. Their demographic data and tumor characteristics are shown in Table 1 . The mean age of the patients was 51 years (16-86). Most patients were Caucasian (50%). The most common histologic subtype was endometrioid (29%). The majority of tumors were either grade 2 or 3 (62%). After comprehensive surgical staging and pathological evaluation, the International Federation of Gynecology and Obstetrics stages were as follows: 61, stage I (71%); 8, stage II (9%); 12, stage IIIA (14%); and 5, stage IIIC (6%).



TABLE 1

Patient demographics
































































Demographic n
Total patients 86
Mean age, y (SD) 51.2 (±13.3)
Surgical stage
I 61 (7%)
II 8 (9%)
IIIA 12 (14%)
IIIC (node positive only) 5 (6%)
Histology
Endometrioid 24 (28%)
Mucinous 14 (16%)
Papillary serous 12 (14%)
Clear cell 8 (9%)
Serous 8 (9%)
Adenocarcinoma 6 (7%)
Brenner 4 (5%)
Mixed epithelial 4 (5%)
Transitional cell 3 (3%)
Unknown 1 (1%)
Signet 1 (1%)

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May 23, 2017 | Posted by in GYNECOLOGY | Comments Off on Is comprehensive surgical staging needed for thorough evaluation of early-stage ovarian carcinoma?

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