Journal Club - November 2004

Tertiary cytoreduction in patients with recurrent ovarian carcinoma.
Leitao MM, Kardos S, Barakat RR, Chi DS.
Gynecol Oncol 2004; 95: 181-188. [Abstract]

Summary
This was a retrospective study from investigators at Memorial Sloan-Kettering Cancer Center that reviewed the outcome of patients with recurrent epithelial ovarian carcinoma who underwent tertiary cytoreductive surgery. Between 1/90 and 12/02 a total of 26 patients were identified. The median time interval between secondary and tertiary cytoreductive surgery was 25.6 months (range 5.4 to 78.8 months) and the median treatment-free interval was 13.4 months (range 0.5 to 61.3 months). The majority (57%) of patients were considered to have platinum-sensitive disease at the time of tertiary cytoreductive surgery. The tertiary debulking procedures were often extensive, with 62% of patients requiring a bowel resection and 12% of patients undergoing a liver resection. Optimal residual disease (maximal tumor diameter „T0.5cm) was accomplished in 81% of all patients.  On multivariate analysis, only a treatment-free interval >12 months and optimal residual disease after tertiary cytoreduction were found to be independently associated with an improved survival outcome. The median survival time for patients undergoing optimal tertiary cytoreduction was 36.3 months compared to a median survival time of just 10.6 months for those patients with suboptimal residual disease. The number of disease sites at the time of recurrence and platinum-sensitivity were not significantly correlated with survival outcome. 

Discussion
The limitations of this study are its retrospective design and the relatively limited number of patients identified for study inclusion. Nevertheless, this is the first study to address the practice of repeated debulking procedures for recurrent ovarian cancer, which is likely more common in clinical practice than is reflected in the published literature. As with most of the literature addressing the topic of secondary cytoreductive surgery, the potential for selection bias in identifying appropriate candidates for repeated efforts at tumor debulking applies here as well. It was a bit surprising that platinum-sensitivity was not an independent predictor of survival, but this observation may be explained, at least in part, by the heavily pretreated nature of the study population, the availability of better salvage agents over time, and possible study selection bias.

Conclusion
The results of this study suggest that in selected patients with recurrent ovarian cancer, serial cytoreductive surgical efforts that result in an optimal volume of residual disease are associated with an improved long-term survival outcome. The best candidates for such an approach appear to be those with a prolonged treatment-free interval (longer than 12 months) in whom a successful resection is likely.

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