Secondary surgery has been used as a second-look or reassessment operation to determine the response to therapy and whether or not to continue with further treatment. This procedure is limited to those in whom there is no evidence of persistent disease by physical examination, tumor markers, or scans, and it has not been found to be of any major benefit in patients with early stage I or stage II disease. The patient who may benefit most from second-look laparotomy is the partial responder with otherwise negative tumor markers and CT scan. These individuals, often with microscopic residual disease, may benefit from additional treatments when they would otherwise have been followed until more advanced disease became evident.
Post-treatment follow-up usually consists of a careful physical examination on a regular basis, usually every 3 months the first 2 years, then every 4 months in years 3 to 5, and every 6 months after 5 years. Thorough abdominal and pelvic/rectal examinations are mandatory. If elevated at the time of initial treatment, CA-125 may be used in follow-up. Scanning techniques, such as CT, MRI, and ultrasonography, may also be of some help. As mentioned above in the section on diagnosis, radionuclide imaging techniques are also being investigated as potentially more sensitive and specific indicators of disease status to aid in post-treatment follow-up.
Recurrent ovarian cancer is defined as disease that is detected at least 6 months after complete remission from primary therapy. While cytoreductive surgery is considered standard in the initial management of ovarian cancer, the role for secondary surgical debulking is less clear. When disease recurs or progresses within 6 months of primary chemotherapy, surgical cytoreduction appears to provide minimal benefit. Limited retrospective evidence, however, does suggest that surgical cytoreduction may improve survival as length of time to recurrence increases.
Major surgical interventions for recurrent and progressive ovarian cancer may be performed to provide relief of symptoms or improve quality of life. Intestinal obstruction is a common problem in women with advanced or recurrent ovarian cancer. Although some patients may be managed conservatively with fluid and electrolyte replacement, the majority of patients will require surgery to relieve the obstruction. The decision to operate depends on the surgeons assessment of the risks of surgery, as well as the patients life expectancy. Surgery for intestinal obstruction in this scenario improves survival at best by only a few months. However, more than 50% of patients can be expected to have improvement, as measured by the ability to leave the hospital. In some patients with diffuse carcinomatosis, palliation may be obtained with the use of either a surgically or percutaneously introduced gastrostomy tube.
The likelihood of a response to second-line chemotherapy in ovarian cancer is influenced by the initial response to chemotherapy, as well as the interval to recurrence. Response rates of 25% to 77% have been recorded in patients with a treatment-free interval of 6 months or more. The longer the treatment-free interval, the greater the response rate. This is true for retreatment with a platinum-based regimen or for other drugs, such as ifosfamide, hexamethylmelamine, and tamoxifen (Nolvadex), which have shown modest activity in phase II trials.
Currently, paclitaxel appears to be the most active agent in patients who have progressed on cisplatin. In addition, dose-intense salvage regimens with cisplatin and carboplatin have been reported with response rates in the 30% range. Although high response rates (70% to 80%) have been reported with dose-intense therapy using autologous bone marrow and peripheral stem-cell support, long-term follow-up is lacking, and a survival benefit has yet to be demonstrated.
The FDA has recently approved topotecan (Hycamtin) for second-line therapy in ovarian cancer based on promising clinical trials that demonstrate equal or superior activity to paclitaxel in the salvage setting.
Liposome-encapsulated doxorubicin (Doxil) offers an enhanced therapeutic ratio and is another promising agent being developed for ovarian cancer. Combinations of these agents with platinum are currently being investigated.
Patients with recurrent disease who are not responsive to treatment with standard chemotherapy may be considered for experimental protocols, including high-dose therapy, new chemotherapeutic agents, and immunotherapy. Protocols involving gene or antigene therapy will likely be available in the near future.
The information in the Society of Gynecologic Oncologists clinical practice guidelines should not be viewed as a body of rigid rules. The guidelines are general and are intended to be adapted to many different situations, taking into account the needs and resources particular to the locality, the institution, or the type of practice. Variations and innovations that improve the quality of patient care are to be encouraged rather than restricted. The purpose of these guidelines will be well served if they provide a firm basis on which local norms may be built.
These guidelines are copyrighted by the Society of Gynecologic Oncologists (SGO). All rights reserved. These guidelines may not be reproduced in any form without the express written permission of the SGO. Requests for reprints should be sent to: Ms. Karen Carlson, SGO Publications, Society of Gynecologic Oncologists, 401 North Michigan Avenue, Chicago, IL 60611.
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