The Society of Surgical Oncology surgical practice guidelines focus on the signs and symptoms of primary cancer, timely evaluation of the symptomatic patient, appropriate preoperative evaluation for extent of disease, and role of the surgeon in
The Society of Surgical Oncology surgical practice guidelines focuson the signs and symptoms of primary cancer, timely evaluation of the symptomaticpatient, appropriate preoperative evaluation for extent of disease, androle of the surgeon in diagnosis and treatment. Separate sections on adjuvanttherapy, follow-up programs, or management of recurrent cancer have beenintentionally omitted. Where appropriate, perioperative adjuvant combined-modalitytherapy is discussed under surgical management. Each guideline is presentedin minimal outline form as a delineation of therapeutic options.
Since the development of treatment protocols was not the specific aimof the Society, the extensive development cycle necessary to produce evidence-basedpractice guidelines did not apply. We used the broad clinical experienceresiding in the membership of the Society, under the direction of AlfredM. Cohen, md, Chief, Colorectal Service, Memorial Sloan-Kettering CancerCenter, to produce guidelines that were not likely to result in significantcontroversy.
Following each guideline is a brief narrative highlighting and expandingon selected sections of the guideline document, with a few relevant references.The current staging system for the site and approximate 5-year survivaldata are also included.
The Society does not suggest that these guidelines replace good medicaljudgment. That always comes first. We do believe that the family physician,as well as the health maintenance organization director, will appreciatethe provision of these guidelines as a reference for better patient care.
Symptoms and Signs Early-stage disease
Evaluation of the Symptomatic PatientEarly-stage disease
Appropriate timeliness of surgical referral
Preoperative Evaluation for Extent of DiseaseTests indicated for all patients
Tests indicated by symptoms
Role of the Surgeon in Initial Management Evaluation of the symptomatic patient
Many studies in the literature have documented improved survival inpatients with advanced ovarian cancer when "optimal" cytoreductionis accomplished. This usually refers to leaving no tumor nodule more than2 cm in diameter. While every effort should be made to achieve optimalcytoreduction, only about 35% to 45% of patients with advanced ovariancancer can achieve an optimal disease status with initial surgery. Thesurgeon must evaluate the patient based on his or her training and expertiseand use his or her surgical judgment to perform appropriate surgery withoutexcessive morbidity. The essentials of the operation are listed below.
These guidelines are copyrighted by the Society of Surgical Oncology(SSO). All rights reserved. These guidelines may not be reproduced in anyform without the express written permission of SSO. Requests for reprintsshould be sent to: James R. Slawny, Executive Director, Society of SurgicalOncology, 85 W Algonquin Road, Arlington Heights, IL 60005
Ovarian cancer is the leading cause of death from gynecologic malignanciesin the United States. In 1996, approximately 26,700 new cases of ovariancancer were diagnosed, and approximately 14,800 women died of this disease.
Several investigators have postulated a causal relationship betweencertain environmental and genetic factors and this malignancy. Lactoseconsumption has been reported to be a dietary risk factor, especially whencombined with an inherited decrease in the levels of galactose-1-phosphateuridyl transferase. Consumption of significant amounts of animal fat mayalso be a risk factor.
Other investigators have established a causal relationship between exogenouschemicals, such as asbestos and talc, and the development of ovarian carcinoma.Pelvic irradiation, viruses (particularly mumps), nulliparity, and nonuseof oral contraceptives are also associated with an increased risk of ovarianmalignancy, presumably because of sustained elevations of gonadotropins.A 1983 summary article on oral contraceptives and ovarian carcinoma founda relative risk of 0.64 (95% confidence interval, 0.57 to 0.73) associatedwith use of oral contraceptives.
The majority of epithelial ovarian cancer cases occur sporadically.In a population-based case-control study, Schildkraut and Thompson foundthat the odds ratios for ovarian cancer in first- and second-degree relativesof patients with the disease were 3.6 (95% confidence interval, 1.8 to7.1) and 2.9 (95% confidence interval, 1.6 to 5.3), respectively, whencompared to women with no family history of the disease.
Increasing evidence indicates that there are a small number of familiesat particularly high risk for developing epithelial ovarian carcinoma,Three hereditary syndromes associated with the occurrence of familial ovariancancer have been described; all three syndromes have an autosomal dominantpattern of transmission with variable penetrance. These include the ovariancancer syndrome, the hereditary breast-ovarian cancer syndrome, and theLynch II syndrome, which includes a predisposition to ovarian, endometrial,and colon cancer.
Ovarian cancer is an insidious disease that produces few or no specificsymptoms, even when advanced. Patients who develop pelvic masses of significantsize, which can occur with both early and advanced disease, may complainof abdominal swelling or symptoms related to pressure on the bladder orrectum. In advanced-stage patients with massive ascites or pleural effusions,respiratory distress may occur.
Signs of ovarian cancer may include pelvic masses or ascites detectableon physical examination and imaging techniques. It is important to recognizethat a significant proportion of patients with advanced ovarian cancer,perhaps 20%, may have essentially normal-sized ovaries, despite the presenceof ascites and extensive upper abdominal tumor.
Evaluation of patients with suspected ovarian cancer should includea complete history and physical examination, with particular attentiongiven to a family history of cancer. Routine testing appropriate for patientsundergoing major abdominal surgery should be performed. Selected tumormarker determinations and imaging studies are indicated. Multiple extensiveimaging studies are usually not required.
The poor survival associated with ovarian cancer is related to the difficultyof making an early diagnosis. The cure rates for patients with diseaselimited to the ovary are 85% to 95%, while survival of patients with tumorspread into the abdomen is 20% to 40%.
It is obvious that significant improvement in overall survival wouldbe achieved by the early diagnosis of ovarian cancer. Unfortunately, noscreening test for ovarian cancer has proven to be of benefit. Serum CA-125testing is not sensitive enough, with almost 50% of women with stage Iovarian cancer having serum levels within the normal range. Pelvic or transvaginalultrasound is not specific enough for routine screening, in that reportedseries to date have resulted in about 10 to 13 negative operations forevery case of ovarian cancer diagnosed. The April 1994 NIH Consensus Statementstated that there were no proven effective methods of screening for ovariancancer.
Invasive epithelial ovarian carcinoma can spread by local extension,lymphatic invasion, intraperitoneal implantation, or hematogenous dissemination,all of which have implications for staging. The TNM staging system forovarian cancer is shown in Table 1, alongwith approximate 5-year survival rates according to stage. Staging accuracydepends on how aggressively the surgeon looks for disease. Approximately75% of patients with invasive epithelial ovarian carcinoma have higherthan stage I disease. In patients with early-stage epithelial ovarian carcinoma,meticulous surgical staging is imperative to ascertain the need for adjuvanttherapy.
As mentioned above, stage is undoubtedly one of the strongest predictorsof survival. Histologic grade and histologic subtype have also been identifiedas independent prognosticators. Other predictors include initial tumorvolume, lymph node involvement, and residual tumor volume at the completionof surgery (optimal cytoreduction).
The surgeon plays a critical role in the management of suspected ovariancancer. This includes establishment of the diagnosis and comprehensivesurgical staging, as well as tumor debulking in patients found to haveadvanced disease. Ovarian cancers are highly responsive to chemotherapy,and both the selection of appropriate postoperative chemotherapy and theefficacy of the therapy depend on appropriate surgical staging and cytoreduction.Surgeons undertaking operations for possible ovarian cancer should haveboth the necessary technical expertise and a thorough understanding ofthe management of the disease itself.
In patients with apparent early-stage ovarian cancer, comprehensivesurgical staging is of paramount importance, since about one-third of patientswill have occult metastatic disease not apparent on gross inspection. Theuterus and contralateral ovary may be preserved in selected cases in youngwomen who wish to preserve childbearing potential.
In patients with advanced-stage disease, optimal cytoreduction (removalof all tumor masses more than 1 to 2 cm in largest diameter) can be accomplishedin about 35% to 45% of patients, and will result in improved response tochemotherapy, median survival, and long-term survival. Aggressive operations,including resection of portions of the intestinal and urinary tracts, aregenerally indicated if they will allow for optimal debulking.
The management of patients with ovarian cancer serves as a prominentexample of the importance of multimodality oncologic therapy. Optimal treatmentof this disease requires the skillful and appropriate integration of cancersurgery and chemotherapy, and is best carried out in centers in which anexperienced and coordinated multidisciplinary team is available.
Follow-up for patients with ovarian cancer who have completed primarychemotherapy depends on the initial stage of disease. Although properlystaged patients with early-stage disease (stage I and stage II withoutresidual disease) rarely benefit from second-look laparotomy, many expertsrecommend second-look operations for patients with advanced disease. Otherexperts do not recommend second-look operations for any patients. If additionaltherapy is available in the event of residual disease, second-look operationshould be considered.
For patients who have a negative second-look laparotomy and for thosewho have a complete clinical response and do not undergo second-look laparotomy,follow-up consists of physical examination with pelvic examination at 3-monthintervals for 2 years and thereafter at 6-month intervals for an additional3 years. Serum CA-125 levels are measured at each visit and Pap smearsare obtained at yearly intervals.
Although some physicians obtain periodic CT scans of the abdomen andpelvis and chest x-rays, the value of such routine testing is not established,and many physicians obtain such tests only if symptoms or findings on examinationare suspicious. Diagnostic imaging is indicated in patients with an elevatedCA-125 level.
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