title: The addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival in patients with stages IIIC-IV epithelial ovarian cancer.
abstract: OBJECTIVE
  To determine the survival impact of adding extensive upper abdominal surgical cytoreduction to standard surgical techniques for advanced ovarian cancer.
  
  
  METHODS
  The records of all patients with stages IIIC-IV epithelial ovarian cancer who underwent primary surgery at our institution from 1998 to 2003 were reviewed. The cohort was divided into 3 groups. Group 1 patients required extensive upper abdominal surgery, such as diaphragm peritonectomy/resection, resection of parenchymal liver or porta hepatis disease and/or splenectomy with or without distal pancreatectomy, to achieve optimal cytoreduction (residual disease<or=1 cm). Group 2 patients were optimally cytoreduced by standard surgical techniques, including hysterectomy, oophorectomy, omentectomy, and bowel resection. Group 3 patients were suboptimally cytoreduced. Primary outcome measures were response to primary chemotherapy, progression-free survival, and overall survival.
  
  
  RESULTS
  The cohort of 262 patients was divided as follows: Group 1, 57 patients; Group 2, 122 patients; and Group 3, 83 patients. The median follow-up was 36 months (range, 1-94 months). Frequency of clinical complete response in Groups 1, 2, and 3 was 82%, 78%, and 57%, respectively. The median progression-free survival for Groups 1, 2, and 3 was 24, 23, and 11 months, respectively. Progression-free survival for Groups 1 and 2 were equivalent (P=0.53) and were significantly longer than for Group 3 (P<0.001). The median overall survival was 84 and 38 months for Groups 2 and 3, respectively, and had not been reached for Group 1 by 68 months. Patients in Group 1 had equivalent overall survival to patients in Group 2 (P=0.74) and improved survival over patients in Group 3 (P<0.001). Prognostic factors significant on multivariate analysis included stage, optimal status, and ascites.
  
  
  CONCLUSIONS
  Patients requiring extensive upper abdominal procedures to achieve optimal cytoreduction demonstrated a similar initial response, progression-free survival, and overall survival to patients optimally cytoreduced by standard surgical techniques. The presence of bulky upper abdominal disease alone did not appear to indicate poor tumor biology. This initial maximal surgical effort was associated with improved survival in patients who would have otherwise been suboptimally cytoreduced.
authors.affiliation: Gynecology Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, MRI-1026, New York, NY 10021, USA.
authors.forename: Eric L
authors.initials: EL
authors.lastname: Eisenhauer
authors.forename: Nadeem R
authors.initials: NR
authors.lastname: Abu-Rustum
authors.forename: Yukio
authors.initials: Y
authors.lastname: Sonoda
authors.forename: Douglas A
authors.initials: DA
authors.lastname: Levine
authors.forename: Elizabeth A
authors.initials: EA
authors.lastname: Poynor
authors.forename: Carol
authors.initials: C
authors.lastname: Aghajanian
authors.forename: William R
authors.initials: WR
authors.lastname: Jarnagin
authors.forename: Ronald P
authors.initials: RP
authors.lastname: DeMatteo
authors.forename: Michael I
authors.initials: MI
authors.lastname: D'Angelica
authors.forename: Richard R
authors.initials: RR
authors.lastname: Barakat
authors.forename: Dennis S
authors.initials: DS
authors.lastname: Chi
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016208:Databases, Factual; D003964:Diaphragm / Q000601:surgery; D018572:Disease-Free Survival; D005260:Female; D013509:Gynecologic Surgical Procedures / Q000706:statistics & numerical data*; D006801:Humans; D008099:Liver / Q000601:surgery; D008875:Middle Aged; D009367:Neoplasm Staging; D009375:Neoplasms, Glandular and Epithelial / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D009519:New York City; D010051:Ovarian Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D010179:Pancreas / Q000601:surgery; D010385:Pelvic Exenteration / Q000379:methods*; D010537:Peritoneum / Q000601:surgery; D013154:Spleen / Q000601:surgery; D016019:Survival Analysis; D016896:Treatment Outcome