title: Tertiary cytoreductive surgery in recurrent ovarian cancer: selection criteria and survival outcome.
abstract: OBJECTIVE
  Studies of tertiary cytoreductive surgery (TCS) in recurrent epithelial ovarian cancer are limited, and appropriate patient selection remains a clinical challenge. We sought to evaluate the impact of TCS on survival and to determine predictors of optimal tertiary resection.
  
  
  METHODS
  Between January 1997 and July 2004, 47 women with recurrent epithelial ovarian cancer underwent TCS at two institutions. All patients received initial platinum and taxane-based chemotherapy following primary cytoreductive surgery. Clinico-pathologic factors and survival were retrospectively abstracted from medical records. Optimal TCS was defined as microscopic residual disease.
  
  
  RESULTS
  Thirty of 47 (64%) patients underwent optimal TCS. Size of tumor implants<5 cm on preoperative imaging was the only significant predictor of achieving optimal TCS. Overall survival after TCS was statistically longer in patients with microscopic versus macroscopic residual disease (24 versus 16 months, p=0.03). After controlling for age, time to progression and optimal TCS, only the presence of diffuse disease at tertiary exploration remained a significant poor predictor of survival. However, in a cohort of patients with limited disease implants, multivariate analysis indicated that optimal TCS retained prognostic significance as a positive predictor of survival. Twelve patients (26%) experienced severe postoperative complications, including six with pulmonary embolism, four with fistulae and two with postoperative myocardial infarctions.
  
  
  CONCLUSIONS
  Size of disease implants on preoperative imaging may guide the selection of candidates for TCS. In those patients with limited disease implants at laparotomy, optimal TCS is associated with improved survival.
authors.affiliation: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Cedars Sinai Medical Center, 8700 Beverly Blvd., Los Angeles, CA 90048, USA.
authors.forename: Amer K
authors.initials: AK
authors.lastname: Karam
authors.forename: Antonio
authors.initials: A
authors.lastname: Santillan
authors.forename: Robert E
authors.initials: RE
authors.lastname: Bristow
authors.forename: Robert
authors.initials: R
authors.lastname: Giuntoli
authors.forename: Ginger J
authors.initials: GJ
authors.lastname: Gardner
authors.forename: Ilana
authors.initials: I
authors.lastname: Cass
authors.forename: Beth Y
authors.initials: BY
authors.lastname: Karlan
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Li
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D003131:Combined Modality Therapy; D018572:Disease-Free Survival; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000188:drug therapy / Q000601:surgery*; D009944:Organoplatinum Compounds / Q000008:administration & dosage; D010051:Ovarian Neoplasms / Q000188:drug therapy / Q000601:surgery*; D012189:Retrospective Studies; D043823:Taxoids / Q000008:administration & dosage
chemical_list: D009944:Organoplatinum Compounds; D043823:Taxoids