E valuation of staging, cytoreduction and second.look
operation of 119 ovarian cancer patients
D e p a r t m e n t o f G y n e c o l o g y a n d O b s t e t r i c s , " H o s p i t a l d a s C l í n i c a s " , R i b e i r ã o P r e t o S c h o o l o f M e d i c i n e , S ã o P a u l o U n i v e r s i t y ( F M R P - U S P ) - R i b e i r ã o P r e t o , B r a s i lO bjective:This study w as conducted on patients w ith ovarian cancer in order to evaluate survival. D esign: A retrospective study of 119 cases of ovarian cancer from January 1977 to D ecem ber 1992 w ith observation unti11993. Location: D epartm ent of G ynecology and O bstetrics, R ibeirão P reto S chool of M edicine, S ão P aulo U niversity. P articipants: O f the 119 cases, 70 (58.8% ) presented epithelial carcinom as and 21 (17.6% ) tum ors of the sexual girdle/strom a. D ata source: The data w ere obtained from the m edicai records of the patients. M easurem ent: S tatistical analysis of survival tim e w as based on the nonparam etric M ann-W hitney test w ith the levei of significance set at P< 0.05. R esults: The patients w ith a negative second look had a m ean survival of 79.4.:t 48.5 m ónths versus 24.2 :t 15.1 m onths for patients w ith a positive second look (P < 0.02). C onclusions: It is concluded that patients w ith a negative second look present a better prognosis com pared to those w ith residual disease.
U N ITE R M S : O varian cancer. G ytoreduction. S econd look. S urvival.
IN TR O D U C TIO N
E
X fO lia tiO nis th e b e st k n o w n fo rm o f d isse m in a tio n o f o v a ria n c a n c e r. E v e n in e n c a p su la te d tu m o rsth e re is th e p re se n c e o f m a lig n a n t c e lls in sid e th e
p e rito n e a l c a v ity . T h e se c e lls a re d istrib u te d th ro u g h o u t th e
c a v ity b y th e re sp ira to ry m o v e m e n ts o fth e d ia p h ra g m a n d
b y th e p e rista ltic a c tiv ity o f th e in te stin e , re su ltin g in a
c lo c k w ise c irc u la to ry m o v e m e n t o f th e p e rito n e a l flu id th a t
e x p la in s th e g re a te r in v o lv e m e n t o f th e rig h t d ia p h ra g m .
P a ssa g e th ro u g h th e ly m p h a tic v e sse ls o f th e d ia p h ra g m
m a y p e rm it a c c e ss to th e p le u ra l sp a c e a n d re su lt in
m a lig n a n t p le u ra l e ffu sio n s1
• In c a se s in w h ic h n o
A d d re ss fo r co rre sp o n d e n ce : E d d ie F e rn a n d o C a n d id o M u rta R u a A lg é n P a ixã o , 1 7 0 - A p ro . 2 0 2 U b e ra b a lM G - B ra sil - C E P 3 8 0 6 0 -2 3 0
m ic ro sc o p ic d ise a se is o b se rv e d o u tsid e th e o v a ry ,
a p p ro x im a te ly o n e th ird o f p a tie n ts p re se n t m a lig n a n t c e lls
in p e rito n e a l c y to lo g y 2 .
In d e e d , e v e n m a lig n a n t tu m o rs a p p a re n tly c o n fin e d
to th e o v a rie s a lre a d y p re se n t o c c u lt m e ta sta se s, m a in ly
d u e to th e ly m p h a tic d ra in a g e o fth e o v a rie s. A b o u t 5 % to
1 0 % o ftu m o rs in a n a p p a re n tly e a rly sta g e a lre a d y p re se n t
m e ta sta se s jn a o rtic o rp e lv ic ly m p h n o d e s. T h is p e rc e n ta g e
re a c h e s a b o u t 7 0 % in th e a d v a n c e d d ise a se 2,3 . H e m a to g e n ic
d isse m in a tio n is re la tiv e ly u n c o m m o n . M e ta sta se s m a y
o c c u r in th e liv e r p a re n c h y m a , e sp e c ia lly w h e n th e d ise a se
is e x te n siv e , in v o lv in g th e in te stin e a n d re su ltin g in th e '
tra n sp o rt o f sh e d c e lls in to th e p o rta l c irc u la tio n . M e ta sta se s
o f th e b ra in o r o th e r site s h a v e b e e n d e sc rib e d , e sp e c ia lly
in th e fin a l sta g e s o f th e d ise a se , p e rh a p s d u e to th e c u rre n t
in c re a se d su rv iv a l o f th e se p a tie n ts4 .5 .
A p p ro x im a te ly o n e th ird o f n e w o v a ria n c a n c e r c a se s
b e lo n g to sta g e s I a n d 1 16
•D e sp ite th e g o o d p ro g n o sis fo r
p a tie n ts w ith lo c a liz e d d ise a se , re tro sp e c tiv e e v a lu a tio n s
sh o w th a t 5 0 % o f th e m su ffe r re c u rre n c e a n d d ie d e sp ite
o f p atien ts w ith lo calized d isease is u n d erestim ated ,
p erh ap s o w in g to p o o r su rg ical stag in g3 •
T h e co rrect su rg ical p ro ced u re fo r th e id en tificatio n
o f tru e early o v arian can cer in clu d es: 1 : v ertical in cisio n o f
su fficien t ex ten sio n to p erIJ:1 it ev alu atio n o f th e en tire
ab d o m en , 2 : to tal h y sterecto m y acco m p an ied b y b ilateral
salp in g o -o o p h o recto m y , 3 : p artial in fraco lic o m en tecto m y ,
4 : ev alu atio n o f th e su rface o f th e tu m o r to d eterm in e
cap su lar in teg rity , 5 : d eterm in atio n o f th e p o ssib le p resen ce
o f ascitic flu id o r co llectio n o f a p erito n eal w ash fo r
cy to lo g ic ex am in atio n , 6 : o b lig ato ry b io p sies o f th e
fo llo w in g h ig h -risk areas: rig h t an d left d iap h rag in , b o th
ab d o m in al g u tters, p elv ic an d p ara-ao rtic ly m p h n o d es,
p erito n eal su rface, an d b io p sy o f an y su sp icio u s lesio n .
A fter th ese p recep ts are o b serv ed , th e ty p e o f
su b seq u en t treatm en t an d th e p atien ts w h o n o lo n g er n eed
co m p lem en tary treatm en t are d efin ed . M an y stu d ies h av e
sh o w n th at in m o st cases su rg ical stag in g is to tally
in ad eq u ate7
.8• F o r ex am p le, am o n g th e p atien ts o p erated
u p o n b y g y n eco lo g ists o r g en ~ ral su rg eo n s, o n ly 5 4 % an d
3 5 % , resp ectiv ely , h ad an ap p ro p riate stag in g p ro ced u re,
as o p p o sed to 9 5 % o f p atien ts o p erated u p o n b y g y n eco lo g ic
o n co lo g ists. T h e site m o st co m m o n ly n eg lected fo r
ev alu atio n w as th e d iap h rag m in 8 3 % o f cases7
• E ffectiv e treatm en t o f o v arian can cer in clu d es p erfect stag in g , an d
fo r th is reaso n th e In tern atio n al F ed eratio n o f G y n eco lo g y
an d O b stetrics (F IG O ) reco m m en d s th at th e ex ten t o f
d isease sh o u ld b e ev alu ated d u rin g su rg ery as cited ab o v e.
F o r a b etter u n d erstan d in g o f th is d isease, w e
co n d u cted a retro sp ectiv e stu d y o f 1 1 9 cases seen at th e
U n iv ersity H o sp ital o f th e R ib eirão P reto M ed icaI S ch o o l,
U n iv ersity o f S ão P au lo , fro m Jan u ary 1 9 7 7 to D ecem b er
1 9 9 2 , w ith em .p h asis o n stag in g , g en eral treatm en t,
cy to red u ctio n an d seco n d -Io o k o p eratio n .
P A T IE N T S A N D M E T H O D S
A to tal o f 3 5 2 p atien ts w ith o v arian n eo p lasias w ere
seen at th e U n iv ersity H o sp ital o fR ib eirão P reto , U n iv ersity
o f S ão P au lo , fro m J an u ary 1 9 7 7 to D ecem b er 1 9 9 2 . O f
th ese n eo p lasias, 1 1 9 (3 3 .8 % ) w ere m alig n an t an d 2 3 3
(6 6 .2 % ) w ere b en ig n o T h e 1 1 9 cases o f m alig n an t
n eo p lasias w ere stu d ied in th e p resen t in v estig atio n . T h e
fo llo w in g d ata w ere o b tain ed fro m th e m ed icaI reco rd s o f
th e p atien ts: F IG O stag in g , cy to red u ctio n , g en eral treatm en t,
seco n d -Io o k ev alu atio n , an d su rv iv al to D ecem b er 1 9 9 3 .
C y to red u ctio n w as d efin ed acco rd in g to th e fo llo w in g
criteria: a) co m p lete w h en n o m acro sco p ic in tra-ab d o m in al
m ass w as p resen t after su rg ery an d th e cy to lo g y o f th e
p erito n eal w ash o r ascitic flu id w as n eg ativ e fo r m alig n an t
cells; b ) ad eq u ate w h en o n e o r m o re m asses sm aller th an 2
cm w ere left o r th e cy to lo g y o f th e p erito n eal w ash o r ascitic
flu id w as p o sitiv e fo r m alig n an t cells; c) in ad eq u ate w h en
o n e o r m o re m asses m easu rin g 2 cm o r m o re w ere p resen t.
M etastatic o v arian can cer w as ex clu d ed fro m an aly sis o f
stag e an d cy to red u ctio n .
S tatistical an aly sis o f su rv iv al tim e w as b ased o n th e
n o n p aram etric M an n - W h itn ey test an d o n th e test fo r tw o
p ro p o rtio n s, w ith th e lev eI o f sig n ifican ce set at P <0 .0 5 .
R E S U L T S
O f th e 1 1 9 cases o f m alig n an t n eo p lasias d etected at
th e U n iv ersity H o sp ital, F acu lty o f M ed icin e o f R ib eirão
P reto , U n iv ersity o f S ão P au lo , fro m 1 9 7 7 to 1 9 9 2 , 7 0
(5 8 .8 % ) w ere m alig n an t ep ith elial n eo p lasias (sero u s an d
m u cin o u s ad en o carcin o m a w ith 4 6 an d 2 1 cases,
resp ectiv ely ), 2 1 (1 7 .6 % ) w ere tu m o rs o fth e sex u al g ird le/
stro m a, 1 2 (1 0 .1 % ) w ere g erm cell tu m o rs, 9 (7 .6 % ) w ere
m etastatic,4 (3 .4 % ) w ere u n d ifferen tiated carcin o m as, an d
3 (2 .5 % ) w ere o f u n certain o rig in o T ab les 1 , 2 an d 3
resp ectiv ely illu strate th e stag in g , ty p e o f treatm en t u sed
an d th e ev alu atio n o f su rg ical cy to red u ctio n fo r all cases o f
o v arian can cer. F ro m 3 7 o fth ese p atien ts, stag ed as IIIB o r
IIIC , ascitic flu id o r p erito n eal w ash sam p les w ere co lle'cted
d u rin g th e p reo p erativ e p erio d . C y to lo g y w as n eg ativ e fo r
n eo p lastic cells in 7 (1 8 .9 % ) o f th e cases ev alu ated . Iatro g en ic ru p tu re o f th e tu m o ral cap su le o ccu rred in
2 (1 .8 % ) o fth e 1 1 0 cases o f o rig in al o v arian can cers, o n e
o f th em b ein g a m u cin o u s tu m o r (stag e IC ) an d th e o th er a
sero u s tu m o r (stag e IIC ). In th e sp ecific case o f th e sero u s
tu m o r, th e p o sto p erativ e p erito n eal w ash w as n eg ativ e fo r
n eo p lastic cells. T h e p atien t w as su b m itted to to tal
la b ia 1
F r e q u e n c y d is tr ib u tio n b y c lin ic a l- s u r g ic a l s ta g in g
p e r fo r m e d o n th e 1 1 0 c a s e s o f o r ig in a l o v a r ia n
c a n c e r tr e a te d a t th e U n iv e r s ity h o s p ita l,
F M R P , fr o m 1 9 7 7 to 1 9 9 2 .
8 ta g e
I
11 111
IV
T o ta l
M U R T A , E .F .C .; A N D R A D E , J .M .; F R E IT A S , M .M .S .; B IG H E T T I, S . - E v a lu a tio n o f s ta n g in g , c y to r e d u c tio n a n d s e c o n d - Io o k o p e r a tio n o f 1 1 9 o v a r ia n c a n c e r
T a b le 2
F re q u e n c y d is trib u tio n b y ty p e o f tre a tm e n t
e m p lo y e d fo r th e to ta l n u m b e r o f 1 1 9 c a s e s o f
o v a ria n c a n c e r tre a te d a t th e U n iv e rs ity H o s p ita l,
F M R P , fro m 1 9 7 7 to 1 9 9 2 .
T re a tm e n t N %
S u rg e ry +C h e m o th e ra p y 5 9 4 9 .6
S u rg e ry 4 2 3 5 .3
S u rg e ry + C h e m o th e ra p y + R a d io th e ra p y 1 3 1 0 .9
S u rg e ry + R a d io th e ra p y 5 4 .2
T o ta l 1 1 9 10 0
T a b le 3
F re q u e n c y d is trib u tio n b y s u rg ic a l c y to re d u c tio n
p ro c e d u re a p p lie d to th e to ta l n u m b e r o f 1 1 0 c a s e s
o f o rig in a l o v a ria n c a n c e r tre a te d a t th e U n iv e rs ity
H o s p ita l, F M R P , fro m 1 9 7 7 to 1 9 9 2 .
C y to re d u c tio n N %
C o m p le te 4 3 3 9 .1
A d e q u a te 3 6 3 2 .7
In a d e q u a te 3 1 2 8 .2
T o ta l 1 1 0 1 0 0
a b d o m i n a l h y s t e r e c t o m y ( T A H )
+
b i l a t e r a l s a l p i n g e c t o m y( B S O ) + o m e n t e c t o m y ( O ) a n d 6 c y c l e s o f c h l o r a m b u c i l
t r e a t m e n t ; t h e s e c o n d l o o k ( S L ) w a s n e g a t i v e a n d n o s i g n s
o f r e c u r r e n c e w e r e d e t e c t e d 3 6 m o n t h s a f t e r t r e a t m e n t .
I n t h e c a s e o f t h e m u c i n o u s t u m o r , c y t o l o g y w a s
n e g a t i v e f o r n e o p l a s t i c c e l l s i n a s c i t i c f l u i d o T h e p a t i e n t
w a s s u b m i t t e d t o T A H + B S O + O a n d r a d i o t h e r a p y ; S L
w a s n e g a t i v e a n d t h e p a t i e n t w a s i n g o o d g e n e r a l c o n d i t i o n
7 2 m o n t h s a f t e r t r e a t m e n t .
S p o n t a n e o u s r u p t u r e o f t h e t u m o r a l c a p s u l e o c c u r r e d
i n 3 ( 2 .7 % ) c a s e s , w i t h s t a g i n g g i v e n i n p a r e n t h e s i s :
g r a n u l o s a c e l l s ( I C ) , i m m a t u r e t e r a t o m a ( I I C ) a n d
d y s g e r m i n o m a ( I C ) . T h e p a t i e n t w i t h t h e g r a n u l o s a c e l l
t u m o r w a s s u b m i t t e d t o T A H + B S O + O + c h l o r a m b u c i l
( 6 c y c l e s ) ; c y t o l o g y w a s n o t p e r f o r m e d a n d S L w a s
n e g a t i v e . A f t e r 7 2 m o n t h s , t h e p a t i e n t w a s i n g o o d g e n e r a l
c o n d i t i o n . I n t h e i m m a t u r e t e r a t o m a c a s e , a s c i t e s h a d
n e o p l a s t i c c e l l s a n d r e t r o u t e r i n e a n d r e c t a l p e r i t o n e a l
i m p l a n t s w e r e p r e s e n t e T h i s p a t i e n t w a s s u b m i t t e d t o T A H
+B S O +O +t e l e c o b a l t t h e r a p y a n d S L w a s n o t p e r f o r m e d .
A r e c u r r e n c e w a s d e t e c t e d 1 1 m o n t h s a f t e r s u r g e r y a n d t h e
p a t i e n t d i e d w i t h i n 2 4 m o n t h s . I n t h e d y s o e r m i n o m a c a s e
c y t o l o g y a n d S L w e r e n o t p e r f o r m e d . T h e p a t i e n t w a ~
s u b m i t t e d t o T A H
+
B S O+
O . S i x t y m o n t h s a f t e r s u r g e r ys h e p r e s e n t e d n o s i g n s o f r e c u r r e n c e .
S e c o n d - I o o k s u r g e r y w a s p e r f o r m e d i n 3 1 ( 2 8 .2 % )
o f t h e 1 1 0 c a s e s o f n o n - m e t a s t a t i c o v a r i a n c a n c e r . T w e n t y
( 6 4 .5 % ) w e r e p o s i t i v e a n d 1 8 ( 9 0 % ) o f t h e m w e r e i n s t a g e
I I I B o r I I I C . O f t h i s g r o u p o f 2 0 p a t i e n t s , o n e w a s l o s t t o
f o l l o w - u p a n d t h e s u r v i v a l o f t h e r e m a i n i n g o n e s r a n g e d
f r o m 8 t o 7 2 m o n t h s a f t e r t h e f i r s t s u r g e r y ( x = 2 4 .2 : t 1 5 .1
m o n t h s ) . F i v e w e r e s t i l l a l i v e a f t e r a f o l l o w - u p o f 2 0 t o 2 8
m o n t h s ( x = 2 2 .4 : t 3 .6 m o n t h s ) . O n t h e o c c a s i o n o f t h e S L ,
c y t o r e d u c t i o n w a s f o u n d t o b e a d e q u a t e i n 7 ( 3 5 % ) c a s e s ,
i n a d e q u a t e i n 1 2 ( 6 0 % ) a n d c o m p l e t e i n 1 ( 5 % ) . O f t h e s e
2 0 p a t i e n t s , f i v e a r e s t i l l a l i v e : t h r e e w i t h a d e q u a t e
c y t o r e d u c t i o n , t w o w i t h i n a d e q u a t e a n d c o m p l e t e
c y t o r e d u c t i o n , r e s p e c t i v e l y , a n d o n e w h o w a s l o s t t o
f o l l o w - u p . T h e m e a n s u r v i v a l o f t h e s e v e n p a t i e n t s w i t h
a d e q u a t e c y t o r e d u c t i o n w a s 2 2 .4 : t 1 2 .9 m o n t h s a n d t h e
s u r v i v a l o f t h e 1 1 p a t i e n t s w i t h i n a d e q u a t e c y t o r e d u c t i o n
w a s 2 5 .7 : t 1 7 .5 m o n t h s ( P = n o t s i g n i f i c a n t ) .
C o m p a r i s o n o f p e r c e n t a g e s u r v i v a l b e t w e e n c a s e s o f
a d e q u a t e c y t o r e d u c t i o n ( 3 p a t i e n t s s t i l l a l i v e o u t o f a t o t a l
o f 7 ) a n d p a t i e n t s w i t h i n a d e q u a t e c y t o r e d u c t i o n ( o n e p a t i e n t
s t i l l a l i v e o u t o f a t o t a l o f 1 2 ) u s i n g t h e t e s t f o r t w o
p r o p o r t i o n s d e m o n s t r a t e d a s i g n i f i c a n t d i f f e r e n c e ( P < 0 .0 5 ) .
O f 1 1 p a t i e n t s w i t h a n e g a t i v e S L , o n e w a s l o s t t o f o l l o w - u p
a n d t h e r e m a i n i n g o n e s a r e s t i l l a l i v e a f t e r a f o l l o w - u p o f
2 1 t o 1 5 6 m o n t h s ( x = 7 9 .4 : t 4 8 .5 m o n t h s ) .
S t a t i s t i c a l a n a l y s i s b y t h e M a n n - W h i t n e y t e s t o f
s u r v i v a l d a t a a f t e r a p o s i t i v e o r n e g a t i v e S L d e m o n s t r a t e d
t h a t , w h e n a l l t h e s t a g e s a r e c o n s i d e r e d t o g e t h e r , p a t i e n t s
w i t h a n e g a t i v e S L ( n = 1 0 ) h a d a l o n g e r s u r v i v a l t h a n
p a t i e n t s w i t h a p o s i t i v e S L ( n = 1 9 ) , i .e ., 7 9 .4 : t 4 8 .5 v e r s u s
2 4 .2 : t 1 5 .1 m o n t h s ( P < 0 .0 2 ) . C o m p a r i s o n o f s t a g e s I a n d
I I d e m o n s t r a t e d t h a t p a t i e n t s w i t h a p o s i t i v e S L ( n = 3 ) a n d
a n e g a t i v e S L ( n = 6 ) h a d a m e a n s u r v i v a l o f 4 4 .7 + 3 0 .4
a n d 8 7 .8 : t 4 7 .7 m o n t h s , r e s p e c t i v e l y ( P = n o t s i g n i f ~ a n t ) .
W h e n s t a g e s I I I a n d I V w e r e c o m p a r e d , p a t i e n t s w i t h a
p o s i t i v e S L ( n = 1 6 ) h a d a m e a n s u r v i v a l o f 1 9 .9 + 7 .2
v e r s u s 6 6 .8 : t 5 4 .2 m o n t h s f o r p a t i e n t s w i t h a n e g a t i ~ S L
( n = 4 ) ( P < 0 .0 2 ) .
A n a l y s i s o f d e a t h r a t e a n d s u r v i v a l u n t i l D e c e m b e r
1 9 9 3 a f t e r a p o s i t i v e o r n e g a t i v e S L b y s t a g i n g d e m o n s t r a t e d
t h a t t h e 6 p a t i e n t s i n s t a g e s I a n d I I w i t h a n e g a t i v e S L
w e r e a l i v e w i t h a m e a n s u r v i v a l o f 8 7 .8 : t 4 7 .4 m o n t h s ,
w h e r e a s t h e 3 p a t i e n t s w i t h a p o s i t i v e S L d i e d . O f t h e s e 3
p a t i e n t s , o n e s h o w e d a d e q u a t e c y t o r e d u c t i o n i n t h e S L a n d
p r e s e n t e d a s u r v i v a l o f 5 0 m o n t h s , a n d t h e o t h e r t w o h a d
i n a d e q u a t e c y t o r e d u c t i o n a n d a m e a n s u r v i v a l o f 4 2 : t 4 2 .4
m o n t h s . T h e 4 p a t i e n t s i n s t a g e s I I I a n d I V w i t h a n e g a t i v e
S L w e r e a l i v e i n D e c e m b e r 1 9 9 3 , w i t h a m e a n s u r v i v a l o f
6 6 .7 : t 5 4 .1 m o n t h s . O f t h e 1 7 p a t i e n t s w i t h a p o s i t i v e S L ,
1 1 ( 6 8 .7 % ) d i e d . O f 6 p a t i e n t s w i t h a d e q u a t e c y t o r e d u c t i o n ,
a n d 3 d ie d a fte r a m e a n s u rv iv a l o f 1 4 .3 :t 3 .2 m o n th s . O f
9 p a tie n ts w ith in a d e q u a te c y to re d u c tio n , o n e w a s a liv e
w ith a m e a n s u rv iv a l o f 2 8 m o n th s a n d 8 d ie d a fte r a
m e a n s u rv iv a l o f 3 2 .8 :t 3 0 .3 m o n th s . O n e p a tie n t w ith
c o m p le te c y to re d u c tio n w a s a liv e , w ith a s u rv iv a l o f 2 0
m o n th s . C o m p a ris o n o f th e d e a th ra te fo r a d e q u a te a n d
in a d e q u a te c y to re d u c tio n in s ta g e s III a n d IV w ith a p o s itiv e
S L s h o w e d a s ig n ific a n t d iffe re n c e (P < 0 .0 5 , te s t fo r tw o
p ro p o rtio n s ) .
D IS C U S S IO N
T h e p rim a ry tre a tm e n t o f o v a ria n c a n c e r s h o u ld
a lw a y s b e s u rg ic a P . In w o m e n w h o h a v e g iv e n b irth to a ll
th e c h ild re n th e y w a n t, s u rg e ry s h o u ld in c lu d e to ta l
h y s te re c to m y w ith b ila te ra l a d n e x e c to m y . P re s e rv a tio n o f
o v a ria n h o rm o n a l fu n c tio n d u rin g th e p re m e n o p a u s e m a y
b e c o n s id e re d , b u t th e b e n e fits d o n o t e x c e e d th e ris k s o f
p re s e rv in g th e c o n tra la te ra l o v a ry , w h ic h m a y c o n ta in a n
o c c u lt tu m o r w ith th e ris k o f s u b s e q u e n t d e v e lo p m e n t o f
c a n c e r.
A m o n g y o u n g w o m e n w h o w a n t to h a v e c h ild re n , if
th e tu m o r is in s ta g e I, g ra d e 1 o r p o s s ib ly g ra d e 2 ,
c o n s e rv a tio n o f th e u te ru s a n d o f th e c o n tra la te ra l a d n e x a
is a p p ro p ria te a n d w id e n e d b io p s y a n d fre e z in g a re
p e rfo rm e d in th e p re s e rv e d o v a ry . E v e n th o u g h th is s u rg e ry
fa c ilita te s th e a p p e a ra n c e o f a d h e s io n s th a t m a y in te rfe re .
w ith c o n c e p tio n , te c h n iq u e s o f in v itro fe rtiliz a tio n m a y b e
u s e d . In th e c a s e s o f s ta g e IA g ra d e 3 o r s ta g e IC , s u rg e ry
is c o n s e rv a tiv e b u t s h o u ld b e fo llo w e d b y c h e m o th e ra p y .
F e w p a tie n ts h a v e b e e n tre a te d in th is w a y a n d th e ris k o f
re c u rre n c e o f th e d is e a s e in th e p re s e rv e d o v a ry is u n k n o w n 3 .
In th e p re s e n t s tu d y , th e re w e re tw o c a s e s o f s ta g e IA w h ic h
w e re s u b m itte d o n ly to u n ila te ra l o o p h o re c to m y : in th e firs t
c a s e th e d ia g n o s is w a s o f w e ll d iffe re n tia te d s e ro u s
c y s ta d e n o c a rc in o m a a n d th e p a tie n t (a 7 1 -y e a r o ld w o m a n )
h a s a s u rv iv a l o f7 2 m o n th s ; in th e s e c o n d c a s e , th e p a tie n t
(a 3 6 -y e a r o ld w o m a n ) h a d a b o rd e rlin e p a p illife ro u s
m u c in o u s c y s ta d e n o c a rc in o m a a n d a s u rv iv a l o f 1 8 8
m o n th s . N e ith e r p a tie n t p re s e n ts s ig n s o f re c u rre n c e .
P a tie n ts w h o w a n t to h a v e c h ild re n s h o u ld b e w a rn e d
th a t th e ir c h ild re n w ill b e a t h ig h e r ris k d u e to th e fa m il~ a l
c a n c e r s y n d ro m e 9 , s in c e th is fa c t m a y in flu e n c e th e ir
d e c is io n w ith re s p e c t to c o n s e rv a tiv e s u rg e ry . M o s t a u th o rs
h a v e re p o rte d th a t, a fte r th e p a tie n ts h a v e h a d th e d e s ire d
n u m b e r o f c h ild re n , s u rg e ry s h o u ld a ls o b e c o m p le te d d u e
to th e ris k o f d e v e lo p in g c a n c e r in th e p re s e rv e d o v a ry ,
a lth o u g h th is ris k h a s n o t y e t b e e n q u a n tifie d in th e lite ra tu re .
T h e s e c o n d lo o k is d e fin e d a s re e x p lo ra tiv e s u rg e ry
a fte r a c o m p le te c h e m o th e ra p y s c h e d u le in o rd e r to d e te c t
p o s s ib le re s id u a l d is e a s e . T h is o p e ra tio n is a n o b je c tiv e
m e a n s o f d e te rm in in g th e re s p o n s e to th e ra p y a n d h a s
c o n trib u te d to th e d e v e lo p m e n t a n d e v a lu a tio n o f p ro g ra m s
o f o v a ria n c a n c e r tre a tm e n t. T h e fin d in g s o b ta in e d b y th is
s e c o n d s u rg e ry a re c o rre la te d w ith s u rv iv a l a n d s e rv e to
e v a lu a te th e c h e m o th e ra p e u tic a n d s u rg ic a l tre a tm e n t. T h e re
a re d o u b ts a b o u t th e in d iv id u a l b e n e fit fo r p a tie n ts s u b m itte d
to a s e c o n d lo o k , b u t th e re a re n o d o u b ts a b o u t th e g e n e ra l
b e n e fits o f tre a tm e n t o f o v a ria n c a n c e r. T h e p re s e n t re s u lts
d e m o n s tra te th a t s u rv iv a l a fte r a n e g a tiv e S L w a s th re e tim e s
h ig h e r (7 9 .4 v e rs u s 2 4 .2 m o n th s ) c o m p a re d to a p o s iiiv e
S L .
S in c e th e S L is a n in v a s iv e p ro c e d u re , s o m e a u th o rs
h a v e p ro p o s e d m e th o d s o f in v e s tig a tio n to re p la c e it,
e s p e c ia lly im a g in g m e th o d s s u c h a s u ltra s o u n d ,
c o m p u te riz e d to m o g ra p h y a n d m a g n e tic re s o n a n c e .
H o w e v e r, s o m e s tu d ie s h a v e d e m o n s tra te d th a t th e s e
m e th o d s a re u n a b le to re v e a l re s id u a lle s io n s s m a lle r th a n
2 c m lO ,1 1~A n o th e r m e th o d e m p lo y e d is la p a ro s c o p y b u t, d u e
to th e n u m b e r o f c o m p lic a ti J n s o f th is p ro c e d u re in th e s e
c a s e s , w ith th e im p o s s ib ility o f re s e c tin g la rg e m a s s e s a n d
th e la c k o f re lia b ility o f n e g a tiv e fin d in g s , la p a ro s c o p y
c a n n o t b e c o n s id e re d a s a s u b s titu te fo r S L 3 .
B lo o d C A -1 2 5 m e a s u re m e n t h a s b e e n u s e d to
d e te rm in e th e re s p o n s e o f th e tu m o r to c h e m o th e ra p y .
H o w e v e r, w h e n u s e d a s a n in d ic a to r o f tu m o r p re s e n c e a t
th e tim e o f S L , th is m e th o d is v a lid o n ly if th e le v e I is h ig h ,
s in c e n e g a tiv ity d o e s n o t e x c lu d e th e p re s e n c e o f re s id u a l
tu m o rs I2 ,1 3 .
In th e 1 9 6 0 's , M u n n e } 1 4 in tro d u c e d th e c o n c e p t te rm e d
m a x im u m s u rg ic a l e ffe c t, re fe rrin g to th e in c re a s e d s u rv iv a l
o f p a tie n ts w ith c o m p le te s u rg e ry a n d c y to re d u c tio n
c o m p a re d to th o s e w ith p a rtia l s u rg e ry . O th e r s tu d ie s h a v e
d e m o n s tra te d s im ila r re s u lts a s s o c ia te d w ith
c h e m o th e ra p y l5 -1 9 o r ra d io th e ra p y 2 0 ,2 1 . C y to re d u c tio n a t th e
tim e o f S L s h o u ld b e c o n s id e re d s in c e a p p ro x im a te ly 4 0 %
o f th e p a tie n ts p re s e n t c lin ic a lly id e n tifia b le m a s s e s . T h e
b e n e fits o f th is s u rg e ry a re c o n tro v e rs ia l, b u t a s tu d y
c o n d u c te d a t th e S lo a n -K e tte rin g M e m o ria l H o s p ita l
s h o w e d th a t p a tie n ts w ith c y to re d u c tio n fo r m ic ro s c o p ic
d is e a s e h a d a b e tte r p ro g n o s is th a n p a tie n ts w h o w e re le ft
w ith m a c ro s c o p ic d is e a s e8
•
In th e p re s e n t s tu d y , th e p e rc e n ta g e o f p o s itiv e S L
w a s 6 4 .5 % . S ta tis tic a l a n a ly s is o f th e s u rv iv a l o f th e s e
p a tie n ts d id n o t s h o w a s ig n ific a n t d iffe re n c e b e tw e e n
a d e q u a te a n d in a d e q u a te c y to re d u c tio n . H o w e v e r, th e d e a th
ra te in th e g ro u p s w ith a d e q u a te c y to re d u c tio n w a s
s ig n ific a n tly lo w e r (P < 0 .0 5 ) c o m p a re d to th e g ro u p w ith
in a d e q u a te c y to re d u c tio n .
M U R T A , E .F .C .; A N D R A D E , J .M .; F R E IT A S , M .M .S .; B IG H E T T I, S . - E v a lu a tio n o f s ta n g in g ,
c y to r e d u c tio n a n d s e c o n d - Io o k o p e r a tio n o f 1 1 9 o v a r ia n c a n c e r
CONCLUSIONS
i.
N o patient w as subm itted to biopsy of the diaphragm
and m aterial for cytology w as not collected from 22
ofthe 51 tum ors in stages I andIl (43.1
% ),procedures
that are of great im portance for staging.
2. The detection of negative cytology in peritoneal or
ascitic fluid during the preoperative
period in cases
w ith IIIB and IIIC staging (7 cases
=
18.9% of the
total of 37 sam ples) suggests the occurrence of faulty
collection, storage or preparation
of this m aterial.
3. The patients w ith a negative second look had a better
prognosis com pared to those w ith residual disease.
A m ong the latter, adequate or inadequate cytoreduction
on the occasion of SL did not im prove prognosis in
term s of survival. H ow ever, the percentage of patients
alive w ith adequate cytoreduction
w as significantly
higher than the percentage of patients w ith inadequate
cytoreduction.
.:--::::':. ,<:-<:;:'::> ,". .-: ...>::;::::\ ...:-:.: ..;.- :/::" "//>
Objetivos: Este estudofoiçondu~idgem pªcient~~.99mcâ~cE3r.de ovário com o deavâlifu asobtêvida.Des~nho: Um.,
estudo retrospectivo de 119 casos de c,âncer de .ovário de janeiro de 1977 a dezembro de 1992 com observação até 1993.
Local: Departamento de Ginecologia e Obstetrícia,> FaculdadE3'de ~ ledicina de Ribeirão Pret<:>.,Universidad~d~ São Paulo.
Participantes: De 119 casos, 70 (58.8%) eramadenocarcinomas epiteliais e 21(17.6%) eram tumores do cordão sexual/
estroma. Fonte de Dados: Os dados foram coletados dos prontuários médicos das pacientes. Mensuração: A análise estatística
da sobrevida foi baseada no teste não-paramétrico de Mann-W hitney com significância de P<0,05. Resultados: As pacientes
com second look negativo tiveram sobrevida de 79,4:f:48,5 meses versus 24,2:t15,1 meses do second look positivo (P < 0,02)~
Conclusão: Conclui-se que as padentes com secong look negativo apresentam prognóstico melhor em relação àquE3lascom
doença residual.
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