Ovarian Cancer: the Place of Conservative Surgery
P. Schwartz
Yale University School of Medicine, New Haven, CT, USA
Introduction
Ovarian cancer is the second most common site for cancer to develop in the female pelvic reproductive organs in the United States , but it is the most deadly of the common pelvic reproductive organ cancers. The mainstay for the management of the common epithelial ovarian cancer is aggressive cytoreductive surgery followed by intense combination chemotherapy. However, aggressive surgery is inappropriate for the less common ovarian germ cell malignancies which represent approximately 5% of all ovarian cancers and early stage sex cord-stromal malignancies which are even less frequent. Additionally, selected cases of young women with common epithelial ovarian cancers in an early stage may be spared aggressive cytoreductive surgery in order to preserve fertility.
Ovarian Germ Cell Malignancies
Conservative management of ovarian germ cell malignancies (OGCM) should be the rule rather than the exception. The tumors almost invariably involve one ovary with the exception of dysgerminoma which has been reported in the literature to involve both ovaries in 5-15% of cases. Young women found to have complex unilateral adnexal masses should undergo surgical removal of the mass. A frozen section should be obtained and if the tumor is an OGCM, the normal appearing contralateral ovary should be biopsied and surgical staging should be completed including at least a partial omentectomy, pelvic and para-aortic lymph node sampling and peritoneal biopsies along with washings of the peritoneum if ascites is not present for cytologic evaluation. OGCM are highly sensitive to the platinum, etoposide and bleomycin regimen (BEP). Experience at Yale University suggests that not only may patients with early stage OGCM preserve fertility, but so may women with advanced stage OGCM, such as dysgerminomas, immature teratomas and endodermal sinus tumors. Failure to perform proper surgical staging may lead to 1) an additional operation or 2) treatment with toxic chemotherapy which has been associated with severe toxicities, including fatalities.
Sex Cord-Stromal Malignancies
Sex cord-stromal malignancies are the least common of the ovarian malignancies. Benign tumors are far more frequent in this group than malignancies. Malignancies, when they occur, are most often granulosa cell tumors and Sertoli-Leydig cell tumors. Other rare tumors in this group include the gynandroblastoma, pure Sertoli cell tumors, pure Leydig cell tumors and undifferentiated sex cord-stromal tumors. For reproductive age women, conservative surgery should be routine as most of these tumors are unilateral ovarian malignancies. In the event that bilateral (Stage IB) disease is present in young women the uterus may be left in place if it does not appear to be involved with the tumor. Following adjuvant chemotherapy with etoposide and cisplatin or the BEP regime, the patient may be a candidate for in vitro fertilization using a donor egg.
Epithelial Ovarian Cancers
Epithelial ovarian cancers represent at least 90% of all ovarian malignancies. Because of their difficulty in diagnosis and poor response to conventional surgery, radiation or chemotherapy, aggressive surgery followed by intense chemotherapy has become the standard method of management of epithelial ovarian cancers. Epithelial ovarian cancers tend to be of a lower stage and grade when they present in younger women. Conservative treatment is now being reported at a more frequent rate. Indications for conservative treatment allowing for contralateral ovarian preservation include the patient’s desire for fertility, early stage disease, tumors of low malignant potential as well as well-and moderately-differentiated cancers and appropriate surgical staging. High grade tumors may also be appropriate for conservative surgery with fertility preservation provided patients receive postoperative adjuvant chemotherapy.
Preservation of reproductive function is being reported in women with early stage epithelial ovarian cancers and does not induce excessive risk for the patient developing a recurrence. Zanetta, et al reported on 56 women with Stage I epithelial ovarian cancers who underwent fertility sparing surgery and compared them to 43 more radically treated patients with Stage I disease. Conservative treatment was conducted in 84% of the nul liparous and in 33% of parous women. Five recurrences (9%) occurred in women treated conservatively and 5 (12%) in those treated more radically. The risk of recurrence in the contralateral ovary was low in this series.
Conclusion
Conservative surgery should be the standard of care for women with OGCM and early stage sex cord-stromal malignancies occurring in reproductive age women. Stage I epithelial ovarian cancer may also be treated conservatively provided proper surgical staging has been performed. Patients who have not been properly surgically staged did significantly worse in two series where one group of women were treated by gynecologic oncologists and the other by community-based physicians. It is extremely important that if one is going to practice conservative surgery for the management of women with any form of ovarian cancer that surgical staging be properly performed, and whenever possible, a gynecologic oncologist be involved in the care of the woman.
References
1. SCHWARTZ PE, CHAMBERS K, CHAMBERS JT, KOHORN EI, MCINTOSH S. Ovarian germ cell malignancies: The Yale University experience. Gynecol Oncol 45:26-21, 1992.
2. ZANETTA G, CHIARI S, ROTA S, BRATING G, MANEO A, TORRI V, MANGIONI C. Br J Obstet Gynaecol 104:1030-1035, 1997.
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