SURGICAL THERAPY 3
The technique of second-look laparotomy has been described in multiple publications. It involves the use of a generous upper and lower midline incision and a thorough evaluation of the entire pelvic and abdominal cavity. Biopsies from the pelvic sidewalls, the serosal surfaces of the rectum and bladder, and the cul-de-sac are required for adequate evaluation of the pelvis. In the upper abdomen, sites to be biopsied include both abdominal gutters, both diaphragmatic surfaces, and any residual omentum. Lymph node sampling should include the right and left paraaortic nodes and the right and left pelvic nodes. Washings for cytologic analysis should include the pelvis, both abdominal gutters, and both diaphragmatic surfaces. In addition to the above, it is important to biopsy adhesions and any suspicious areas in the abdomen or pelvis. Most experts would recommend a minimum of 25 biopsies, and often 40-50 samples are necessary to evaluate the patient adequately at second-look laparotomy. Some investigators are evaluating laparoscopic second-look surgical reassessment. When small-volume unresectable disease is discovered, the patient may be spared a full laparotomy. The reliability of a negative second-look laparoscopy has yet to be determined.
The chances of a patient having residual disease at second-look laparotomy is directly related to a variety of prognostic factors. The fate of patients who have a negative second-look laparotomy has been evaluated by several investigators, who concluded that 17% of patients (ranging from 5% to 57% with a weighted mean of 17%) with a negative second-look laparotomy will develop recurrent cancer. If one considers only patients with stage III and stage IV cancer who have grade 2 or 3 histologic features, the recurrence rate approaches 50%.
Second-look laparotomy is not accepted as standard therapy by all physicians who treat ovarian cancer. Some authorities have argued that second-look laparotomy has never been proven to improve survival, whereas others have pointed out the lack of effective second-line therapy as a contraindication to second-look laparotomy. Although the first statement is true in that no randomized trial has addressed the question of survival benefit in epithelial ovarian cancer, there are reports of success with salvage therapy (covered later in this section). The major benefit appears to be in patients diagnosed with minimal disease.
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Secondary Cytoreductive Surgery. Although there is wide acceptance of the concept of primary cytoreductive surgery, few publications have addressed the concept of secondary cytoreductive surgery. A review of the literature indicated that 32-74% of patients could have their disease secondarily cytoreduced to a microscopic level at second-look laparotomy. The review also revealed that an even greater number of patients could have their disease reduced to an optimal level. Two groups of researchers found improved survival in patients whose ovarian cancer was secondarily cytoreduced to small-volume disease at second-look laparotomy. A 50% 5-year survival rate was reported in patients who either were found to have microscopic disease or whose disease was cytoreduced to a microscopic level at second-look laparotomy.