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News for Your Practice
Ovarian cancer: What can we expect of second-look laparotomy?
Christina S. Chu, MD Assistant Professor, Division of Gynecologic Oncology, Department of Ob/Gyn, University of Pennsylvania Medical Center, Philadelphia Stephen C. Rubin, MD Professor and Chief, Division of Gynecologic Oncology, Department of Ob/Gyn, University of Pennsylvania Medical Center, Philadelphia
Most therapies are localized. Most other studies have focused on therapies localized to the peritoneal cavity. Results for intraperitoneal 32P and WAR are mixed. Several different regimens of intraperitoneal chemotherapy have produced median disease-free survival rates of 18 to 41 months.24-27 In 1998, Barakat et al27 examined the use of intraperitoneal cisplatin and etoposide, reporting a statistically improved median disease-free survival for patients receiving intraperitoneal consolidation (median disease-free survival not yet reached), compared with patients treated by observation (28.5 months).
Bottom line
Second-look laparotomy reveals that approximately 50% of patients with a complete clinical response still harbor residual disease after primary chemotherapy. Even women who achieve a complete pathologic response have recurrence rates as high as 60%. While SLL can be a useful tool, the information it yields must be weighed against the potential morbidities of invasive surgery. Given its limited prognostic value, SLL should be offered only when results will influence clinical decision-making, or as part of a clinical trial.
Is laparoscopy equal to laparotomy for second-look procedures?
Advocates of laparoscopy as a substitute for SLL report lower blood loss, shorter hospitalization, and decreased costs for laparoscopy.28
Clough et al29 performed the first study of second-look laparoscopy in 20 patients, using immediate laparotomy as a control. In 12 patients, adequate exploration was hindered by adhesions, and only 2 were able to undergo sufficient laparoscopic adhesiolysis. Overall, only 41% of patients could be completely explored at laparoscopy, versus 95% for laparotomy. However, obvious carcinomatosis was apparent in 3 patients at laparoscopy, rendering laparotomy unnecessary.
In general, laparoscopic second look has been reported to be a safe, feasible alternative to laparotomy. Although intraabdominal adhesions occur in as many as 70% of patients,30,31 complete laparoscopic evaluation may still be possible in up to 92%.32,33
How accurate?
Concerns remain about the accuracy of laparoscopic second look. Prior to 1985, several studies reported false-negative rates of 19% to 77%,33,34 although a 1999 study documented a false-negative rate of only 14%.29 The clinical impact of these false negatives is controversial. Some authors have reported no differences in clinical endpoints such as disease recurrence28 and overall survival35 for patients undergoing laparoscopy versus laparotomy. In contrast, a multivariate analysis by Gadducci et al10 showed a significantly prolonged disease-free interval for patients treated by laparotomy.
Switch to laparotomy for maximal cytoreduction
Laparoscopy may spare patients with obvious unresectable carcinomatosis a full laparotomy, though many patients will still require conversion to an open procedure to achieve maximal cytoreduction. Given these considerations, laparoscopy has only a limited role in second-look evaluation.
The authors report no financial relationships relevant to this article.
