KEY POINTS
The disturbing fact that epithelial ovarian cancer often recurs after clinical remission poses this challenge: How do we identify the women with subclinical disease who may benefit from additional consolidation therapy?- Second-look laparotomy (SLL) is the only way to confirm complete pathologic response to ovarian cancer therapy.
- Offer SLL only to patients for whom results will affect decision-making—and only after discussion with the patient and a gynecologic oncologist.
- Although negative SLL findings confer improved prognosis, disease recurs in up to 60% of patients.
- Candidates should be in clinical remission as determined by physical examination, abdominopelvic imaging, and serum CA-125 determination.
Given the inability of noninvasive studies such as computed tomography, magnetic resonance imaging, and positron emission tomography to reliably detect small-volume and microscopic disease, second-look laparotomy (SLL) is the only technique capable of confirming a complete pathologic response to therapy.
Ob/Gyns involved in care of women with advanced ovarian cancer face the challenge of weighing the benefits of SLL against the potential morbidities of invasive surgery. This article describes those benefits, surgical technique, the prognostic significance of findings, and the status of salvage and consolidation therapies.
What SLL conveys
“Second look laparotomy” has rather loosely described many secondary surgeries for ovarian cancer, but we adopt the more rigorous definition: “a systematic surgical reexploration in asymptomatic patients who have no clinical evidence of tumor following initial surgery and completion of a planned program of chemotherapy.”1
Procedures to debulk recurrent or residual disease, relieve symptomatic tumor, or accomplish interval cytoreduction cannot be deemed second-look laparotomy.
Prognostic, therapeutic limitations complicate the decision
Although negative findings at SLL confer an improved prognosis, disease ultimately recurs in up to 60% of patients.2,3 Moreover, despite intensive research, consistently effective consolidation and salvage regimens remain elusive.
SLL may provide some information about prognosis, but that information is far from certain. Because of the cost and morbidity inherent in SLL, routine use has largely been limited to patients in clinical trials, where findings may serve as a surrogate endpoint for investigational therapies.
For these reasons, we strongly recommend careful discussion of this complex decision with patients prior to surgery, in consultation with a gynecologic oncologist.
Which patients are and are not candidates?
Candidates should be in clinical remission as determined by physical examination, abdominopelvic imaging, and serum CA-125 determination. Although SLL will detect residual disease in up to 50% of patients undergoing the procedure after primary chemotherapy, SLL is an imperfect method of determining the true response to therapy. Thus, it should be offered only to patients for whom results will influence clinical decision-making.
Patients with stage I disease treated with appropriate chemotherapy should not undergo SLL because of the low incidence of positive findings.4
Residual disease: 30% to 50%
Second-look laparotomy requires thorough inspection of the peritoneal cavity and retroperitoneum, but when properly performed on appropriate candidates, SLL detects residual disease in 30% to 50% of patients.2,5
Generally, stage and volume of residual disease at initial surgery are most closely correlated with findings. In a review of 31 series, patients with stage III and IV disease undergoing surgery had fewer negative SLLs (39% and 33%, respectively) than patients with stage I and II disease (81% and 69%, respectively).6 Similarly, in pooled data on 1,797 patients, 72% of those with no gross residual disease at the conclusion of primary surgery had negative findings at SLL, compared with 50% of those with optimal residual, and only 23% of those with suboptimal residual.6
Surgical technique
Surgery begins with a large vertical incision and involves the components listed in the TABLE.
If gross disease is apparent:
Consider surgical cytoreduction, which is typically performed at the surgeon’s discretion.
In the absence of gross tumor:
Use a 5-point strategy to search thoroughly for occult disease.
- Take washings for cytology from the abdomen and pelvis;
- lyse any adhesions to allow adequate examination of all peritoneal surfaces;
- obtain random biopsies from the pelvis, bladder serosa, vaginal cuff, culde-sac, paracolic gutters, and hemidiaphragms, as well as adhesions, sites of prior documented tumor, infundibulopelvic ligament pedicles, and areas suspicious for tumor recurrence;
- consider removing the uterus, adnexae, omentum, and appendix, if not done at the primary surgery; and
- sample any remaining pelvic and paraaortic lymph nodes.
Meticulous sampling is crucial