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Journal of Postgraduate Medicine, Vol. 52, No. 4, October-December, 2006, pp. 246-247 Expert's Comments Second look laparotomy for ovarian germ cell tumors: To do or not to do? Sood AK Director of Ovarian Cancer Research, Departments of Gynecologic Oncology and Cancer Biology, U.T.M.D. Anderson Cancer Center, 1155 Herman Pressler, Unit 1362, P.O. Box 301439 Houston, Texas 77230-1439 Code Number: jp06087 The improvement in cure rates and survival of women with ovarian germ cell tumors over the last three decades has been a great advance in the care of women with gynecologic malignancies. This success has been based largely on the improvements in chemotherapy regimens. Initial regimens included combination of vincristine, dactinomycin and cyclophosphamide (VAC), which resulted in a substantial improvement in cure rates.[1] Subsequent advances included the introduction of the vinblastine, bleomycin and cisplatin (VBP) regimen and then finally the currently used combination of bleomycin, etoposide and cisplatin (BEP).[2] Other advances in the care of women with germ cell tumors include fertility-sparing surgery and understanding the role of second-look surgery, which is the focus of the paper by George and colleagues in the current issue of the Journal. Second-look laparotomy was originally incorporated in the management of patients with epithelial ovarian cancer to assess disease status after a fixed number of chemotherapy treatments and this practice was extended to patients with other ovarian tumors, including germ cell.[3] The frequency of second-look surgery has decreased in patients with epithelial ovarian malignancies and its routine use for patients with germ cell tumors has been questioned. In a study of non-dysgerminomatous ovarian germ cell tumors, Gershenson and associates reported negative findings in 52 of the 53 women who had undergone second-look laparotomy.[4] Williams and colleagues reported on 117 patients with malignant ovarian germ cell tumors who underwent second-look laparotomy after treatment with cisplatin-based chemotherapy in three trials of the Gynecologic Oncology Group.[2] This study concluded that patients with either completely resected tumor or advanced-stage, incompletely resected tumor without elements of teratoma rarely, if ever, benefit from second-look laparotomy. Twenty-four patients with incompletely resected tumors containing immature teratoma underwent chemotherapy followed by second-look laparotomy. Of these patients, 16 had mature teratoma at second look, 7 of whom had bulky persistent masses. Fourteen of the total 16 and 6 of the 7 with bulky residual tumor remained disease free after surgical resection. All 4 patients with negative findings remained free of tumor. In the current manuscript, George and colleagues extended prior work and focused on patients with residual masses based on radiological imaging following initial surgery and chemotherapy. Twenty nine out of 35 patients with residual masses on imaging following initial combination therapy underwent a laparotomy and of these, 16 had only necrosis or fibrosis.[5] The authors concluded that laparotomy was not beneficial in tumors without a teratomatous component, < 5 cm residual following chemotherapy and normalization of tumor markers after 2 cycles of chemotherapy. The findings of this study are consistent with previous publications in that patients with either complete or incomplete resection of non-teratomatous germ cell tumors do not appear to benefit from second look surgery. Previous studies suggest that patients with incompletely resected tumor containing teratoma may benefit from second-look laparotomy.[2] However, several questions remain unanswered. For example, among patients with residual masses, is the surgery truly beneficial? Should the scope of surgery be limited to assessment of disease or cytoreduction? If the primary goal of a second-look surgery is for assessment of disease status, could additional biomarkers or imaging modalities replace such an invasive procedure? In summary, findings of this paper are consistent with prior studies, suggesting a selective role for second-look laparotomy. Whether this procedure actually improves the outcome of patients remains to be demonstrated and it is possible that with emerging technologies and therapeutic approaches, second-look surgery may not be needed. References
Copyright 2006 - Journal of Postgraduate Medicine |
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