The impact of bulky upper abdominal disease cephalad to the greater omentum on surgical outcome for stage IIIC epithelial ovarian, fallopian tube, and primary peritoneal cancer

Abstract

Objective: To analyze the impact of bulky upper abdominal disease (UAD) cephalad to the greater omentum on surgical outcomes for patients with stage IIIC epithelial ovarian, fallopian tube, and primary peritoneal carcinoma.

Methods: All patients with stage IIIC epithelial ovarian, fallopian tube, and primary peritoneal carcinoma who underwent primary cytoreductive surgery at our institution from 1989 to 2005 were eligible for the study. UAD cephalad to the greater omentum was defined as cancerous lesions involving the diaphragm, liver, porta hepatis, spleen, pancreas, stomach, and lesser sac. The study group was divided into three groups based on the presence and size of UAD cephalad to the greater omentum at the beginning of surgery-group 1, no disease; group 2, < or = 1 cm disease; and group 3, bulky disease > 1 cm. These three groups were further divided into two subsets based on the routine use of extensive upper abdominal surgery after January 1, 2001. Standard statistical analyses were utilized.

Results: We identified 490 patients who met study inclusion criteria. Their median age was 61 years (range, 25-88). UAD status was recorded in 474 patients as follows: group 1 (no UAD), 116 (24%); group 2 (< or = 1 cm UAD), 161 (34%); and group 3 (bulky UAD > 1 cm), 197 (42%). Bulky UAD was associated with ascites volume (P<0.001). Among the patients with ascites volumes > 500 ml, 54% had bulky UAD cephalad to the greater omentum, 37% had minimal UAD, and 9% had no evidence of UAD. Optimal surgical outcome (< or = 1 cm residual disease) was achieved in 81%, 63%, and 39% of patients in groups 1, 2, and 3, respectively (P<0.001). A significant increase in optimal cytoreduction was observed after 2001 (40% before 2001 vs. 78% after 2001; P<0.001). This effect was more pronounced in patients with bulky UAD (11%, before 2001 vs. 70% after 2001) than in patients with no or minimal UAD (P<0.001).

Conclusion: The upper abdomen cephalad to the greater omentum is frequently involved in patients with stage IIIC ovarian, tubal, and peritoneal carcinoma. This disease site is significantly associated with large-volume ascites and suboptimal cytoreduction. Over the course of 17 years, however, the significant improvement in optimal cytoreduction rates has been most apparent in patients with bulky UAD. These findings emphasize the importance of comprehensive training, preparation, and referral when appropriate to centers that specialize in the surgical management of patients with advanced ovarian, tubal, and peritoneal carcinoma.