Jinekolojik Kanserlerde Sitoredüktif Cerrahi
Özet
Sitoredüktif cerrahi, jinekolojik kanserlerde batın içinde gözle görülür tümöral doku bırakmayacak şekilde tüm implant ve peritoneal yüzeylerin cerrahi olarak çıkarılması prosedürüdür. Post-operatif dönemde tümör yükünü azaltarak hastanın yaşam kalitesini artıran bu tedavi yöntemi, optimal sitoredüksiyon sağlandığında toplam sağkalımda en önemli prognostik faktörlerden biri olmaktadır. İleri evre over kanserlerinde optimal cerrahi sınır 1 cm ve altındaki rezidü tümör olarak tanımlanmakta ve kemoterapinin tümöre daha iyi nüfuz etmesini hedeflemektedir. Cerrahi başarısı, operatörün deneyimine ve merkezin hacmine yüksek oranda bağlıdır. Kompleks olgularda bağırsak rezeksiyonları, diyafram stripping, splenektomi ve parsiyel hepatektomi gibi üst karın cerrahileri gerekebilir. Cerrahi öncesi rezektabilite tahmini kısıtlı olduğundan Fagotti skoru ve Peritoneal Kanser İndeksi gibi modeller kullanılmakta, şüpheli durumlarda laparoskopi önerilmektedir. Son yıllarda mikroskopik düzeyde başarı için hipertermik intraperitoneal kemoterapi (HIPEC) uygulamaları ve nüks olgularda sekonder sitoredüksiyon cerrahileri ön plana çıkmaktadır. Bu prosedürler ayrıca metastatik endometrial kanserlerde de sağkalımı iyileştirmektedir.
Cytoreductive surgery is a procedure in gynecological cancers defined as the surgical removal of all implants and peritoneal surfaces, leaving no macroscopically visible tumor tissue inside the abdomen. This treatment modality, which improves the patient's quality of life by reducing the postoperative tumor burden, constitutes one of the most critical prognostic factors in overall survival when optimal cytoreduction is achieved. In advanced ovarian cancers, optimal cytoreduction is defined as residual disease of 1 cm or less, aiming to enhance chemotherapy perfusion into the tumor. The success of the surgery is highly dependent on the surgeon's experience and hospital volume. In complex cases, extensive upper abdominal surgeries such as bowel resections, diaphragm stripping, splenectomy, and partial hepatectomy may be required. Since preoperative predictability is limited, models like the Fagotti score and Peritoneal Cancer Index are utilized, and laparoscopic evaluation is recommended in ambiguous cases. In recent years, hyperthermic intraperitoneal chemotherapy (HIPEC) applications targeting microscopic cytoreduction and secondary cytoreductive surgeries in recurrent cases have become prominent. These comprehensive procedures also significantly improve survival outcomes in patients with metastatic endometrial cancer.
Referanslar
Du Bois A, Reuss A, Pujade-Lauraine E, Harter P, Ray-Coquard I, Pfisterer J. Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d'Investigateurs Nationaux Pour les Etudes des Cancers de l'Ovaire (GINECO). Cancer. 2009;115(6):1234-44.
Lemoine L, Sugarbaker P, Van der Speeten K. Pathophysiology of colorectal peritoneal carcinomatosis: Role of the peritoneum. World J Gastroenterol. 2016;22(34):7692-707.
Salani R., Cosgrove CM. Cancer of the ovary, fallopian tube, and peritoneum: Surgical cytoreduction UpToDate. Retrieved February 15, 2022, from https://www.uptodate.com/contents/cancer-of-the-ovary-fallopian-tube-and-peritoneum-surgical-cytoreduction.
Chi DS, Eisenhauer EL, Lang J, et al. What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol 2006;103:559.
Winter WE 3rd, Maxwell GL, Tian C, et al. Prognostic factors for stage III epithelial ovarian cancer: a Gynecologic Oncology Group Study. J Clin Oncol 2007;25:3621.
Chiva LM, Castellanos T, Alonso S, et al. Minimal macroscopic residual disease (0.1-1 cm). Is it still a surgical goal in advanced ovarian cancer? Int J Gynecol Cancer. 2016;26:906–911.
Aletti GD, Dowdy SC, Gostout BS, et al. Aggressive surgical effort and improved survival in advanced-stage ovarian cancer. Obstet Gynecol. 2006;107:77–85.
Angeles MA, Martínez-Gómez C, Migliorelli F, et al. Novel Surgical Strategies in the Treatment of Gynecological Malignancies. Curr Treat Options Oncol. 2018;19(12):73.
Lheureux S, Braunstein M, Oza AM. Epithelial ovarian cancer: evolution of management in the era of precision medicine. CA Cancer J Clin 2019;69:280-304.
Dessapt AL, Huchon C, Ngo C, Bats AS, Bensaid C, Lecuru F. Is complete cytoreductive surgery feasible in this patient with ovarian cancer? Surg Oncol. 2016;25(3):326-31.
Bristow RE, Tomacruz RS, Armstrong DK, et al. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol 2002; 20:1248.
Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA Cancer J Clin. 2021;71(3):209-249.
Hernandez-Lopez LA, Elizalde-Mendez A. How far should we go in optimal cytoreductive surgery for ovarian cancer? Chin Clin Oncol. 2020;9(5):70.
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2013. CA Cancer J Clin. 2013;63(1):11-30.
Vitale SG, Marilli I, Lodato M, et al. The role of cytoreductive surgery in advanced-stage ovarian cancer: a systematic review. Updates Surg 2013;65:265-70.
Chang SJ, Bristow RE, Chi DS, Cliby WA. Role of aggressive surgical cyto¬reduction in advanced ovarian cancer. J Gynecol Oncol 2015;26:336-42.
Schmeler KM, Tao X, Frumovitz M, et al. Prevalence of lymph node metastasis in primary mucinous carcinoma of the ovary. Obstet Gynecol. 2010;116:269-273.
Harter P, Sehouli J, Lorusso D, et al. LION: Lymphadenectomy in ovarian neoplasms—a prospective randomized AGO study group led gynecologic cancer intergroup trial. J Clin Oncol. 2017;35:5500.
Chan JK, Urban R, Hu JM, et al. The potential therapeutic role of lymph node resection in epithelial ovarian cancer: a study of 13,918 patients. Br J Cancer. 2007;96:1817–22.
Lengyel E. Ovarian cancer development and metastasis. Am J Pat¬hol 2010;177:1053-64.
Vizzielli G, Costantini B, Tortorella L, et al. Influence of intraperitoneal dissemination assessed by laparoscopy on prognosis of advanced ovarian cancer: an exploratory analysis of a single-institution experience. Ann Surg Oncol. 2014;21(12):3970-7.
Escayola C, Ferron G, Romeo M, et al. The impact of pleural disease on the management of advanced ovarian cancer. Gynecol Oncol. 2015;138:216–220.
Ledermann JA, Raja FA, Fotopoulou C, et al. Newly diagnosed and relapsed epithelial ovarian carcinoma; ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2013;24 suppl 6:vi24-32.
Risum S, Hogdall C, Loft A, et al. Does the use of diagnostic PET/CT cause stage migration in patients with primary advanced ovarian cancer? Gynecol Oncol. 2010;116:395–398.
Fagotti A, Fanfani F, Ludovisi M, et al. Role of laparoscopy to assess the chance of optimal cytore-ductive surgery in advanced ovarian cancer: a pilot study. Gynecol Oncol. 2005;96:729–735.
Sugarbaker PH. Surgical responsibilities in the management of peritoneal carcinomatosis. 2010;713–24.
Fagotti A, Ferrandina G, Fanfani F, et al. A Laparoscopy-based score to predict surgical outcome in patients with advanced ovarian carcinoma: a pilot study. Ann Surg Oncol. 2006;13:1156–61.
Petrillo M, Vizzielli G, Fanfani F, et al. Definition of a dynamic laparoscopic model for the prediction of incomplete cytoreduction in advanced epithelial ovarian cancer: proof of a concept. Gynecol Oncol. 2015;139(1):5-9.
Bristow RE, del Carmen MG, Kaufman HS, Montz FJ. Radical oophorec¬tomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 2003;197:565-74.
Hoffman MS, Zervose E. Colon resection for ovarian cancer: intraoperati¬ve decisions. Gynecol Oncol 2008;111:S56-65.
Giorda G, Gadducci A, Lucia E, et al. Prognostic role of bowel involvement in optimally cytoreduced advanced ovarian cancer: a retrospective study. J Ovarian Res 2014;7:72.
Mourton SM, Temple LK, Abu-Rustum NR, et al. Morbidity of rectosigmoid resection and primary anastomosis in patients undergoing primary cytoreductive surgery for advanced epithelial ovarian cancer. Gynecol Oncol 2005;99:608.
Tebes SJ, Cardosi R, Hoffman MS. Colorectal resection in patients with ovarian and primary peritoneal carcinoma. Am J Obstet Gynecol 2006;195:585.
Kingham TP, Pachter HL. Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg 2009;208:269.
Lago V, Flor B, Matute L, et al. Ghost Ileostomy in Advanced Ovarian Cancer: A Reliable Option. Int J Gynecol Cancer 2018;28(7):1418-1426.
Kalogera E, Nitschmann CC, Dowdy SC, Cliby WA, Langstraat CL. A pros¬pective algorithm to reduce anastomotic leaks after rectosigmoid resecti¬on for gynecologic malignancies. Gynecol Oncol 2017;144:343-7.
Jauffret C, Lambaudie E, Bannier M, Buttarelli M, Houvenaeghel G. Place de la cœlioscopie robot-assistée dans la prise en charge des récidives de cancers pelviens [Robot-assisted laparoscopy in the management of recurrent pelvic cancer]. Gynecol Obstet Fertil. 2011;39(12):674-80.
Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al. The addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival in patients with stages IIIC-IV epithelial ovarian cancer. Gynecol Oncol 2006;103:1083-90.
Prader S, Harter P, Grimm C, et al. Surgical management of cardiophrenic lymph nodes in patients with ad¬vanced ovarian cancer. Gynecol Oncol 2016;141:271-5.
Chi DS, Franklin CC, Levine DA, et al. Improved optimal cytoreduction rates for stages IIIC and IV epithelial ovarian, fallopian tube, and primary peritoneal cancer: a change in surgical approach. Gynecol Oncol 2004;94:650.
Chi DS, Eisenhauer EL, Zivanovic O, et al. Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol 2009;114:26.
Cliby W, Dowdy S, Feitoza SS, et al. Diaphragm resection for ovarian cancer: technique and short-term complications. Gynecol Oncol 2004;94:655.
Eisenkop SM, Nalick RH, Wang HJ, Teng NN. Peritoneal implant elimination during cytoreductive surgery for ovarian cancer: impact on survival. Gynecol Oncol 1993;51:224.
Tsolakidis D, Amant F, Van Gorp T, et al. Diaphragmatic surgery during primary debulking in 89 patients with stage IIIB-IV epithelial ovarian cancer. Gynecol Oncol 2010;116:489.
Fanfani F, Fagotti A, Gallotta V, et al. Upper abdominal surgery in advanced and recurrent ovarian cancer: role of diaphragmatic surgery. Gynecol Oncol 2010;116:497.
Eisenkop SM, Spirtos NM, Lin WC. Splenectomy in the context of primary cytoreductive operations for advanced epithelial ovarian cancer. Gynecol Oncol 2006;100:344.
Magtibay PM, Adams PB, Silverman MB, et al. Splenectomy as part of cytoreductive surgery in ovarian cancer. Gynecol Oncol 2006;102:369.
Scholz HS, Tasdemir H, Hunlich T, et al. Multivisceral cytoreductive surgery in FIGO stages IIIC and IV epithelial ovarian cancer: results and 5-year follow-up. Gynecol Oncol 2007;106:591.
Martinez A, Pomel C, Mery E, Querleu D, Gladieff L, Ferron G. Celiac lymph node resection and porta hepatis disease resection in advanced or recurrent epithelial ovarian, fallopian tube, and primary peritoneal cancer. Gynecol Oncol. Elsevier Inc. 2011;121:258–63.
Markman M. Intraperitoneal chemotherapy in the management of malignant disease. Expert Rev Anticancer Ther. 2001;1(1):142-8.
Kampinga HH, Dynlacht JR, Dikomey E. Mechanism of radiosensitization by hyperthermia (> or = 43 degrees C) as derived from studies with DNA repair defective mutant cell lines. Int J Hyperthermia. 2004;20(2):131-9.
Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei syndrome? Lancet Oncol. 2006;7:69–76.
Kim J, Bhagwandin S, Labow DM. Malignant peritoneal mesothelioma: a review. Ann Transl Med. 2017;5:236.
Spiliotis J, Halkia E, Lianos E, et al. Cytoreductive surgery and HIPEC in recurrent epithelial ovarian cancer: a prospective randomized phase III study. Ann Surg Oncol. 2015;22(5):1570-5.
Chiva LM, Gonzalez-Martin A. A critical appraisal of hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced and recurrent ovarian cancer. Gynecol Oncol. 2015;136(1):130-5.
Van Driel WJ, Koole SN, Sikorska K, et al. Hyperthermic Intraperitoneal Chemotherapy in Ovarian Cancer. N Engl J Med. 2018;378(3):230-240.
Bommert M, Harter P, Heitz F, du Bois A. When should Surgery be used for Recurrent Ovarian Carcinoma? Clin Oncol (R Coll Radiol). 2018;30(8):493-497.
Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30.
Galaal K, Al Moundhri M, Bryant A, Lopes AD, Lawrie TA. Adjuvant chemotherapy for advanced endometrial cancer. Cochrane Database Syst Rev. 2014;2014(5):CD010681.
Shih KK, Yun E, Gardner GJ, Barakat RR, Chi DS, Leitao MM Jr. Surgical cytoreduction in stage IV endometrioid endometrial carcinoma. Gynecol Oncol. 2011;122(3):608-611.
Barlin JN, Puri I, Bristow RE. Cytoreductive surgery for advanced or recurrent endometrial cancer: a meta-analysis. Gynecol Oncol. 2010;118(1):14-8.
Philp L, Kanbergs A, Laurent JS, Growdon WB, Feltmate C, Goodman A. The use of neoadjuvant chemotherapy in advanced endometrial cancer. Gynecol Oncol Rep. 2021;36:100725.
Rabinovich A. Neo-adjuvant chemotherapy for advanced stage endometrial carcinoma: a glimmer of hope in select patients. Arch Gynecol Obstet. 2016;293(1):47-53.
Vergote I, Tropé CG, Amant F, et al. European Organization for Research and Treatment of Cancer-Gynaecological Cancer Group; NCIC Clinical Trials Group. Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med. 2010;363(10):943-53.
Wilkinson-Ryan I, Frolova AI, Liu J, et al. Neoadjuvant chemotherapy versus primary cytoreductive surgery for stage IV uterine serous carcinoma. Int J Gynecol Cancer. 2015;25(1):63-8.
Albright BB, Monuszko KA, Kaplan SJ, et al. Primary cytoreductive surgery for advanced stage endometrial cancer: a systematic review and meta-analysis. Am J Obstet Gynecol. 2021;225(3):237.e1-237.e24.
