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Optimal Cytoreduction in Stage IV Ovarian Carcinoma

St Vincent Hospital and Health Centers, Indiana University Medical Center, Indianapolis, IN

To the Editor: In the March 1999 issue of the Journal of Clinical Oncology, Drs Bonnefoi, A'Hern, and Fisher, et al, in their article entitled the "Natural History of Stage IV Epithelial Ovarian Cancer," state that "the size of residual disease is not a prognostic factor in this group of patients, and, therefore, the role of debulking surgery in these patients needs to be reconsidered."

When one looks at the patient characteristics in Table 2, one notes immediately that optimum measures of cytoreduction were not used. Eighty-two percent of the patients had lesions larger than 2 cm in size after cytoreductive surgery, and only 4% of the patients had no residual disease before chemotherapy was started. According to the article, 10% had less than 2 cm of residual disease, but as we now know, residual disease must be reduced to less than 1 cm in any diameter in order to achieve optimal cytoreduction.

It is certainly possible that stage IV disease is biologically different than stage III disease, as the authors state. On the other hand, one cannot compare apples and oranges, and I am afraid that this is what the authors did.

REFERENCES

1. Bonnefoi H, A'Hern RP, Fisher C, et al: Natural history of stage IV epithelial ovarian cancer. J Clin Oncol 17:767-775, 1999[Abstract/Free Full Text]

Optimal Cytoreduction in Stage IV Ovarian Carcinoma

University Hospital, Geneva, Switzerland
Royal Marsden Hospital, London, United Kingdom

In Reply: Dr Geisler criticizes the 2-cm cutoff we chose in our study.¹ We agree that increasingly collaborative groups are using less than or more than 1 cm of residual disease to define optimal/suboptimal debulking. This is a relatively recent change, with many trials previously using 2 cm to separate these two important prognostic groups, either to include patients in different studies according to the size of residual disease (eg, the Southwest Oncology Group, who reported in 1992 the results of a trial comparing two chemotherapy regimens in suboptimal > 2-cm stage III and IV epithelial ovarian carcinoma [EOC] and in 1996 the results of a trial conducted in stage III EOC with residual disease 2 cm)^2,3 or to stratify the results (eg, the Gruppo Interegionale Cooperativo Oncologico Ginecologia, the National Cancer Institute of Canada, and the Scotish Cooperative Group).^4-6

The Gynecologic Oncology Group (GOG) has defined suboptimally debulked disease as greater than 1 cm since 1986. However, it is interesting to note that in 1994 Hoskins et al⁷ on behalf of the GOG, found no survival difference between patients with less than 1 cm and those with 1 to 2 cm residuum.

Our series covers a period of time in which 2 cm was widely used to describe the adequacy of surgery (1972 to 1994), and this was how optimal/suboptimal debulking was defined in the patients' charts. We therefore used these contemporaneous records in our analysis; to do otherwise would have been to jeopardize the accuracy of the data in our report.

REFERENCES

1. Bonnefoi H, A'Hern RP, Fisher C, et al: Natural history of stage IV ovarian cancer. J Clin Oncol 17:767-775, 1999

2. Alberts DS, Green S, Hannigan EV, et al: Improved therapeutic index of carboplatin plus cyclophoshamide: Final report by the Southwest Oncology Group of a phase III randomized trial in stages III and IV ovarian cancer. J Clin Oncol 10:706-717, 1992[Abstract/Free Full Text]

3. Alberts DS, Liu PY, Hannigan EV, et al: Intraperitoneal cisplatin plus intravenous cyclophoshamide versus intravenous cisplatin plus intravenous cyclophoshamide for stage III ovarian cancer. N Engl J Med 335:1950-1955, 1996[Abstract/Free Full Text]

4. Gruppo Interegionale Cooperativo Oncologico Ginecologia: Randomised comparison of cisplatin with cyclophosphamide/cisplatin and with cyclophosphamide/doxorubicin/cisplatin in advanced ovarian cancer. Lancet 2:353-359, 1987[Medline]

5. Swenerton K, Jeffrey J, Stuart G, et al: Cisplatin-cyclophoshamide versus carboplatin-cyclophosphamide in advanced ovarian cancer: A randomized phase III study of the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 10:718-726, 1992[Abstract/Free Full Text]

6. Kaye SB, Paul J, Cassidy J, et al: Mature results of a randomized trial of two doses of cisplatin for the treatment of ovarian cancer. J Clin Oncol 14:2113-2119, 1996[Abstract/Free Full Text]

7. Hoskins WJ, McGuire WP, Brady MF, et al: The effect of diameter of largest residual disease on survival after primary cytoreductive surgery in patients with suboptimal residual epithelial ovarian carcinoma. Am J Obstet Gynecol 170:974-980, 1994[Medline]

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Geisler, H. E. Articles by Gore, M. E. Search for Related Content PubMed PubMed Citation Articles by Geisler, H. E. Articles by Gore, M. E. Social Bookmarking                            What's this?