RESULTS
The present study represents an 8-year retrospective review of operative procedures in patients with early ovarian cancer at a single institution. Fifty-two patients were identified within the study period (Table 1). Most patients had ovarian cancer (n=50); one patient had tubal cancer and one patient had primary peritoneal carcinoma. Thirty-seven and 15 patients were identified and comprised of the current FIGO stage I and II groups, respectively. The median age of the patients was 46-year-old (range, 22-70 year). Twelve patients (23%) had serous histology. The remaining 40 patients (77%) had non-serous histology: mucinous, 9 (17%); endometrioid, 11 (21%); clear cell carcinoma, 14 (27%), transitional cell, 2 (4%) and; mixed carcinoma, 4 (8%). Architecture grade 3 tumours were found in 13 (25%) patients. Serum CA-125 was checked preoperatively in 50 patients (96%); 27 patients (54%) had elevated serum CA-125 level (>35 U/mL). The medical value of serum CA-125 was 43 U/mL (range, 8-4389 U/mL). The co-existence of endometriosis was identified in 16 (31%) patients. The endometriosis was identified in adnexa, 6 (12%); rectum, 5 (10%); adnexa and rectum, 2 (4%); and pelvic peritoneum, 3(6%).
Table 2 details the surgical procedures performed in 52 patients. Forty-five patients (87%) underwent hysterectomy; five patients had undergone hysterectomy because of myoma in the past and the uterus was preserved in two patients. Fifty patients (96%) underwent bilateral salpingooophorectomies; unilateral ovary and salpinx were preserved in two patients. Pelvic peritonectomy was performed with hysterectomy and salpingooophorectomy to remove all suspicious metastatic lesions. Pelvic and paraaortic lymph node dissection was performed in 45 (87%) and 46 (88%) patients, respectively. All 52 patients underwent omentectomy. Thirty-nine patients (75%) underwent appendectomies; the appendix was missed at the time of diagnosis of ovarian cancer because the appendix had been removed in 4 and 3 patients for appendicitis and incidental appendectomy, respectively. Resection of the rectosigmoid colon was performed in 15 patients for complete removal of suspicious metastatic lesions. The rectal wall was adherent to surrounding tissues such as the uterus, adnexa, and pelvic peritoneum in 10 patients and obliteration between the rectum and surrounding tissue was identified in 5 patients. Splenectomy was performed in one patient for splenic injury and in one patient for complete removal of suspicious metastatic disease. Cholecystectomy was performed in 2 patients because of chronic cholecystitis and gallstone, respectively. Small bowel resection and re-anastomosis were performed in two patients because of adhesion from the previous operation. Diaphragmatic peritonectomy was performed in a patient with stage 1 huge mucinous cystadenocarcinoma for complete removal of a suspicious metastatic lesion. Ileostomy was performed in one patient who revealed a positive leakage test at anastomosis between the rectal stump and sigmoid colon and the reversal of ileostomy was repaired 1 year later. One case of external iliac vein laceration measuring 8 mm was managed with a vascular suture using Prolene 4–0. Ureteroneocystostomy was performed in one patient for complete removal of all suspicious lesions at lower urinary tract who revealed left hydroureteronephrosis suggesting infiltrative tumour invasion. One patient underwent ureteroureterostomy for intraoperative ureteral injury. With these surgical procedures, complete cytoreduction was attained in all patients.
Table 3 described surgical outcomes. The median operation time was 328 minutes. The median estimated blood loss was 400mL. Eleven patients received transfusion; the median transfusion was 2 pints. Postoperative complications occurred in 23% of patients, the most common being mild ileus (5 patients). Four patients experienced febrile morbidity, which improved with conservative management. Wound dehiscence was noticed in three patients. Atelectasis was identified in three patients. Pancreatic juice leakage, arrhythmia, and lymphedema were identified in a patient, respectively. All these complications were well managed with conservative management. Rectovaginal fistula or leakage was not identified in all 15 patients who underwent resection of the rectosigmoid colon. The median day for flatus passage and tolerable diet was 3 and 5 days from surgery, respectively. Forty-two patients received adjuvant chemotherapy; the median day of adjuvant chemotherapy from surgery was 13 days. The median postoperative hospital stay was 12 days.
Pathological outcomes of resection of the rectosigmoid colon were summarized in Table 4. Of 15 patients with resection of the rectosigmoid colon, cancer invasion and endometriosis were identified at resected rectum in 6 (40.0%) and 5 (33.3%) patients, respectively (Fig 1). Superficial invasion (up to serosa or subserosa) and deep invasion (up to muscle or mucosa) of cancer were identified in 3 and 3 patients, respectively. Superficial invasion and deep invasion of endometriosis were identified in 4 and 1 patient, respectively. Fibrosis and/or adhesion were identified in 4 patients. Peri-adnexal endometriosis was identified in 2 patients and another 2 patients had previous operation history.
The median follow-up of 52 patients was 50 months (range, 8-98). The 5-year disease-free survival rate was 85.9%. All patients have survived at the time of the current analysis.