Second-look surgery in the management of epithelial ovarian carcinoma

The constructs for incorporating second-look surgery (SLL) in the treatment schema for ovarian epithelial carcinoma are being challenged. Although second-look surgery remains the hallmark for assessing disease status at the completion of adjuvant chemotherapy, its continued utility must demonstrate potential benefits in both the presence and absence of disease. While critics cite as unacceptable the recurrence rates (20-50%) after negative SLL, the patients so identified have demonstrated chemosensitivity and harbor optimal tumor volumes if present and possibly more biologically favorable tumors. These very characteristics should render negative SLL patients ideal candidates for consolidation therapy. Furthermore, age, histologic grade, and residual volume stratifies patients into high- and low-risk categories for recurrence after negative second look and should further facilitate consolidation therapy selection. Similarly, longevity following positive SLL is correlated adversely to advancing age and the histologic grade and the residuum of the tumor identified at reexploration. Recognizing that age and grade are predetermined factors, aggressive secondary cytoreduction has the potential of extending longevity. The latter is supported by mathematical tumor kinetic models and several focused, large, single-institution retrospective analyses. Therefore, the value of SLL is apparent but the criteria for its continued utilization in advanced ovarian cancer should include its performance by appropriately trained surgeons and the availability of (and preferably prospective trials for) both consolidation and salvage therapy to which all patients would optimally be afforded access.