1. Patient characteristics
Of all 11 patients, two patients (patients 6 and 9) underwent primary laparotomy and the others underwent primary laparoscopy. Primary surgery was hysterectomy and bilateral salpingo-oophorectomy with cytoreductive surgery. Only one patient underwent unilateral oophorectomy with biopsy of the contralateral site for endometrioid carcinoma (patient 9). All second look surgery had undergone by laparoscopy. But one patient had been converted to laparotomy due to adhesion (patient 10). All patients had undergone primary surgery followed by six cycles of platinum-based chemotherapy. The median age of subjects was 54 years (range, 30 to 89 years). The median follow-up period was 54 months. The median difference between primary surgery and second look procedure was 8 months.
2. Second look laparoscopy results
Of 11 patients who underwent second look laparoscopy, eight patients (72.7%) had positive pathologic findings and three patients (27.3%) had negative pathologic findings (patients 7 to 9) (Table 1). The median number of biopsies taken was 7 (range, 1 to 20). Two patients underwent additional retroperitoneal lymphadenectomy on second look surgery (patients 3 and 10). The median hospital stay for second look laparoscopy was 10.45 days, and postoperative complications were not reported.
At the close of this study, the following findings were noted. Three patients with negative findings on tumor markers, imaging, and second look laparoscopy had no recurrence (5 years after second look laparoscopy) (patients 7 to 9). Seven patients (63.6%) who had positive second look laparoscopy are surviving with the disease (5 years after second look laparoscopy) and were treated with consolidation chemotherapy (patients 2 to 6, 10, 11). And one patient (12.5%) who had negative imaging study but positive tumor markers and second look laparoscopy succumbed to disease (patient 1).
3. Tumor markers and imaging studies
CA 125 level was higher in only one patient of eight patients with positive second look laparoscopy (12.5%, patient 1). The CA 125 level was determined at least 4 weeks before the second look laparoscopic procedure.
Four patients had a recorded increase in FDG uptake (36.4%; patients 3, 4, 9, 11). The increased standardized uptake value in specific regions of the scans of the three patients corresponded to positive biopsies from those regions (patients 3, 4, 11) (Fig. 1). The patient 9 had positive finding on PET-CT, but pathologic negative findings on second-look laparoscopy were interpreted as PET-CT uptake due to non-specific inflammation. The standardized uptake value cut off used in our institution is four. None of the patients had abnormal CT scan findings.
Figure 1. Pre-second look laparoscopy PET-CT results. Arrows are indicating area of FDG uptakes. Increasing in FDG uptake on right peri-external vessel area (patient 3) (A), omental seeding (patient 4) (B), left paraspinal area of L2 spine, false positive (patient 9) (C), and right posterior side from bladder (patient 11) (D).
The sensitivity, specificity, positive predictive value and negative predictive value of the study were calculated based on the recurrence of cancer. And the recurrence was diagnosed by positive pathologic finding in second look laparoscopy. The negative predictive rates of PET-CT, CT scan, and tumor markers were 27.3%, 25.0%, and 27.3%, respectively (Table 2).
4. Treatment after second look laparoscopy
Eight patients had positive findings on second look laparoscopy (patients 1 to 6, 10, 11). The seven patients were treated with consolidation chemotherapy and the other one died of advanced stage and disseminated intravascular coagulation (patient 1). Four patients were treated with topotecan-cisplatin chemotherapy, and two patients were treated with Taxotere-cisplatin chemotherapy. One patient was treated with monotherapy topotecan regimen. Three patients with negative second look laparoscopy did not receive consolidation treatment (patients 7 to 9). Their disease-free survival were not calculated because of the recent nature of their disease.
The 5-year survival rate was 77.78% and it was calculated except two patients due to loss of following (patients 8 and 10). The 5-year survival rate for stage I was 100%, stage II was 100%, stage III was 66.67% and stage IV was 66.67%. The 5-year recurrence rate was 0%, 50%, 66.67%, and 33.33% for stages I, II, III, and IV, respectively. The 5-year survival rate of patients with consolidation therapy was 66.67%, and the 5-year recurrence rate was 33.33%.