Current status of staging laparotomy in colorectal and ovarian cancer.

Abstract

Colon and rectal carcinomas. Accurate staging of colon and rectal carcinomas (CRCs) is vital to insure appropriate surgical and adjuvant therapy, and appropriate enrollment in and interpretation of adjuvant or neoadjuvant trials. Historically, CRC staging has relied on pathologic examination of surgical speciments. These newer techniques of endoscopic and intraoperative ultrasound, laparoscopy, and radioimmunoguided surgery may permit increased accuracy of staging by the surgeon. Cautious interpretation of investigations of these modalities is warranted, as studies include small numbers of patients and some of the work is preliminary. Despite this, we remain optimistic that as surgeons become more familiar with these techniques and as these modalities become more widely available, more accurate staging will facilitate optimal patient management in terms of complete resection of occult disease and appropriate adjuvant therapy. Ovarian carcinoma. The survival of patients with ovarian cancer has not appreciably changed in the past several decades. There are several reasons for this, some of which are related to the surgical procedures used to diagnose and treat these cancers. First, despite a great deal of literature that suggests an elevated CA-125 level in a postmenopausal woman with a pelvic mass is virtually diagnostic of ovarian carcinoma, an unexceptably large number of patients are still explored in community hospitals by a surgeon or obstetrician-gynecologist who is not prepared or adequately trained to perform the aggressive cytoreductive surgery that the patients require. Similarly, a large percentage of patients with "apparent" early ovarian cancer are not fully surgically staged at their initial surgery and often require reoperation to accurately define the extent of their disease, which will then determine the need for adjuvant therapy. Despite ongoing health care reforms, these patients should be referred to centers where the appropriate surgical procedure can be performed by an experienced gynecologic oncologist. Second-look laparotomy (SLL) has become more and more controversial, mainly because of a lack of effective second-line therapy, and should not be performed unless the patient fully understands its limitations and is willing preoperatively to participate in a subsequent trial based on the operative findings. Laparoscopy, both in the initial staging surgery and at reassessment laparotomy (SLL), is being re-evaluated but should be considered experimental until definitive trials determine its role.