Multivariate analysis of prognostic factors in patients with ovarian cancer stage I and II

Intraoperative Rupture of the Ovarian Capsule in Early-Stage Ovarian Cancer: A Meta-analysis

OBJECTIVE

To examine the effects of intraoperative ovarian capsule rupture on progression-free survival and overall survival in women who are undergoing surgery for early-stage ovarian cancer.

DATA SOURCES

MEDLINE using PubMed, EMBASE (Elsevier), ClinicalTrials.gov, and Scopus (Elsevier) were searched from inception until August 11, 2020.

METHODS OF STUDY SELECTION

High-quality studies reporting survival outcomes comparing ovarian capsule rupture to no capsule rupture among patients with early-stage epithelial ovarian cancer who underwent surgical management were abstracted. Study quality was assessed with the Newcastle-Ottawa Scale, and studies with scores of at least 7 points were included.

TABULATION, INTEGRATION, AND RESULTS

The data were extracted independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between ovarian capsule rupture and oncologic outcomes. Seventeen studies met all the criteria for inclusion in the meta-analysis. Twelve thousand seven hundred fifty-six (62.6%) patients did not have capsule rupture and had disease confined to the ovary on final pathology; 5,532 (33.7%) patients had intraoperative capsule rupture of an otherwise early-stage ovarian cancer. Patients with intraoperative capsule rupture had worse progression-free survival (hazard ratio [HR] 1.92, 95% CI 1.34-2.76, P<.001), with moderate heterogeneity (I2=41%, P=.07) when compared with those without capsule rupture. Pooled results from these studies showed a worse overall survival (HR 1.48, 95% CI 1.15-1.91, P=.003), with moderate heterogeneity (I2=53%, P=.02) when compared with patients without intraoperative capsule rupture. This remained significant in a series of sensitivity analyses.

CONCLUSION

This systematic review and meta-analysis of high-quality observational studies shows that intraoperative ovarian capsule rupture results in decreased progression-free survival and overall survival in women with early-stage ovarian cancer who are undergoing initial surgical management.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO, CRD42021216561.

Association between AXIN1 gene polymorphisms and epithelial ovarian cancer in Chinese population

Aim: The study was aimed to explore the association between AXIN1 gene polymorphism and epithelial ovarian cancer (EOC) susceptibility as well as prognosis. Methods: A total of 165 EOC cases and 327 healthy controls were recruited to participate in this study. In total three tag SNPs in AXIN1 gene were genotyped using PCR-restriction fragment length polymorphism. Results: Significantly increased EOC risk was found associated with the A/C heterozygous genotype of rs12921862, the C allele and C/T genotype in the rs1805105 and the T/T genotype of rs370681. Meanwhile, Kaplan-Meier survival curves showed that patients with rs12921862 C/C genotype improved overall survival in the EOC group. Conclusion: Our results suggest that the AXIN1 gene may be related to susceptibility and overall survival in EOC.

Pretreatment lymphocytopenia is an adverse prognostic biomarker in advanced-stage ovarian cancer

The aim of this study was to investigate the prognostic significance of lymphocytopenia in advanced‐stage ovarian cancer. We retrospectively reviewed 506 patients with advanced‐stage ovarian cancer at Yonsei Cancer Hospital. This study included two cohorts of patients: a neoadjuvant chemotherapy (NAC) group (N = 247) and a primary debulking surgery (PDS) group (N = 259). The absolute lymphocyte count was recorded before treatment. A receiver operating characteristic (ROC) curve analysis was used to determine the cutoff for defining lymphocytopenia in the NAC cohort and followed by multivariate analysis. Subsequently, lymphocytopenia was assessed in the PDS cohort by multivariate analysis. A further analysis was performed to evaluate the absolute lymphocyte count as a continuous variable. An absolute lymphocyte count of 1.49 × 109/L was determined as the cutoff for the ROC curve analysis in the NAC cohort, and the multivariate analysis revealed that lymphocytopenia was an independent prognostic factor for poor progression‐free survival (PFS) [hazard ratio (HR), 1.50; 95% confidence interval (CI), 1.07‐2.11] and overall survival (OS) (HR, 2.02; 95% CI, 1.21‐3.40). In the PDS cohort, the multivariate analysis showed that lymphocytopenia was an independent prognostic factor for poor PFS (HR, 1.73; 95% CI, 1.20‐2.49) and OS (HR, 1.87; 95% CI, 1.27‐2.75). The absolute lymphocyte count was a significant factor when analyzed as a continuous variable in both the NAC and PDS cohorts. Pretreatment lymphocytopenia is an independent adverse prognostic factor in patients with advanced‐stage ovarian cancer.

Preoperative neutrophil-to-lymphocyte ratio is a predictor of survival of epithelial ovarian cancer: a systematic review and meta-analysis of observational studies

Inflammation plays an important role in the development and progression of epithelial ovarian cancer (EOC). However, no meta-analysis has comprehensively and quantitatively investigated the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) in EOC patients. Therefore, we performed a meta-analysis to quantify the prognostic impact of this biomarker. We searched the PubMed and Web of Science databases from their inception through December 31, 2016, and examined observational studies evaluating the association of preoperative NLR with progression-free survival (PFS) and overall survival (OS) of EOC patients. A random-effects model was used to summarize hazard ratios (HRs) with 95% confidence intervals (CIs). Twelve retrospective cohort studies including 3,154 EOC patients were identified. Elevated NLR in EOC patients was associated with worse PFS (summarized HR=1.80; 95% CI = 1.22–2.65; I² = 79.1%) and OS (summarized HR = 1.72; 95% CI = 1.18–2.51; I² = 73.5%) compared with low NLR. No evidence of publication bias was detected by funnel plot analysis and formal statistical tests. Although the results were robust in all subgroup analyses, not all results were statistically significant. We determined that adjustments for CA-125 level and performance status might be sources of heterogeneity. These combined results indicate that preoperative NLR is an important predictor of prognosis in EOC patients. Since the high heterogeneity and retrospective study design of included studies, these results require further validation with prospective cohort and trials enrolling larger patient populations and conducting longer follow-up examinations.

Investigating Preoperative Hematologic Markers for Prediction of Ovarian Cancer Surgical Outcome

PURPOSE

The current study aimed at assessing the association between neutrophil-lymphocyte ratio (NLR) and platelet lymphocyte ratio (PLR) for the prognosis of the surgical outcome of epithelial ovarian cancer (EOC).

MATERIALS AND METHODS

EOC patient medical records of surgical operations between January, 2005 and December, 2015 were reviewed and their data of clinicopathological complete blood counts (CBCs) and surgical outcomes were collected. To assess their effects on surgical outcomes, PLR and NLR optimal predictive values were determined and then compared with each other.

RESULTS

A statistically significant relation was found between surgical outcomes and NLR and PLR (p<0.001 and p<0.001), for which new cutoff points were gained (PLR: 192,3,293; NLR: 3). The sensitivity and specificity were 0.74 and 0.67, respectively for PLR and 0.74 and 0.58, for NLR.

CONCLUSIONS

NLR and PLR seem to be useful methods for the prediction of surgical outcomes in patients with EOCs. Increased NLR and PLR proved to be beneficial for poor surgical outcomes. Moreover, PLR increase showed further help in the predicting outcome of EOC suboptimal debulking.

Laparoscopic Versus Laparotomic Surgical Staging for Early-Stage Ovarian Cancer: A Case-Control Study

STUDY OBJECTIVE

To evaluate the oncologic outcomes of patients with early-stage ovarian cancer (eOC) managed by laparoscopy or laparotomy in a single high-volume gynecologic cancer center.

DESIGN

Retrospective case-control study (Canadian Task Force classification II-2).

SETTING

Catholic University of the Sacred Hearth, Rome, Italy.

PATIENTS

Data of consecutive women with eOC undergoing comprehensive laparoscopic staging between 2007 and 2013 were matched with a cohort of patients undergoing open surgery between 2000 and 2011. Four-year survival outcomes were analyzed using the Kaplan-Meier method.

MEASUREMENTS AND RESULTS

Sixty women undergoing staging via laparoscopy were compared with a cohort of 120 patients undergoing open surgery. Baseline characteristics were similar between groups. Seventy percent of patients underwent adjuvant platinum based chemotherapy without differences between the 2 groups. Operative time (p = .01), estimated blood loss (p = .032), and median hospital stay (p = .001) were higher in patients submitted to laparotomic versus laparoscopic staging. As of October 2015, median duration of follow-up was 38 months (range, 24 -48), recurrent disease was documented in 16 patients (13.3%) in the laparotomic group and in 5 patients (8.3%) in the laparoscopic group (p = .651), without differences in the pattern of recurrence presentation. Four-year progression-free survival (PFS) and overall survival (OS) rates were 89% and 92% in the laparoscopic group, respectively, and 81% and 91% in the laparotomic group, without any statistical significant difference between the groups (4-year PFS p = .651; 4-year OS p = .719).

CONCLUSION

The findings of the present study suggests that in the surgical treatment of FIGO stage I ovarian cancer, laparoscopy is associated with equivalent oncologic outcome compared with a conventional abdominal approach.

Role of minimally invasive surgery in complex adnexal tumours and ovarian cancer

Ovarian cancer is one of the most common causes of cancer-related death in women. Adnexal masses are frequently diagnosed during reproductive age and often require surgical removal. The risk of malignancy when dealing with a complex adnexal mass should be defined prior to surgery and several scoring systems may be useful for this purpose. Laparoscopic management of ovarian tumours allows a minimally invasive approach with respect to several oncological assumptions. In the last decade concerns have been raised regarding the risk of cyst rupture and tumour spillage as a consequence of the laparoscopic technique itself both in early and advanced stages of ovarian cancer. Although limited data have been reported in the literature on the use of minimally invasive techniques in ovarian cancer, the clear benefits of this approach must be balanced with the potential hazards in different clinical situations. Laparoscopic staging in borderline tumours and presumed early-stage ovarian cancer performed by a laparoscopic oncologist seems to be safe and effective when compared to laparotomy. The precise role of laparoscopy in patients with more advanced cancer is still to be defined, and the risk of suboptimal surgery should never outweigh the potential benefits of minimally invasive surgery. Thus, a tailored prediction of optimal laparoscopic debulking is mandatory in these patients.

Staging laparoscopy for the management of early-stage ovarian cancer: a metaanalysis

OBJECTIVE

We sought to perform a quantitative analysis on operative outcomes of laparoscopic staging surgery in patients with presumed early-stage ovarian cancer using a metaanalysis.

STUDY DESIGN

Electronic searches for studies of laparoscopic staging surgery in patients with ovarian cancer were performed within 3 electronic databases (Medline, Embase, and the Cochrane Library) using the key words "ovarian cancer," "early stage," "laparoscopy," "staging surgery," "staging laparoscopy," and "recurrence." Two authors independently screened articles, and those meeting the defined inclusion/exclusion criteria were included in the metaanalysis.

RESULTS

We identified 11 observational studies. The combined results of 3 retrospective studies showed that the estimated blood loss in laparoscopy was significantly lower than that for laparotomy (P < .001). The overall upstaging rate after laparoscopic surgery was 22.6% (95% confidence interval [CI], 18.1-27.9%) without significant heterogeneity among all study results. The overall incidence of conversion from laparoscopy to laparotomy was 3.7% (95% CI, 2.0-6.9%). The overall rate of recurrence in studies with a median follow-up period of ≥19 months was 9.9% (95% CI, 6.7-14.4%).

CONCLUSION

Through our quantitative analysis, we concluded that the operative outcomes of a laparoscopic approach in patients with early-stage ovarian cancer could be compatible with those of laparotomy. In the future, further randomized controlled trials may be needed.

Platelet to lymphocyte ratio as a prognostic factor for epithelial ovarian cancer

Objective

To determine whether preoperative platelets to lymphocyte ratio (PLR) could predict disease stage, surgical outcome, and survival in patients with epithelial ovarian cancer (EOC).

Methods

Medical records of EOC patients who had surgery between January 2004 and December 2010 were reviewed. Clinicopathological and complete blood count data were collected. The optimal predictive value of PLR to predict advanced stage, suboptimal surgery, and survival was determined and compared with those of thrombocytosis (≥400,000 cells/mm³) and neutrophil to lymphocyte ratio (NLR) ≥2.6.

Results

A total of 166 EOC patients were included in the study. PLR of 200 yielded better predictive values than those of thrombocytosis and NLR ≥2.6. The area under curve (AUC), sensitivity, specificity, positive and negative predictive values, and accuracy of PLR to predict advanced stage were: 0.66, 59.0%, 72.7%, 65.7%, 66.7%, and 66.3%, respectively. The corresponding values to predict suboptimal surgery were: 0.70, 70.0%, 69.8%, 50.0%, 84.4%, and 69.9%. The patients who had PLR≥200 had significantly shorter progression-free and overall survivals than those with PLR<200. Stage, grade, surgical outcome, thrombocytosis, and PLR were significant prognostic factors for survivals by univariable analyses while only stage remained significant by multivariable analysis.

Conclusion

PLR had potential clinical value in predicting advanced stage disease or suboptimal surgery. PLR was a better prognostic indicator for survivals of EOC patients compared to thrombocytosis or NLR>2.6.

Adnexal masses suspected to be benign treated with laparoscopy

OBJECTIVE

Guidelines for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists have been developed by the American College of Obstetrician Gynecologists (ACOG). We set out to evaluate the negative predictive value of these guidelines and to assess a modified algorithm involving minimally invasive surgery in the treatment of women with masses suspected to be benign.

METHODS

257 consecutive patients with adnexal masses of 8cm to 13cm on preoperative ultrasound examination meeting Triage Criteria set forth in ACOG Committee Opinion 280. Patients meeting the selection criteria were scheduled for operative laparoscopy, washings, adnexectomy, bagging, and colpotomy. A total of 240 patients successfully completed intended treatment (93.38%), and 234 of these did not require admission (97.5%). There was a low incidence of significant complications: 97.50% of women were successfully treated as outpatients, 97.92% of surgeries lasted <136 minutes, and <97.08% had blood loss <200mL. The negative predictive value of ACOG Committee Opinion 280 Triage Criteria as a deselector for having invasive ovarian malignancy in our population was 95.57% for premenopausal and 90.91% for postmenopausal women.

CONCLUSIONS

Laparoscopic adnexectomy, bagging, and colpotomy is a desirable goal for patients with ovarian masses in the 8cm to 13cm range meeting selection criteria affording a minimally invasive approach with attendant benefits including outpatient treatment (97.5%), few complications, low likelihood of iatrogenic rupture of the ovarian capsule (1.25%), and low necessity for reoperation after final pathology is evaluated (6.03%). Negative predictive value of ACOG Committee Opinion 280 is confirmed in a community gynecology practice and is recommended to form the basis of a new treatment algorithm for women with adnexal masses.

Increasing experience in laparoscopic staging of early ovarian cancer

We assessed the effect of increasing experience of a single surgeon (learning curve) in the laparoscopic staging procedure for women with early ovarian cancer and compared the results with the literature. We retrospectively analysed a total of 25 women with apparent early-stage ovarian cancer who underwent a laparoscopic staging procedure by the same surgeon. Three time periods, based on date of surgery, were compared with respect to operating time, amount of lymph nodes harvested and surgical outcome. There was no significant difference in operation time, estimated blood loss and hospital stay between the three periods. There was, however, a significant increase in the median number of pelvic and para-aortal lymph nodes harvested (group1 = 6.5, group 2 = 8.0 and group 3 = 21.0; P < 0.005). For the total period, median operation time was 235 min and median estimated blood loss was 100 ml. The median length of hospital stay was 4.0 days. Two intraoperative and two postoperative complications occurred. The upstaging rate was 32%. The mean interval between initial surgery and laparoscopic staging was 51.2 days. Mean duration of follow-up was 43 months, range (1–116 months). Five (20%) patients had recurrences, and two (8%) patients died of the disease. In conclusion, there is a significant learning curve for the laparoscopic full staging procedure in ovarian cancer. In our study this is mainly reflected in the amount of lymph nodes harvested and not in the total operating time.

Prognostic factors for high-risk early-stage epithelial ovarian cancer: a Gynecologic Oncology Group study

BACKGROUND

The purpose was to identify the factors predictive of recurrence and survival in patients with high-risk (stage I, grade 3; stage IC, stage II, or clear cell) epithelial ovarian cancer after adjuvant therapy.

METHODS

Data was extracted from patients who underwent primary surgery followed by adjuvant therapy in 2 randomized trials by the Gynecologic Oncology Group (Protocols 95 and 157). Kaplan-Meier survival estimates and Cox proportional hazards model adjusted for covariates were used for analyses.

RESULTS

Of 506 patients (median age = 56.2 years), 347 (68.6%) had stage I and 159 (31.4%) had stage II cancers. The 5-year recurrence-free (RFS) and overall survivals (OS) were 75.5% and 81.7%, respectively. On multivariate analysis, older age, higher stage, higher grade, and malignant cytology were independent prognostic factors predictive for recurrence and poorer survival. The risk of recurrence was higher for those >/=60 versus < 60 years (hazards ratio [HR] = 1.57, 95% confidence interval [CI], 1.12-2.19), stage II (stage II: HR = 2.70, 95% CI, 1.41-5.16) versus stage IA or IB, grade 2 (HR = 1.84, 95% CI, 1.04-3.27) and grade 3 (HR = 2.47, 95% CI, 1.39-4.37) versus grade 1, and positive versus negative cytology (HR = 1.72, 95% CI, 1.21-2.45). By using these factors in a prognostic index, those with low-risk (no or 1 risk factor), intermediate-risk (2 factors), and high-risk (3-4 risk factors) disease had survivals of 88%, 82%, and 75%, respectively (P < .05).

CONCLUSIONS

Age, stage, grade, and cytology are important prognostic factors in high-risk early-stage epithelial ovarian cancer. This information may be used in the design of future clinical trials.

Ovarian cancer

Ovarian cancer accounts for 4% of all cancers in women and is the leading cause of death from gynaecologic malignancies. Because early-stage ovarian cancer is generally asymptomatic, approximately 75% of women present with advanced disease at diagnosis. Survival is highly dependent on stage of disease: 5-year survival in patients with early-stage is 80-90% compared to 25% for patients with advanced-stage disease. For all patients, a comprehensive surgical staging should be performed to obtain the histological confirmation of diagnosis and to evaluate the extent of disease. Patients with early-stage should both be optimally staged and be treated with adjuvant platinum-based chemotherapy if they have a medium or high-risk tumour. For advanced disease the currently recommended management is primary cytoreductive surgery followed by platinum-paclitaxel combination chemotherapy. Appropriate salvage therapy is based on the timing and nature of recurrence and the extent of prior chemotherapy. Surgical resection should be considered in patients with long-term remission, especially in those with isolated recurrences and good performance status. Platinum-based combination represents the standard second-line chemotherapy in patients with platinum-sensitive relapsed ovarian cancer. Salvage chemotherapy in platinum-refractory patients usually results in low response rates and short survival.

Correlation between MIB1-determined tumor growth fraction and incidence of tumor recurrence in early ovarian carcinomas

PURPOSE

The decision concerning adjuvant therapy remains difficult in patients with very early stage ovarian carcinomas [Fédération Internationale de Gynécologie et d' Obstétrique (FIGO) Ia/b]. Therefore, we compared the MIB1-determined tumor growth fraction in archival tumor tissue with tumor recurrence and outcome of disease, and in relationship to other stages and clinical and morphological findings.

PATIENTS AND METHODS

Ninety-two patients were followed in early stages of ovarian carcinomas (FIGO I and II) with no tumor residuals and were analyzed for tumor recurrences and long-term overall survival (mean 6.0 years, median 5.5). Fifty-eight patients had stage I tumors, among these were 38 in the sub-stages Ia/b. Tumor growth fraction (MIB1) in tissues from primary surgery was compared with the status of patients and disease, histology, and immunohistochemistry for carcinoembryonic antigen (CEA), CA125, CA153, steroid hormone receptors, and angiogenesis (chisquare test, Kaplan-Meier and discriminant analyses).

RESULTS

Tumor-associated deaths occurred in 27 cases, tumor recurrences occurred in 35 cases. In contrast to the advanced stages of disease, the MIB1-determined tumor growth fraction outweighted all other parameters in the prediction of the course of disease (p < 0.001), followed by tumor grading (p = 0.001) and FIGO-substages (p = 0.026) in this retrospective study. Particularly in the very early stages, MIB1 predicted tumor recurrences in 84% of the cases (p < 0.001). Recurrences were not observed below a tumor growth fraction of 10% but prevailed in cases of more than 15%.

CONCLUSION

Our data suggest MIB1 as an interesting additional tool for the decision of adjuvant therapy in patients with very early stages of ovarian carcinomas, which should be tested in prospective trials.

[Management of adnexal tumors: role and risks of laparoscopy]

The laparoscopic management of adnexal tumeurs remains controversial because of the potentials risks of cancer dissemination suggested by many case reports and national surveys. From experimental data, the laparoscopic treatment of gynecologic cancer has potential advantages and disadvantages. The risk of dissemination appears high when a large number of malignant cells are present so that adnexal tumors with external vegetations, and bulky lymph nodes may be considered as contra-indications to CO2 laparoscopy. Laparoscopic surgery has become the gold standard in the treatment of benign adnexal tumeurs, whereas laparotomy remains the standard for the treatment of malignant tumors. The surgical diagnosis is the key to adequate management of adnexal tumeurs. In our experience, after a careful preoperative evaluation, the laparoscopic diagnosis of malignancy is reliable. Moreover in national surveys, many malignant tumeurs were considered as benign despite suspicious laparoscopic findings. Using strict guidelines, laparoscopic diagnosis can be proposed for both non suspicious and complex tumeurs, thus avoiding many unnecessary laparotomies for benign tumeurs suspicious at ultrasound. The more controversial limits of laparoscopic treatment are discussed. If a laparotomy was performed for all tumeurs suspicious at surgery, 80% of the cases would be treated by laparoscopy. The role of laparoscopy for restaging and second look operations for ovarian cancer requires further evaluation.

Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma

BACKGROUND

Previous studies on prognostic factors in stage I invasive epithelial ovarian carcinoma have been too small for robust conclusions to be reached. We undertook a retrospective study in a large international database to identify the most important prognostic variables.

METHODS

1545 patients with invasive epithelial ovarian cancer (International Federation of Gynaecology and Obstetrics [FIGO] stage I) were included. The records of these patients were examined and data extracted for univariate and multivariate analysis of disease-free survival in relation to various clinical and pathological variables.

FINDINGS

The multivariate analyses identified degree of differentiation as the most powerful prognostic indicator of disease-free survival (moderately vs well differentiated hazard ratio 3.13 [95% CI 1.68-5.85], poorly vs well differentiated 8.89 [4.96-15.9]), followed by rupture before surgery (2.65 [1.53-4.56]), rupture during surgery (1.64 [1.07-2.51]), FIGO 1973 stage Ib vs Ia 1.70 [1.01-2.85]) and age (per year 1.02 [1.00-1.03]). When the effects of these factors were accounted for, none of the following were of prognostic value: histological type, dense adhesions, extracapsular growth, ascites, FIGO stage 1988, and size of tumour.

INTERPRETATION

Degree of differentiation, the most powerful prognostic indicator in stage I ovarian cancer, should be used in decisions on therapy in clinical practice and in the FIGO classification of stage I ovarian cancer. Rupture should be avoided during primary surgery of malignant ovarian tumours confined to the ovaries.

Management of adnexal masses: role and risk of laparoscopy

Laparoscopic surgery has become the gold standard in the treatment of benign adnexal masses, whereas laparotomy remains the standard for the treatment of malignant tumors. The laparoscopic management of adnexal masses remains controversial because of the potential risks of cancer dissemination suggested by many case reports and national surveys. Experimental data show potential advantages and disadvantages for the laparoscopic treatment of gynecologic cancer. Since the risk of dissemination appears high when a large number of malignant cells are present, adnexal tumors with external growths and bulky lymph nodes may be considered contra-indications to CO(2) laparoscopy. Surgical diagnosis is the key to adequate management of adnexal masses. In our experience, laparoscopic diagnosis of malignancy is reliable after a careful pre-operative evaluation has been performed. Moreover, national surveys have revealed that despite suspicious laparoscopic findings, many malignant masses were considered benign at the outset. Using strict guidelines, laparoscopic diagnosis can be proposed for both non-suspicious and complex masses, thus avoiding many unnecessary laparotomies for benign masses suspicious at ultrasound. The more controversial limits of laparoscopic treatment are discussed. If a laparotomy was performed for all masses suspicious at surgery, 80% of the cases would be treated by laparoscopy. The role of laparoscopy for restaging and second-look operations for ovarian cancer requires further evaluation.