Conservative treatment in epithelial ovarian cancer: results of a multicentre study of the GCCLCC (Groupe des Chirurgiens de Centre de Lutte Contre le Cancer) and SFOG (Société Française d'Oncologie Gynécologique)

Philippe Morice1,8, Eric Leblanc2, Annie Rey1, Marc Baron3, Denis Querleu4, Jérôme Blanchot5, Pierre Duvillard1, Catherine Lhommé1, Damienne Castaigne1, Jean Marc Classe6, Pascal Bonnier7 and GCCLCC6 and SFOG7

1 Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif, 2 Centre Oscar Lambret, 3 rue Frédéric Combemale, 59020 Lille, 3 Centre Henri Becquerel, Rue d'Amiens, 76038 Rouen, 4 Institut Claudius Regaud, 20–24 rue du Pont Saint Pierre, 31052 Toulouse, 5 Centre Eugene Marquis, Rue de la Bataille de Flandre Dunkerque, 35042 Rennes, 6 Groupe des Chirurgiens de Centre de Lutte Contre le Cancer and 7 Société Française d'Oncologie Gynécologique, France

8 To whom correspondence should be addressed at: Service de Chirurgie, Institut Gustave Roussy, 39 rue Camille Desmoulins, 94805 Villejuif Cedex, France. Email: morice{at}igr.fr


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
BACKGROUND: Results of conservative management of epithelial ovarian cancer (EOC) remain controversial in the literature. The aim of this study was to assess the clinical outcomes and fertility following fertility-sparing surgical management of EOC in a retrospective multicentre study. METHODS: A multicentre retrospective study was performed by members of two French groups. Six inclusion criteria were defined: (i) Histological review by the same pathologist; (ii) age ≤40 years; (iii) conservative management; (iv) complete peritoneal staging; (v) delivery of a platinum-based chemotherapy in stage ≥IC; and (vi) follow-up >1 year. RESULTS: Thirty-four patients fulfilled the inclusion criteria: 30 had stage IA disease; three had stage IC and one had stage IIA. Eleven patients had recurrence: 10 patients had invasive disease and one had borderline recurrence. Among 10 patients with invasive recurrence, initial stage and grade were: stage IA G1, n=1; stage IA G2, n=4; stage IA G3, n=1; and stage≥IC, n=4. All patients with stage > IA had recurrence. Ten pregnancies were observed in nine patients. CONCLUSION: Conservative surgery for patients with EOC could be considered in young patients with stage IA G1 disease. This procedure should not be performed in patients with FIGO stage > IA.

Key words: conservative surgery/epithelial ovarian tumour/pregnancy/recurrence/restaging surgery


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The standard surgical treatment of patients with stage I or II epithelial ovarian cancer (EOC) is based on hysterectomy with bilateral salpingo-oophorectomy with peritoneal sampling (peritoneal washing, omentectomy, multiple peritoneal biopsies and removal of peritoneal implants in stage II disease) with or without lymph node sampling. Conservative treatment of at least a part of one ovary and the uterus in order to preserve fertility in young patients has been proposed in selected patients with EOC (Di Saia, 1989Go; Morice et al., 2003Go). However, the results and limits of such treatment remain unclear. Only three studies involving a large number of patients have been published on the results of conservative management of EOC (Colombo et al., 1994Go; Zanetta et al., 1997Go; Morice et al., 2001Go; Schilder et al., 2002Go). However, as the results of such management in these studies were discordant, we decided to conduct a large retrospective multicentre analysis of conservative management of EOC in our country, to attempt to clearly define the limits of such management.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
A questionnaire was sent to the physician members of two French societies (Groupe des Chirurgiens de Centre de Lutte Contre le Cancer and Société Française d'Oncologie Gynécologique) in order to collect cases of conservative management of EOC. This study received the approval of an Institutional Review Board in January 2003. Criteria used to select patients were as follows. (i) Epithelial ovarian tumour (slide of the initial ovarian tumour and recurrent disease were centralized and reviewed in the same institution. Slides were reviewed by the same pathologist: P.D.). An invasive tumour was defined as the presence of stromal infiltration >10 mm2. Tumour grade was defined according to the classification of Silverberg (2000)Go. In patients with clear-cell carcinoma, histological and cytological grades were defined. (ii) Conservative management with preservation of at least one part of the ovary and the uterus. (iii) Age limit ≤40 years because the aim of such conservative surgery was to preserve fertility. (iv) All patients had to have undergone a (salpingo)-oophorectomy on the side of the ovarian tumour with complete peritoneal staging (including peritoneal washing, omentectomy, multiple peritoneal biopsies) during initial complete surgery or at the time of a restaging procedure but before the administration of chemotherapy, if prescribed. Uterine curettage, lymphadenectomy, biopsy of the remaining ovary and an appendectomy were optional. These procedures could have been performed during the surgical treatment of the ovarian tumour (if patients were adequately diagnosed and treated during the first surgical procedure) or at second ‘restaging’ surgery (via laparotomy or laparoscopy). (v) Adjuvant chemotherapy had to have been administered at least to patients with a stage ≥IC, in which case a minimum number of four courses of platinum-based chemotherapy was mandatory. (vi) Follow-up >1 year after the conservative treatment.

The FIGO stage (International Federation of Gynecology and Obstetrics, 1987Go) was defined using the macroscopic description during the surgical procedure(s) and histological analysis of specimens removed during initial and restaging surgery (if the initial procedure was incomplete).

Patient follow-up included a clinical examination, blood marker measurements and an ultrasound scan at least every 6 months during the first year following the procedure, then yearly afterwards.

The recurrence rate, overall survival (OS), disease-free survival (DFS), fertility outcome and the number of pregnancies were studied. The characteristics of patients who developed a recurrence were studied. OS and DFS probabilities were estimated from the first surgical procedure to the last visit, using the Kaplan–Meier method.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Of the 59 potentially eligible patients reviewed, 25 were excluded: eight patients had an ovarian tumour of a different histological type (non-epithelial tumour in four cases and a borderline tumour in four), seven patients initially treated conservatively underwent a total hysterectomy at the time of restaging or second-look procedures (in the absence of recurrent disease), five patients had incomplete staging [not performed in three cases or omission of at least one of the previously described procedure(s) in two patients], one underwent complete staging but after six courses of chemotherapy, one patient did not receive adjuvant chemotherapy for stage IC disease (clear-cell tumour), one patient whose slides of the initial tumour were not available for the centralized review, one patient aged >40 years at the time of initial surgery and one patient with a follow-up of <12 months. Thus, 34 patients fulfilled the six inclusion criteria and were our study group.

Patient characteristics
The median age of the 34 patients evaluated at the time of the surgical procedure was 27 years (range 14–36). Twenty-three patients were nulliparous. Four patients had a history of infertility. Two of them had undergone ovulation induction therapy. Two patients had a previous history of borderline ovarian tumour (BOT). Patients presented with disease-related symptoms in 68% of the cases (23/34). Abdominal distension (41%, 14/34) and pain (32%, 11/34) were the most frequent presenting symptoms. EOC was diagnosed in six (18%) asymptomatic patients during the abdomino-pelvic ultrasound examination. In five patients, the presenting symptom was unknown. In one patient, the EOC was diagnosed during pregnancy (at 16 weeks) on routine pelvic ultrasound.

The histological types were: serous (3–9%), mucinous (21–62%), endometrioid (5–15%), small-cell (2–5%) and mixed (mucinous and serous) EOC (3–9%). Tumour differentiation was: grade 1 (15–44%), grade 2 (15–44%) and grade 3 (4–12%). The distribution of these 34 patients according to FIGO staging was: 30 stage IA (grade 1, n=13; grade 2, n=14; grade 3, n=3); three stage IC (grade 1, n=2; grade 3 n=1) and one stage II (grade 2).

Complete initial staging surgery was performed in two patients and a restaging surgical procedure in 32 patients over a median interval of 45 (range 7–149) days since the first operation. A laparoscopic approach was used for restaging surgery in four cases. Twenty-six and 24 patients underwent a para-aortic and a pelvic lymphadenectomy respectively. None of them was upstaged following the histological analysis of lymph nodes. In one patient with a previous history of BOT (case no. 11 in Table I), mixed endosalpingiosis components and non-invasive implants were found in nodes. An appendectomy was performed in 16 patients and uterine curettage in nine. Of 23 patients with mucinous or mixed histological subtype, 13 underwent an appendectomy. Twenty-five patients had a routine biopsy of the contralateral ovary (normal in all cases). Among the 32 patients who underwent restaging surgery, two (6%) were upstaged (peritoneal implants were observed on the Fallopian tube serosa in one case and peritoneal cytology was positive in the other patient). Thirty-three patients had stage I and one had stage II disease.


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Table I. Characteristics of 11 patients who developed a recurrence

 
Adjuvant platinum-based chemotherapy was given to 10 patients. The median number of chemotherapy courses was 6 (range 4–6). Five patients received a paclitaxel + platinum regimen. Adjuvant chemotherapy was administered to three patients with stage > IA and to seven patients with stage IA disease (stage IA grade 1, n=1; stage IA grade 2, n=4; stage IA grade 3, n=2). Second-look surgery was performed in one patient and was normal.

Recurrence and survival
The recurrence and survival rates according to disease stage were studied in these 34 patients treated conservatively after restaging surgery. The median duration of follow-up was 47 months (range 11–224). Twenty-four patients were alive and disease-free. Two patients underwent a laparoscopic or a laparotomic cystectomy for a suspicious lesion on the remaining ovary. In these two cases the histology was benign. Eleven patients developed a recurrence over an average period of 16 months (range 2–48). The characteristics of those 11 patients are detailed in Table I. Among seven patients with mucinous or mixed subtype, three patients underwent lymphadenectomy during the surgical management of their initial disease. Ten patients had recurrent invasive disease and one patient (with stage IA grade 1 disease) had a borderline recurrence on the preserved ovary (case no. 11 in Table I). Among these 11 patients, the first recurrence was observed on the contralateral remaining ovary in nine cases (isolated at this site in five patients). One patient (case no. 10) treated for a stage IA grade 2 tumour (with a normal routine biopsy specimen of the remaining ovary at restaging surgery) rapidly developed a contralateral tumour 2 months after restaging surgery. Ten patients underwent removal of the remaining ovary at surgical treatment of the recurrence and eight had a hysterectomy.

One patient developed an ‘unusual recurrence’. This case was previously published as a case report by the team who treated her (Baron et al., 2002Go). This young patient was initially treated for a large ovarian tumour by laparotomy. She underwent a transverse low incision laparotomy with a right salpingo-oophorectomy but with peroperative rupture of the tumour. The histological analysis demonstrated the presence of a mucinous BOT together with small foci of invasive well-differentiated carcinoma. Three months later she underwent a restaging laparotomy including complete peritoneal staging, lymphadenectomy and appendectomy. As all specimens were negative, no adjuvant chemotherapy was administered but this lesion was considered as a stage IC tumour due to peroperative rupture of the lesion during initial surgery. Four years later she developed an isolated wound recurrence (without peritoneal or ovarian disease) which was treated by surgical resection followed by chemotherapy (platinum-based and paclitaxel). A contralateral wound recurrence was observed 2 years later. This patient is currently under treatment for pleural effusion.

Seven patients with stage IA disease and all patients with stage ≥IC developed a recurrence. Among 10 patients with an invasive recurrence, stages and grades were: stage IA G1, n=1; stage IA G2, n=4; stage IA G3, n=1; stage ≥IC, n=4. OS rates at 3 and 5 years (CI) for all patients were respectively 96% (79–99) and 84% (62–95). The DFS rates at 3 and 5 years (CI) for all patients were respectively 74% (57–87) and 63% (43–80) (Figure 1). OS and DFS rates at 5 years (CI) for patients with stage IA disease were respectively: 87% (62–96) and 78% (59–90) (Figure 2). According to the tumour grade, DFS at 5 years (CI) for patients with stage IA disease was 92% (67–99) in patients with grade 1 and 70% (43–88) in patients with grade 2 disease (Figure 3).



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Figure 1. Survival curves for all patients with epithelial ovarian cancer.

 


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Figure 2. Survival curves for patients with stage IA disease.

 


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Figure 3. Disease-free survival curves according to the tumour grade in patients with stage IA disease.

 
Ovarian function and fertility results
Ten pregnancies (nine spontaneous and one induced) were observed in nine patients. Among the 23 patients who are alive without recurrent disease (and who were not treated radically at the time of recurrent disease), nine pregnancies were observed in eight patients over an interval of 12 months to 16 years following initial surgery. One patient developed a recurrence after a pregnancy. Six of the pregnancies had a normal outcome, one was a miscarriage (after an IVF procedure) and one is ongoing. In two cases, the outcome of the pregnancy is unknown. One patient had two pregnancies after a laparoscopic cystectomy for a suspicious lesion on the remaining ovary (benign cyst). The patient who had a borderline recurrence underwent a salpingo-oophorectomy on the side of the recurrent disease with multiple biopsies and preservation of the uterus. This patient is currently trying to become pregnant (ovum donation). No patient underwent completion surgery after a possible pregnancy (in the absence of recurrent disease).


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Results of conservative management in EOC continues to fuel debate in the literature. This treatment was initially proposed to young patients with a low parity and: stage IA disease; an encapsulated tumour with no adhesions; no invasion of the capsule, lymphatics or mesovarium; negative peritoneal washings; and a close follow-up (Di Saia, 1989Go). However, data concerning such surgical management of EOC are rare. As prospective (randomized) studies are unrealistic because indications for conservative management are uncommon, only well-conducted retrospective series could provide a better picture of the results of such treatment. If we exclude the present series, only two series published in the literature included a sufficient number of patients: an Italian series of 56 patients (Colombo et al., 1994Go; Zanetta et al., 1997Go), and an American study of 52 patients recruited in eight centres (Schilder et al., 2002Go). In the Italian and the American series, 43% (24/56) and 19% (10/52) of patients had stage IC respectively (Colombo et al., 1994Go; Zanetta et al., 1997Go; Schilder et al., 2002Go). These two series seem to suggest that conservative management could be safely proposed, even in patients with stage IC disease. In addition, Raspagliesi et al. (1997)Go reported on a series of 10 patients treated conservatively with discouraging prognostic factors: two patients had stage IA grade 3 disease, two patients had stage IC disease and six patients had stage III disease. Of these 10 patients with high-risk ovarian cancer, none developed a recurrence (Raspagliesi et al., 1997Go). In terms of disease stage, is there a limit to conservative surgery?

Three years ago, however, we published a preliminary series about the results of conservative surgery of EOC in a group of patients treated in a single institution (Morice et al., 2001Go). These preliminary results were disturbing because all patients with a disease stage > IA developed a recurrence. In an attempt to explain such a difference with the Italian and American series, we decided to conduct a retrospective multicentre study in our country. Very strict inclusion criteria were defined in order to obtain the most accurate results. The definition of these inclusion criteria is a key to explain the differences observed. Among the 59 potentially eligible patients reviewed in the present series, 34 fulfilled all inclusion criteria. In these inclusion criteria, only patients with complete peritoneal staging were enrolled so that the definition of the tumour stage would be as precise as possible. A recent randomized study demonstrated the therapeutic implications of complete peritoneal staging in patients with early stage disease (Trimbos et al., 2003Go). This staging procedure is particularly important in patients with apparently early-stage disease, as adjuvant therapy may be avoided in patients with stage IA or IB disease (and grade 1 or 2 tumours). Staging should include peritoneal cytology or washing, an omentectomy and multiple peritoneal biopsies (Di Saia, 1989Go; Morice et al., 2003Go). Nodal staging was deemed optional because the benefit of this procedure is still controversial in patients with EOC.

The second inclusion criterion concerned the use of chemotherapy. As one of the major differences between published series concerns clinical outcomes in patients with stage ≥IC disease, we preferred to include only patients who received adjuvant chemotherapy for stage ≥IC disease. The interest of adjuvant treatment in patients with stage IC disease continues to be debated in the literature. However, in the present series, we decided to enrol only patients with stage ≥IC disease treated by conservative surgery followed by adjuvant therapy in order to ensure that a subsequent recurrence would not be related to the absence of adjuvant treatment. Only one patient in the present series was treated exclusively by surgery for stage ‘IC’ disease (case no. 9 in Table I). This case is amply detailed in the Results section. Although this lesion could have been classified initially as stage IA or IC disease, it was considered by the team who treated her as a stage IC tumour due to its peroperative rupture (absence of peritoneal cytology during initial surgery). This is the only case of stage IC disease which was not treated with adjuvant chemotherapy in the present series. Furthermore, the characteristics of the recurrence (wound recurrence at 48 months) observed in this case were probably not related to the absence of adjuvant treatment during the initial management. In the Italian series, 11 out of 19 patients with stage IC disease did not receive adjuvant treatment (Colombo et al., 1994Go). In Schilder et al.'s (2002)Go series, 2/10 patients with stage IC disease were treated exclusively by surgery. The type of chemotherapy is also important. The standard treatment is a platinum-based chemotherapy. In the study published by Schilder et al. (2002)Go, 5/19 patients received adjuvant treatment containing melphalan alone. In the present series, patients who received regimens other than platinum-based chemotherapy were excluded.

The last important inclusion criterion, and probably one of the most important, concerns the centralized histological review of the ovarian tumour by the same pathologist (patients were excluded if histological slides of the initial tumour were not available). In Schilder et al.'s (2002)Go series, the histological slides were reviewed by one pathologist in each of the eight centres which participated in this multicentre study. The final centralized review was performed only in dubious cases concerning the histological subtype or tumour grade (Schilder et al., 2002Go). In the present series, four patients reviewed were reclassified as having a borderline tumour and the tumour grade was reclassified in one patient. A routinely centralized pathological review is probably a key point.

Our results confirm, as do those in the Italian and American series, that conservative management could be safely proposed in patients with stage IA grade 1 disease. However, unlike the other series, and even if the number of patients with stage ≥IC is low, the fact that all of them developed a recurrence seems to suggest that such management should not be proposed to patients with a stage ≥IC tumour. This result could not be explained by the absence of adjuvant treatment, the absence of complete surgical staging (misdiagnosis of a more advanced stage disease) or inadequate chemotherapy, all of which were among our inclusion criteria. Furthermore, most of the recurrent lesions were on the remaining ovary (8/10 invasive recurrences). Consequently, the spared ovary is the site of the first recurrence in the majority of patients. This point was not so evident in the other two series: only 2/5 recurrent lesions were located on the preserved ovary in the Italian series and 3/5 in the American series (Colombo et al., 1994Go; Zanetta et al., 1997Go; Schilder et al., 2002Go).

We also observed that the DFS of stage IA grade 2 disease was quite different from that reported in the literature following radical surgery, even if the number of such patients is small in the present study. In the literature, the survival of patients with this type of tumour varies from 77 to 94%, whereas in our study the DFS in patients with a stage IA grade 2 tumour was only 70% (Dembo et al., 1990Go; Young et al., 1990Go; Baiocchi et al., 1998Go; Villa et al., 1998Go). In the Italian and American series, respectively 2/8 and 2/6 patients with stage IA grade 2 disease developed a recurrence (Colombo et al., 1994Go; Zanetta et al., 1997Go; Schilder et al., 2002Go). Thus, in three main series about conservative surgery, the risk of recurrence appears to be increased following conservative surgery in patients with stage IA grade 2 disease. Systematic adjuvant chemotherapy is not routinely indicated in patients who undergo radical treatment, but could such treatment reduce the risk of recurrence after conservative surgery? In the present series, 2/4 patients with recurrent stage IA grade 2 disease received adjuvant treatment and in the Italian series both patients with recurrent lesions received six courses of platinum-based chemotherapy (Zanetta et al., 1997Go).

In our retrospective study, only 1/3 patients with stage IA grade 3 disease developed a recurrence. But the number of patients with stage IA grade 3 disease is too small to draw a definitive conclusion about this subgroup of patients. Furthermore, two of them had a very small grade 3 borderline or endometrioid tumour (with a clear-cell component in one of them). This point (small tumour size) explained why some patients were treated exclusively by surgery for stage IA grade 3 disease whereas these patients are treated routinely with adjuvant treatment in our institution. With a follow-up of 23 and 29 months, neither of the two above-mentioned patients developed a recurrence. However, if the question is whether conservative management of stage IA grade 3 disease is appropriate, such surgery should not be proposed to patients with a ‘bulky’ stage IA tumour and grade 3 disease. The histological subtype can also be an important prognostic factor. Schilder et al. (2002)Go did not observe a higher recurrence rate in five patients with a clear-cell tumour. However, in general, clear-cell tumours seem to have a worse prognosis than their serous, mucinous and endometrioid counterparts (Dembo et al., 1990Go; Young et al., 1990Go; Baiocchi et al., 1998Go; Villa et al., 1998Go). In this series, 1/2 patients with this kind of tumour developed a recurrence (the other patient had a very small tumour <1 cm within a large endometrioid cyst). In our opinion, conservative management could be considered in patients with a serous, mucinous or an endometrioid tumour but should not be performed in patients with more aggressive tumours such as clear-cell or anaplastic carcinoma. How can we explain the higher recurrence rate observed in our series after conservative management of stage IC or IA grade 2 disease? One of the dangers of the conservative treatment of EOC is not to remove a microscopic invasive cancer in the remaining ovary. Munnell (1969)Go estimated the risk of microscopic cancer on the contralateral macroscopically normal ovary to be 12%. These findings explain why routine biopsies on the contralateral ovary were recommended (Munnell, 1969Go; Di Saia, 1989Go). However, such a procedure could lead to adhesions and subsequent infertility. In the study by Zanetta et al. and in our series, none of the patients with a macroscopically normal ovary had microscopic metastasis found on routine biopsies (Colombo et al., 1994Go; Zanetta et al., 1997Go). This procedure should be performed only in patients with suspicious lesions of the remaining ovary.

Two recent series focus on the evaluation of the risk of occult contralateral involvement in patients with unilateral macroscopic stage I EOC (Benjamin et al., 1999Go; Amsalem et al., 2003Go). In the series by Benjamin et al. (1999)Go, only 3/118 patients (2.5%) with stage I EOC had occult ovarian involvement. None of these three patients had stage IA disease: two of them had stage IC (grade 1 and 3) and the last one had stage IB grade 3 disease (Benjamin et al., 1999Go). In the series reported by Amsalem et al. (2003)Go, 3/25 patients with surgical stage IA or IC disease had microscopic occult involvement of the contralateral ovary: two had stage IB grade 3 disease and the last patient had histological stage III grade 1 disease. These findings suggest that microscopic contralateral involvement could be found in patients with stage IC and/or in patients with early stage disease but a grade 3 tumour. Such findings were not observed in patients with a stage IA grade 1 or 2 tumour.

Recently an interesting paper was published about the incidence of premalignant lesions in the contralateral ovary in patients with unilateral ovarian cancer (Kaur et al., 2004Go). Premalignant lesions (inclusion cysts, nuclear atypia and epithelial stratification) and Bcl-2 overexpression were seen more frequently in patients with contralateral ovarian cancer compared to control groups (Kaur et al., 2004Go). The histological subtype and disease stage were detailed but the tumour grade was not given. Perhaps these premalignant lesions were mainly observed in a specific subgroup of patients with stage IA and could so explain a higher risk of recurrences if conservative surgery were performed.

According to these results, indications for conservative surgery in patients treated for an EOC should be rigorously and wisely selected. The main objective for conservative surgery is to preserve fertility. Zanetta et al. (1997)Go and Schilder et al. (2002)Go reported 27 pregnancies in 20 patients and 26 full-term deliveries in 17 patients treated conservatively. In our series, 10 pregnancies were observed in nine patients. Perhaps these results could be improved using a laparoscopic approach for the restaging procedure, thereby reducing the risk of postoperative adhesions that could impact on subsequent fertility (Leblanc et al., 1999Go).

One unsolved question is whether radical surgery ought to be recommended after the completion of pregnancy(ies) in order to reduce the risk of recurrence. Di Saia (1989)Go recommended performing radical surgery when the desire for reproduction is no longer being considered. Moore et al. (1999)Go recently published a case report of an infertile patient with an early-stage poorly differentiated tumour who developed a recurrence 10 years following the treatment of the ovarian tumour. As the recurrence rate reported in our series is relatively high, and as late recurrences could occur (48 months in this series), we think that such completion surgery should be proposed to patients whose pregnancy(ies) was(were) successful.

In conclusion, our results confirm that conservative surgery could be safely performed in young patients treated for a stage IA grade 1 EOC who wish to preserve their fertility. However, this procedure should be evaluated in patients with stage IA grade 2 disease but should not be performed in patients with FIGO stage > IA.


    Acknowledgements
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
We thank Lorna Saint Ange for editing the manuscript and to the following clinicians and pathologists for providing pathological material, clinical and follow-up data: Drs Avigdor, Cabaret, Demol, Gornes, Hoffman, Husson, Lacroix-Triki, Pelleray, Petit and Vuillemin.


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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
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Submitted on September 6, 2004; accepted on January 10, 2005.