Optimal Management of Bowel Obstruction in Patients with Ovarian Cancer
ABSTRACT & COMMENTARY
Synopsis: The decision regarding optimal management of bowel obstruction in ovarian cancer patients should be individualized.
Source: Gadducci A, et al. Int J Gynecol Cancer 1998; 8:177-182.
Gadducci and colleagues identified 34 patients who developed intestinal obstruction during their disease course among 67 women who died of progressive ovarian cancer. Twenty-eight of the 34 patients died of this complication. Median interval time from initial diagnosis to obstruction was 19.5 months (range, 6-77 months). Twenty-two patients underwent surgery, and 12 received conservative treatment. Median interval time from obstruction to death was 65.5 days. In a univariate analysis, survival after obstruction was significantly related to the type of therapy (surgical vs nonsurgical; P = 0.0011) and to the scoring system based on the criteria proposed by Krebs and Goplerud (including age, nutritional status, tumor status, ascites, previous chemotherapy, and previous irradiation; £ 6 vs > 6, P = 0.0001) but not to interval time from diagnosis to obstruction, age, number of previous chemotherapy regimens, or number of previous operations. A multivariate analysis showed that the score was the only independent prognostic factor. If a significant palliation from surgery is defined as a survival of at least two months, such benefit was obtained by 87.5% of the 16 patients with a score of £ 6 compared to 16.7% of the six patients with a higher score. Gadducci et al conclude that the decision regarding optimal management of bowel obstruction in ovarian cancer patients should be individualized. They also emphasized that the Krebs' and Goplerudscore seems to offer reliable eligibility criteria for those patients deemed surgical candidates at the time of obstruction.
COMMENT BY DAVID M. GERSHENSON, MD
Intestinal obstruction occurs during the course of ovarian cancer in at least 25% of patients, and it is a major cause of death from this malignancy. The appropriate clinical management of an ovarian cancer patient with a bowel obstruction is one of the most challenging situations facing physicians. Until the past decade or so, most of these patients were subjected to surgery to alleviate intestinal obstruction. Like this report, several prior studies documented a median survival after surgery for intestinal obstruction in the range of 2-3 months. Almost concomitantly, interventional radiologists and gastroenterologists were beginning to report the use of percutaneous gastrostomy for palliation of intestinal obstruction in cancer patients. Although this procedure did not solve the problem of providing nutrition, it did obviate the necessity for a nasogastric tube while, at the same time, alleviating persistent nausea and vomiting. Gadducci et al have attempted to identify clinical criteria that will assist the clinician in the selection of those patients who might benefit from surgery rather than percutaneous gastrostomy. Based on their findings, they have concluded that the criteria described by Krebs and Goplerud provide the best indicator of who might benefit from surgery. Among their surgically treated patients, median survival was 215 days for the 16 patients with a score £ 6 compared to 36 days for the six patients with a higher score. Although the parameters on which the scoring system is based may not all be precise, conceptually this is the correct approach. Future studies should attempt to refine the criteria used to select candidates for surgery since the reported operative mortality is in the range of 10-25%. For those patients who do not undergo surgery, percutaneous gastrostomy provides excellent palliation in the majority of cases.
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