Surgery for patients with newly diagnosed advanced ovarian cancer: which patient, when and extent?

Abstract

The past decade has seen a paradigm shift in the number of AvdEOC patients that are being treated with upfront neoadjuvant chemotherapy instead of PCS. However, although neoadjuvant chemotherapy may reduce morbidity at the time of interval cytoreductive surgery, no favorable impact on survival has been demonstrated and it may induce resistance to chemotherapy. Therefore, optimizing patient selection for PCS is crucial. Furthermore, surgical innovations in patients diagnosed with AvdEOC should focus on improving survival outcomes.

Quality Indicators and Survival Outcome in Stage IIIB-IVB Epithelial Ovarian Cancer Treated at a Single Institution

“…An analysis of the European Organization for Research and Treatment of Cancer (EORTC) randomized trial by van Meurs et al has reported quite similar five-year survival rates in patients with large metastatic tumors in stage IIIC and less extensive metastatic tumors in stage IV at both primary surgery and neoadjuvant chemotherapy followed by cytoreductive surgery (23). It points out that neoadjuvant chemotherapy may prevent unnecessary postoperative morbidity and mortality (24,25) and promote higher chances of achieving complete cytoreduction during surgery (9). However, the available randomized data on the role of neoadjuvant chemotherapy in survival are limited in patients with intraabdominal FIGO stage IIIC versus stage IIIC based on nodal status only (26).…”

“…It was confirmed already in 2009 by du Bois et al that overall survival is significantly better when cancer is treated with primary cytoreduction with no visible residual cancer tissue (0 mm) (7). Intention within macroscopic radical surgery in FIGO III-IV disease has changed a lot over the past 10 years by striving for direct upfront retroperitoneal dissection and diaphragmatic stripping, splenectomy, gastrointestinal and partial liver resection and pelvic peritonectomy (9)(10)(11)(12).…”

“…Macroscopic radical surgery involves extensive removal of all visible tumor tissue to achieve no macroscopically visible residual disease (0 mm). Clinical guidelines recommend primary surgery for patients with advanced ovarian cancer if there is a high likelihood of achieving complete cytoreduction with acceptable morbidity (8,9). It was confirmed already in 2009 by du Bois et al that overall survival is significantly better when cancer is treated with primary cytoreduction with no visible residual cancer tissue (0 mm) (7).…”

The Peritoneal Cancer Index is a Strong Predictor of Incomplete Cytoreductive Surgery in Ovarian Cancer

“…Consequently, identifying these patients preoperatively is of great value. 6 Currently, the extent of tumor load is estimated by different imaging methods, usually by computed tomography (CT) and magnetic resonance imaging (MRI) or preoperative laparoscopy. However, no universally accepted reference standard exists for the imaging of peritoneal carcinomatosis.…”

Upfront debulking surgery for high-grade serous ovarian carcinoma: current evidence

“…Lower rates of chemoresistance have been welldocumented in patients who underwent upfront debulking surgery due to minimal tumor load (3,39). Subsequent chemotherapy in patients with IDS found to be inadequate in patients received neoadjuvant chemotherapy followed by higher rates of recurrence demonstrating a clear advantage of primary cytoreductive surgery (56). For instance, in patients with celiac lymph node involvement, upfront debulking surgery aiming for lymphadenectomy offers higher survival rates, since positive celiac lymph nodes are accompanied with higher incidence of chemo-resistance and more advanced disease with higher rates of recurrence if not removed at the time of the surgery.…”