Timing of debulking surgery in advanced ovarian cancer

Abstract

It is clear that primary debulking remains the standard of care within the treatment of advanced ovarian cancer (FIGO stage III and IV). This debulking surgery should be performed by a gynecological oncologist without any residual tumor load, or so-called "optimal debulking." Over the last decades, interest in the use of neoadjuvant chemotherapy together with an interval debulking has increased. Neoadjuvant therapy can be used for patients who are primarily suboptimally debulked due to an extensive tumor load. In this situation, based on the randomized European Organization for Research and Treatment of Cancer-Gynaecological Cancer Group trial, interval debulking by an experienced surgeon improves survival in some patients who did not undergo optimal primary debulking surgery. Based on the GOG 152 data, interval debulking surgery does not seem to be indicated in patients who underwent primarily a maximal surgical effort by a gynecological oncologist. Neoadjuvant chemotherapy can also be used as an alternative to primary debulking. In retrospective analyses, neoadjuvant chemotherapy followed by interval debulking surgery does not seem to worsen prognosis compared to primary debulking surgery followed by chemotherapy. However, we will have to wait for the results of future randomized trials to know whether neoadjuvant chemotherapy followed by interval debulking surgery is a good alternative to primary debulking surgery in stage IIIc and IV patients. Open laparoscopy is probably the most valuable tool for evaluating the operability primarily or at the time of interval debulking surgery.

The role of neoadjuvant chemotherapy in treating advanced epithelial ovarian cancer

“…These studies have been extensively reviewed and due to their retrospective nature, the results are, fraught with biases including variable patient selection and lack of wellmatched control groups [48][49][50][52][53][54]. In many studies, patients selected to undergo NACT were older, had a greater tumor burden, higher stage and grade of disease, a poorer performance status, and had other medical co-morbidities precluding them from undergoing aggressive cytoreductive surgery compared to control groups.…”

The Safety and Efficacy of Laparoscopic Surgical Staging and Debulking of Apparent Advanced Stage Ovarian, Fallopian Tube and Primary Peritoneal Cancers

“…19,20 In situations where the ability to achieve an optimal cytoreduction is unlikely, neoadjuvant chemotherapy followed by interval cytoreduction may be appropriate. 3 Thus, laparoscopy offers a less morbid approach for determining which patients will likely have suboptimal cytoreduction at the time of primary surgery and hence benefit from neoadjuvant chemotherapy. Vergote et al 21 reported a series of 285 patients who underwent open laparoscopy to determine whether optimal debulking is possible.…”

“…2 In patients with disease thought not to be optimally resectable, the use of neoadjuvant chemotherapy to reduce tumor load can allow for interval surgical debulking. 3 Advances in laparoscopic surgery have extended this minimally invasive surgical approach to managing ovarian cancer. In early stage ovarian cancer, multiple studies have demonstrated feasibility and efficacy of complete laparoscopic staging.…”

Debulking surgery for incompletely operated advanced epithelial ovarian carcinoma

“…Despite the well known evidence in early stage ovarian cancer patients, we are aware of no data on the role of secondary MDS in patients with advanced stage disease or prognostic factors for these patients [3][4][5][6][7][8][9][10]. Two previous studies, EORTC/GCCG-55865 and GOG-152 had analyzed the role of re-surgery in these advanced staged patients [11,12].…”