Surgery plays a key role in diagnosing and staging ovarian cancer through removal of tumors and lymph nodes. The goal of primary surgery is optimal tumor reduction through techniques like en-bloc resection. Additional surgeries like interval cytoreduction may allow further tumor removal and provide access for chemotherapy. Studies on secondary cytoreduction suggest improved survival with complete tumor removal, especially for recurrent cancers with a long treatment-free interval, but the benefit requires further validation through randomized trials.

1. Knowledge is Power
Ovarian cancer series-2012
The Role of Surgery in the Management of
Ovarian Cancer
Jeffrey Y. Lin, M.D.
Director, Gynecologic Oncology
Sibley Memorial Hospital

2. Objectives

To learn the role of surgery in the treatment of
ovarian cancer

To understand when surgery may be beneficial
and when it may be harmful

3. Primary surgery for ovarian cancer
Rationale

Usually performed as a laparotomy

Establish primary cancer diagnosis

Stage assignment based on surgico-pathologic
findings (distribution of disease)

Perform surgical “cytoreduction” of metastatic
lesions if present

Establishment of intraperitoneal (IP) access for
chemotherapy

Correct any obstructive problems

4. Surgical cytoreduction

Goal: to remove all gross metastatic
disease

Technical principles
− Use of retroperitoneal spaces
− En-bloc resection
− Resection of gi and urinary tracts with
reconstruction
− Resection of peritoneal surfaces
− Resection of metastatic lymph nodes

5. Surgical cytoreduction

Laparotomy with
vertical incision for
good exposure of
entire abdomen

6. Surgical cytoreduction

En-bloc resection

Peritoneal stripping

7. Surgical cytoreduction
subdiaphragmatic resection

Recent emphasis
on upper abdominal
surgery
− Omentum
− Spleen
− Diaphragm
− Liver, gall
bladder,
pancreas

8. Surgical cytoreduction

Completion of pelvic
resection

9. Types of additional surgery

Interval cytoreduction

Secondary, tertiary cytoreductive surgeries

Second-look laparotomy

Palliative surgeries, generally for end-stage
obstructive diseases
− Colostomy
− Gastrostomy

10. Rationale for additional surgery

Disease assessment

Acquistion of fresh tumor for molecular testing,
drug resistance/sensitivity assays, cell culture

Opportunity for secondary cytoreduction to
improve survival

Option for hyperthermic intraperitoneal
chemotherapy

11. Second-look laparotomy

Many patients with advanced ovarian cancer
will have residual disease after completion of
postoperative chemotherapy

Second-look laparotomy traditionally has been
regarded as the most sensitive test to identify
persistent cancer

Variations include laparoscopic approach

12. Problems with second-look
laparotomy

In women with a negative result, many recur
eventually (false negative rate 20-50%, Gynecol
Oncolog, Podratz and Cliby, 1994)

Moderate morbidity associated with second-look
surgery

No demonstrable survival benefit

Newer tumor markers and PET/CT may offer
competitive sensitivity

High economic costs

13. Secondary cytoreduction
Salani R, et al, Cancer, 2007

Retrospective analysis of 55 women with
recurrent ovarian cancer and secondary
CTR in 1997-2005

Selection criteria included CR to
chemotherapy, >12 mos from recurrence to
initial surgery, 5 or less sites of recurrence

Median age was 58 yrs, median tumor free
interval was 32 mos

Rate of complete CTR was 75%

14. Secondary cytoreduction
Salani (continued)

Survival
− TFI>18 mos, then 49 mos vs 3 mos
− Only 1-2 sites of tumor, then 50 mos vs
12 mos
− Complete CTR, then 50 mos vs 7.2 mos
− Age did not seem to be a statistically
significant factor

Morbidity for surgery
− EBL 200 cc
− Length of stay was 5 days
− 1 death from sepsis (1.8%)

15. Secondary cytoreduction
Oksefjell H et al., Annals Oncolog, 2009

Retrospective analysis from Radium
Hospital 1985-2000 of 789 women with
recurrent ovarian cancer

Separation into 3 groups
− Chemotherapy only (n=572)
− Surgery with localized disease (1-2
lesions) (n=84)_
− Surgery with dessiminated disease
(n=133)
− Noted whether surgery was also for
obstructive disease

16. Secondary cytoreduction
Oksefjell (continued)

49% rate of complete cytoreduction (no
macro disease)

Most patients with bowel obstruction had
dessiminated disease

Patients treated solely with chemotherapy
tended to have higher stage disease and
more were older than 70 yrs

Chemotherapy with taxane agent gave the
best median survival (MS) of 3.7 yrs

17. Secondary Surgical Cytoreduction
Oksfejell (continued)

MS with chemotherapy
was 1.1 yrs

MS with complete CTR
was 4.5 yrs

MS with 0-2 cm CTR
was 2.3 yrs

Subset of chemotherapy
(>12 mos TFI) was 2-2.6
Significant prognostic
factors were TFI,
desseminated disease
and age >70 yrs

18. Interval cytoreduction
Vergote I, et al, NEJM, 2010

Randomized prospective trial of the Gynecologic
Cancer Intergroup Collaboration of 632 women
with stage IIIC/IV ovarian, peritoneal or fallopian
tube cancer to either cytoreductive
surgery/postoperative chemotherapy or
neoadjuvant chemotherapy/interval cytoreduction
(CTR)

Rate of successful primary CTR (<1 cm) was
42%

Neoadjuvant chemotherapy was 3 courses of a
platinum-based combination, followed by interval
CTR with 3 additional courses of chemotherapy
afterwards

19. Interval cytoreduction
Vergote (continued)

Survival (median overall)
− Primary surgery group was 29 mos
− Neoadjuvant group was 30 mos (hazard ratio
was 0.98 (CI 0.84-1.13))

Authors conclusion was that either approach
was reasonable for bulky advanced disease but
that primary surgery was advisable for earlier
stage III and less disease

20. Conclusions

Surgery is an important component in the
management of ovarian cancer

Additional surgeries after primary
chemotherapy may be of value

While secondary surgical cytoreduction
may be well accepted, the context in which
it is to be employed is still being developed
and its absolute benefit still has not been
established by a randomized clinical trial