Surgery for Ovarian Cancer: Rationale and Guidelines

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Ovarian cancer is the second most common gynecologic cancer in women and the leading cause of death caused by gynecologic malignancy. Surgery plays a fundamental role in treating this challenging disease. Goals of primary surgery for ovarian cancer are to establish diagnosis, proper staging, determination of prognosis, and optimal cytoreduction of gross disease before chemotherapy for improved outcome. In addition to standard removal of the ovaries, uterus, omentum, and pelvic and para-aortic lymph nodes for early disease, extended surgical techniques used to debulk advanced disease include bowel resection, splenectomy, partial liver resection, peritoneal or diaphragmatic stripping, and use of laser or ultrasound (CUSA). Secondary surgery is used in a variety of situations. Second-look procedures were performed historically to determine response to chemotherapy to delineate duration of treatment, but now are best used in a research setting with the advent of improved chemotherapeutic agents. As a high percentage of patients have a gynecologic malignancy recurrence after primary treatment, many practitioners perform secondary cytoreductive procedures for recurrent disease. Additionally, in the recurrent setting, surgery may be necessary for relief of bowel obstruction and palliation of symptoms. Surgical management of ovarian cancer must be performed by surgeons, such as gynecologic oncologists, who have a firm understanding of the disease process, display good clinical judgment, and are adequately trained to perform the complex surgery that commonly is required for appropriate care.

Correspondence: Benjamin E. Greer, MD, Professor, Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Box 356460, University of Washington School of Medicine, 1959 NE Pacific Street, Seattle, Washington 98195-6460. E-mail: bengreer@u.washington.edu
  • 1

    American Cancer Society. Cancer Facts and Figures 2004.Washington, DC: The American Cancer Society; Available at: http://www.cancer.org. Accessed September 2004.

    • Search Google Scholar
    • Export Citation
  • 2

    GreerBERutledgeFNGallagerHS. Staging or restaging laparotomy in early-stage epithelial cancer of the ovary. Clin Obstet Gynecol1980;23:293303.

    • Search Google Scholar
    • Export Citation
  • 3

    YoungRCDeckerDGWhartonJT. Staging laparotomy in early ovarian cancer. JAMA1983;250:30723076.

  • 4

    CassILiAJRunowiczCD. Pattern of lymph node metastases in clinically unilateral stage I invasive epithelial ovarian carcinomas. Gynecol Oncol2001;80:5661.

    • Search Google Scholar
    • Export Citation
  • 5

    MunozKAHarlanLCTrimbleEL. Patterns of care for women with ovarian cancer in the United States. J Clin Oncol1997;15:34083415.

  • 6

    SchilderJ MThompsonAMDePriestPD. Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy. Gynecol Oncol2002;87:17.

    • Search Google Scholar
    • Export Citation
  • 7

    WaltonLEllenbergSSMajorFJr. Results of second-look laparotomy in patients with early-stage ovarian carcinoma. Obstet Gynecol1987;70:770773.

    • Search Google Scholar
    • Export Citation
  • 8

    BellJBradyMLageJ. A randomized phase III trial of three versus six cycles of carboplatin and paclitaxel as adjuvant treatment in early stage ovarian epithelial carcinoma: A Gynecolog Oncology Group study (Abstr 1). Gynecol Oncol2003;88:156.

    • Search Google Scholar
    • Export Citation
  • 9

    AyhanATuncerZSTuncerR. Is routine appendectomy beneficial in the management of ovarian cancer?Eur J Obstet Gynecol Reprod Biol1994;57:2931.

    • Search Google Scholar
    • Export Citation
  • 10

    BeseTKosebayDKaleliS. Appendectomy in the surgical staging of ovarian carcinoma. Int J Gynaecol Obstet1996;53:249252.

  • 11

    RosePGRealeFRFisherA. Appendectomy in primary and secondary staging operations for ovarian malignancy. Obstet Gynecol1991;77:116118.

    • Search Google Scholar
    • Export Citation
  • 12

    RosePGAbdul-KarimFW. Isolated appendiceal metastasis in early ovarian carcinoma. J Surg Oncol1997;64:246247.

  • 13

    OzolsRFBundyBNGreerBE. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: A Gynecologic Oncology Group Study. J Clin Oncol2003;21:3194-3200.

    • Search Google Scholar
    • Export Citation
  • 14

    VaseyPA. Role of docetaxel in the treatment of newly diagnosed advanced ovarian cancer. J Clin Oncol2003;21(suppl 10):S136S144.

  • 15

    BookmanMAGreerBEOzolsRF. Optimal therapy of advanced ovarian cancer: carboplatin and paclitaxel vs. cisplatin and paclitaxel (GOG 158) and an update on GOG 182-ICON5. Int J Gynecol Cancer2003;13:735740.

    • Search Google Scholar
    • Export Citation
  • 16

    GriffithsCTParkerLMFullerAFJr. Role of cytoreductive surgical treatment in the management of advanced ovarian cancer. Cancer Treat Rep1979;63:235240.

    • Search Google Scholar
    • Export Citation
  • 17

    SmithJPDayTGJr. Review of ovarian cancer at the University of Texas Systems Cancer Center, M.D. Anderson Hospital and Tumor Institute. Am J Obstet Gynecol1979;135:984993.

    • Search Google Scholar
    • Export Citation
  • 18

    OmuraGABradyMFHomesleyHD. Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience. J Clin Oncol1991;9:11381150.

    • Search Google Scholar
    • Export Citation
  • 19

    HackerNFBerekJSLagasseLD. Primary cytoreductive surgery for epithelial ovarian cancer. Obstet Gynecol1983;61:413420.

  • 20

    HoskinsWJBundyBNThigpenJT. The influence of cytoreductive surgery on recurrence-free interval and survival in small-volume stage III epithelial ovarian cancer: a Gynecologic Oncology Group study. Gynecol Oncol1992;47:159166.

    • Search Google Scholar
    • Export Citation
  • 21

    Farias-EisnerRTengFOliveiraM. The influence of tumor grade, distribution, and extent of carcinomatosis in minimal residual stage III epithelial ovarian cancer after optimal primary cytoreductive surgery. Gynecol Oncol1994;55:108110.

    • Search Google Scholar
    • Export Citation
  • 22

    BristowRETomacruzRSArmstrongDK. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol2002;20:12481259.

    • Search Google Scholar
    • Export Citation
  • 23

    NicklinJLCopelandLJO'TooleRV. Splenectomy as part of cytoreductive surgery for ovarian carcinoma. Gynecol Oncol1995;58:244247.

  • 24

    Gillette-ClovenNBurgerRAMonkBJ. Bowel resection at the time of primary cytoreduction for epithelial ovarian cancer. J Am Coll Surg2001;193:626632.

    • Search Google Scholar
    • Export Citation
  • 25

    FioricaJVHoffmanMSLaPollaJP. The management of diaphragmatic lesions in ovarian carcinoma. Obstet Gynecol1989;74:927929.

  • 26

    BrandEPearlmanN. Electrosurgical debulking of ovarian cancer: a new technique using the argon beam coagulator. Gynecol Oncol1990;39:115118.

    • Search Google Scholar
    • Export Citation
  • 27

    DeppeGMalviyaVKMaloneJMJr. Use of Cavitron Ultrasonic Surgical Aspirator (CUSA) for palliative resection of recurrent gynecologic malignancies involving the vagina. Eur J Gynaecol Oncol1989;10:12.

    • Search Google Scholar
    • Export Citation
  • 28

    van DamPATjalmaWWeylerJ. Ultraradical debulking of epithelial ovarian cancer with the ultrasonic surgical aspirator: a prospective randomized trial. Am J Obstet Gynecol1996;174:943950.

    • Search Google Scholar
    • Export Citation
  • 29

    ReimerRRHooverR. Acute leukemia after alkylating-agent therapy of ovarian cancer. N Engl J Med1977;297:177181.

  • 30

    GreeneMHBoiceJDJrGreerBE. Acute nonlymphocytic leukemia after therapy with alkylating agents for ovarian cancer: a study of five randomized clinical trials. N Engl J Med1982;307:14161421.

    • Search Google Scholar
    • Export Citation
  • 31

    FriedmanJBWeissNS. Second thoughts about second-look laparotomy in advanced ovarian cancer. N Engl J Med1990;322:10791082.

  • 32

    RubinSCJonesWB. Second-look laparotomy in stage I ovarian cancer following comprehensive surgical staging. Obstet Gynecol1993;82:139142.

    • Search Google Scholar
    • Export Citation
  • 33

    LuesleyDLawtonF. Failure of second-look laparotomy to influence survival in epithelial ovarian cancer. Lancet1988;2(8611):599603.

  • 34

    FiorentinoMVNicolettaMOTumoloS. Uselessness of surgical second-look in epithelial ovarian cancer: a randomized study (Abstr). Proc Am Soc Clin Oncol1999;13:259.

    • Search Google Scholar
    • Export Citation
  • 35

    GreerBEBundyBNOzolsRF. Implications of second-look laparotomy (SLL) in the context of Gynecologic Oncology Group (GOG) Protocol 158: a non-randomized comparison using an explanatory analysis (Abstr 2). Gynecol Oncol2003;88:156157.

    • Search Google Scholar
    • Export Citation
  • 36

    van der BergMELvan LentMBuyseM. The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. N Engl J Med1995;332:629634.

    • Search Google Scholar
    • Export Citation
  • 37

    RosePNerenstoneSBradyM. A phase III randomized study of interval secondary cytoreduction in patients with advanced stage ovarian carcinoma with suboptimal residual disease: a Gynecologic Oncology Group study (Abstr #802). Program and abstracts of the American Society of Clinical Oncology, 38th Annual MeetingMay 18–21Orlando FL2002.

    • Search Google Scholar
    • Export Citation
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