Surgery for Ovarian Cancer: Rationale and Guidelines

Restricted access

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

    Greer BE, Rutledge FN, Gallager HS. Staging or restaging laparotomy in early-stage epithelial cancer of the ovary. Clin Obstet Gynecol 1980;23:293303.

    • Search Google Scholar
    • Export Citation
  • 3

    Young RC, Decker DG, Wharton JT. Staging laparotomy in early ovarian cancer. JAMA 1983;250:30723076.

  • 4

    Cass I, Li AJ, Runowicz CD. Pattern of lymph node metastases in clinically unilateral stage I invasive epithelial ovarian carcinomas. Gynecol Oncol 2001;80:5661.

    • Search Google Scholar
    • Export Citation
  • 5

    Munoz KA, Harlan LC, Trimble EL. Patterns of care for women with ovarian cancer in the United States. J Clin Oncol 1997;15:34083415.

  • 6

    Schilder J M, Thompson AM, DePriest PD. Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy. Gynecol Oncol 2002;87:17.

    • Search Google Scholar
    • Export Citation
  • 7

    Walton L, Ellenberg SS, Major F Jr. Results of second-look laparotomy in patients with early-stage ovarian carcinoma. Obstet Gynecol 1987;70:770773.

    • Search Google Scholar
    • Export Citation
  • 8

    Bell J, Brady M, Lage J. 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 Oncol 2003;88:156.

    • Search Google Scholar
    • Export Citation
  • 9

    Ayhan A, Tuncer ZS, Tuncer R. Is routine appendectomy beneficial in the management of ovarian cancer? Eur J Obstet Gynecol Reprod Biol 1994;57:2931.

    • Search Google Scholar
    • Export Citation
  • 10

    Bese T, Kosebay D, Kaleli S. Appendectomy in the surgical staging of ovarian carcinoma. Int J Gynaecol Obstet 1996;53:249252.

  • 11

    Rose PG, Reale FR, Fisher A. Appendectomy in primary and secondary staging operations for ovarian malignancy. Obstet Gynecol 1991;77:116118.

    • Search Google Scholar
    • Export Citation
  • 12

    Rose PG, Abdul-Karim FW. Isolated appendiceal metastasis in early ovarian carcinoma. J Surg Oncol 1997;64:246247.

  • 13

    Ozols RF, Bundy BN, Greer BE. 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 Oncol 2003;21:3194-3200.

    • Search Google Scholar
    • Export Citation
  • 14

    Vasey PA. Role of docetaxel in the treatment of newly diagnosed advanced ovarian cancer. J Clin Oncol 2003;21(suppl 10):S136S144.

  • 15

    Bookman MA, Greer BE, Ozols RF. 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 Cancer 2003;13:735740.

    • Search Google Scholar
    • Export Citation
  • 16

    Griffiths CT, Parker LM, Fuller AF Jr. Role of cytoreductive surgical treatment in the management of advanced ovarian cancer. Cancer Treat Rep 1979;63:235240.

    • Search Google Scholar
    • Export Citation
  • 17

    Smith JP, Day TG Jr. Review of ovarian cancer at the University of Texas Systems Cancer Center, M.D. Anderson Hospital and Tumor Institute. Am J Obstet Gynecol 1979;135:984993.

    • Search Google Scholar
    • Export Citation
  • 18

    Omura GA, Brady MF, Homesley HD. Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience. J Clin Oncol 1991;9:11381150.

    • Search Google Scholar
    • Export Citation
  • 19

    Hacker NF, Berek JS, Lagasse LD. Primary cytoreductive surgery for epithelial ovarian cancer. Obstet Gynecol 1983;61:413420.

  • 20

    Hoskins WJ, Bundy BN, Thigpen JT. 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 Oncol 1992;47:159166.

    • Search Google Scholar
    • Export Citation
  • 21

    Farias-Eisner R, Teng F, Oliveira M. The influence of tumor grade, distribution, and extent of carcinomatosis in minimal residual stage III epithelial ovarian cancer after optimal primary cytoreductive surgery. Gynecol Oncol 1994;55:108110.

    • Search Google Scholar
    • Export Citation
  • 22

    Bristow RE, Tomacruz RS, Armstrong DK. Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. J Clin Oncol 2002;20:12481259.

    • Search Google Scholar
    • Export Citation
  • 23

    Nicklin JL, Copeland LJ, O'Toole RV. Splenectomy as part of cytoreductive surgery for ovarian carcinoma. Gynecol Oncol 1995;58:244247.

  • 24

    Gillette-Cloven N, Burger RA, Monk BJ. Bowel resection at the time of primary cytoreduction for epithelial ovarian cancer. J Am Coll Surg 2001;193:626632.

    • Search Google Scholar
    • Export Citation
  • 25

    Fiorica JV, Hoffman MS, LaPolla JP. The management of diaphragmatic lesions in ovarian carcinoma. Obstet Gynecol 1989;74:927929.

  • 26

    Brand E, Pearlman N. Electrosurgical debulking of ovarian cancer: a new technique using the argon beam coagulator. Gynecol Oncol 1990;39:115118.

    • Search Google Scholar
    • Export Citation
  • 27

    Deppe G, Malviya VK, Malone JM Jr. Use of Cavitron Ultrasonic Surgical Aspirator (CUSA) for palliative resection of recurrent gynecologic malignancies involving the vagina. Eur J Gynaecol Oncol 1989;10:12.

    • Search Google Scholar
    • Export Citation
  • 28

    van Dam PA, Tjalma W, Weyler J. Ultraradical debulking of epithelial ovarian cancer with the ultrasonic surgical aspirator: a prospective randomized trial. Am J Obstet Gynecol 1996;174:943950.

    • Search Google Scholar
    • Export Citation
  • 29

    Reimer RR, Hoover R. Acute leukemia after alkylating-agent therapy of ovarian cancer. N Engl J Med 1977;297:177181.

  • 30

    Greene MH, Boice JD Jr, Greer BE. Acute nonlymphocytic leukemia after therapy with alkylating agents for ovarian cancer: a study of five randomized clinical trials. N Engl J Med 1982;307:14161421.

    • Search Google Scholar
    • Export Citation
  • 31

    Friedman JB, Weiss NS. Second thoughts about second-look laparotomy in advanced ovarian cancer. N Engl J Med 1990;322:10791082.

  • 32

    Rubin SC, Jones WB. Second-look laparotomy in stage I ovarian cancer following comprehensive surgical staging. Obstet Gynecol 1993;82:139142.

    • Search Google Scholar
    • Export Citation
  • 33

    Luesley D, Lawton F. Failure of second-look laparotomy to influence survival in epithelial ovarian cancer. Lancet 1988;2(8611):599603.

  • 34

    Fiorentino MV, Nicoletta MO, Tumolo S. Uselessness of surgical second-look in epithelial ovarian cancer: a randomized study (Abstr). Proc Am Soc Clin Oncol 1999;13:259.

    • Search Google Scholar
    • Export Citation
  • 35

    Greer BE, Bundy BN, Ozols RF. 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 Oncol 2003;88:156157.

    • Search Google Scholar
    • Export Citation
  • 36

    van der Berg MEL, van Lent M, Buyse M. The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. N Engl J Med 1995;332:629634.

    • Search Google Scholar
    • Export Citation
  • 37

    Rose P, Nerenstone S, Brady M. 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 Meeting, May 18–21, Orlando FL, 2002.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 166 137 55
PDF Downloads 73 59 4
EPUB Downloads 0 0 0