Neoadjuvant chemotherapy in advanced epithelial ovarian cancer is the final concept that merits discussion for treatment of advanced disease. Neoadjuvant implies delivering chemotherapy before a cytoreductive operation. Maximal operative effort with the goal of optimal (less than 1 cm disease) cytoreduction or "debulking" is the current cornerstone of surgical management in advanced epithelial ovarian cancer. Some series indicate that approximately 50% of patients can be primarily optimally debulked. The reasons for surgeons not being able to complete optimal cytoreduc-tions are many, but clearly biologic tumor heterogeneity is an important factor.72 Furthermore, for patients with poor performance status and severe debilitation from their disease, or comorbidities, aggressive surgical cytoreduction can be extremely hazardous. Given these concepts, there has been increasing enthusiasm in recent years for using neoadjuvant chemotherapy to reduce tumor burden and improve patient performance status before an aggressive attempt at cytoreduction. Currently, a randomized trial is underway to evaluate the role of neoadjuvant chemotherapy in advanced epithelial ovarian cancer.73 To date, several investigators have reported data on this therapy, but no distinct standard protocol for the use of neoadjuvant chemotherapy has been defined or accepted by clinicians.74-76
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