Surgical Principles

A substantial number of patients with advanced-stage ovarian cancer present with bulky upper abdominal disease, malignant pleural effusions, or even intraparenchymal liver disease and may require diaphragmatic or intestinal procedures, splenectomy with or without a distal pancreatectomy, and peritoneal stripping to achieve an optimal cytoreduction. A survey of the Society of Gynecologic Oncologists (SGO) in 2000 revealed that up to 45% of patients deferred several procedures such as splenectomy with or without distal pancreatectomy, diaphragm stripping with or without full-thickness resection, and excision of grossly positive aortic nodes during i—i—i—i—i—i—i—i—i—i—i—i—i—i—i—i—i—i 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Years until deceased or last follow-up i—i—i—i—i—i—i—i—i—i—i—i—i—i—i—i—i—i 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Years until deceased or last follow-up

Deaths Censored Total

Microscopic

20

47 67

<0.5 cm

24

46 70

0.5-1 cm

61

38 99

1-2 cm

43

10 53

>2 cm

145

31 176

Figure 7-3. Overall survival, stage IIIC ovarian cancer, 19892003, according to maximal residual disease. (From Chi DS, Eisenhauer EL, Lang J, et al: What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol 103:559-564, 2006, Figure 1.)

primary cytoreduction because of their concern about morbidity and unproven efficacy.14 Recent data demonstrate, however, the technical feasibility of ultra-radical surgery and the significant survival advantage afforded by optimal tumor removal even in stage IV patients. In the largest retrospective study examining 225 women with stage IV epithelial ovarian cancer, Akahira and associates15 reported in their multivariate analysis that performance status, histology, and residual disease after cytoreductive surgery were independent prognostic predictors of outcome. The overall median survival for optimally debulked patients was 32 months compared with 16 months for suboptimally reduced patients.

In the presence of grossly unresectable disease, radical procedures, including bowel resection, are of little value and only add to the potential morbidity and mortality associated with surgery for epithelial ovarian cancer, particularly in patients who are nutritionally depleted.16

Surgery for ovarian cancer requires that the abdominal incision be adequate to explore the entire abdominal cavity and allow safe cytoreductive surgery. A vertical incision is recommended but not required. Any ascites or free peritoneal fluid should be collected for cytology. If no free peritoneal fluid is present, separate peritoneal washings can be obtained from the pelvis, paracolic gutters, and infradiaphragmatic area. Patients with stage III or IV disease do not require cytologic assessment. All peritoneal surfaces including the surface of both diaphragms and the serosa and mesentery of the entire gastrointestinal tract should be visualized and palpated for evidence of metastatic disease with careful inspection of the omentum and removal, if possible, of at least the infracolic omentum. When possible, an extrafascial total

Figure 7-4. Carcinoma of the ovary: patients treated in 19992001. Survival in stage IIIC patients by completeness of surgery, n = 2160. (From Heintz A, Odicino F, Maisonneuve P, et al: Carcinoma of the ovary. Int J Gynaecol Obstet 95(Suppl 1):S161-S192, 2006, Figure 12.)

Residual Disease

Patients (N)

Mean Age (yr)

Overall Survival (%) at

Hazards Ratio* (95% CI)

1 Year

2 Years

3 Years

4 Years

5 Years

No micro residual

73

55.8

94.4

87.1

76.8

68.6

63.5

Reference

No macro residual

285

56.3

95.0

85.0

77.9

69.3

62.1

1.0 (0.6-1.6)

<2 cm

495

58.9

86.8

68.7

52.3

40.8

32.9

2.3 (1.5-3.5)

>2 cm

602

60.6

82.0

56.4

42.6

32.0

24.8

3.0 (1.9-4.5)

Unknown

705

61.1

79.6

56.3

40.7

29.3

24.1

2.9 (1.9-4.5)

*Hazards ratio and 95% confidence intervals obtained from a Cox model adjusted for age, stage, and country.

*Hazards ratio and 95% confidence intervals obtained from a Cox model adjusted for age, stage, and country.

abdominal hysterectomy and bilateral salpingo-oophorectomy should be performed. If this is not possible, at minimum a biopsy of the ovary and sampling of the endo-metrium must be performed. All remaining gross disease within the abdominal cavity should be resected when possible.

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