7 The influence of cytoreductive surgery on progression-free interval and survival in epithelial ovarian cancer

Abstract

In 1980, Dr George E. Moore published an editorial in Surgery, Gynecology and Obstetrics entitled 'Debunking debulking'. He included advanced ovarian cancer in his personal list of 'faulty' debulking procedures. Some of hist statements have merit. He contends that overly aggressive procedures that leave microscopic tumour cells that will soon grow and kill the patient are unindicated. He further points out that one cubic centimetre of tumour will contain approximately a billion cells. However, there are factors in ovarian cancer that should cause one to take exception to Dr Moore's statement. First, there is good evidence that the use of cisplatin-based multidrug chemotherapy may eradicate microscopic tumour deposits in a significant number of patients. Secondly, even multiple aggregates of tumour with a billion or more cancer cells can be eradicated in some cases, and in others can be reduced sufficiently to allow significant palliation. In evaluating the information which has been reviewed in this discussion of cytoreductive surgery for advanced ovarian cancer, it is apparent that cytoreductive surgery is not only indicated, but mandated in many facets of the management of ovarian cancer. The following principles seem to be supported by the existing literature: 1. Current diagnostic techniques do not enable us to diagnose ovarian cancer while still confined to the ovary. Therefore, in the immediate future we will still encounter a large number of patients with advanced disease. 2. The number of complete clinical responses and the number of complete pathological responses (negative second-look surgical reassessments) are greatest in those patients who begin adjunctive therapy with minimal residual disease. 3. Median duration of survival is longer, and long-term survival more likely, in those patients giving complete clinical or complete pathological responses. 4. Some patients appear to benefit from secondary cytoreductive surgery. However, at the present time, evidence of benefit from secondary cytoreductive surgery appears to be limited to those patients who have responded to adjunctive therapy and are found to have residual disease at surgical reassessment. There is no good evidence to support secondary cytoreductive surgery as an 'interval' procedure or its use in patients with progression on primary adjunctive therapy. This development of better chemotherapy regimens, such as cisplatin-based chemotherapy, has resulted in a greater need for effective primary cytoreductive surgery as it is apparent that, on utilizing these new regimens, better results are obtained in patients with minimal residual disease.(ABSTRACT TRUNCATED AT 400 WORDS)