Controversies in surgery in ovarian cancer — what is its real role?

Abstract

Rupture of an ovarian malignant tumour should be avoided at the time of surgery for an early ovarian cancer. Laparoscopic removal of ovarian cysts should be restricted to patients with preoperative evidence that the cyst is benign. Degree of differentiation is the most important independent prognostic factor in stage I disease and should be used in decisions on therapy in clinical practice and the future FIGO (International Federation of Gynecology and Obstetrics) classification of stage 1. In early ovarian cancer, staging adequacy and tumour grade were the only two statistically significant prognostic factors for survival in the multivariate analysis of the EORTC (European Organisation for Research and Treatment of Cancer) ACTION (Adjuvant ChemoTherapy In Ovarian Neoplasms) trial. According to the present data there is no scientific basis to rely only on adjuvant chemotherapy or on optimal staging procedure in medium and high risk stage I ovarian cancer. Primary debulking surgery by a gynaecological oncologist remains the standard of care in advanced ovarian cancer. Optimal debulking surgery should be defined as no residual tumour load. Interval debulking is defined as an operation performed after a short course of induction chemotherapy, usually 2 or 3 cycles. Based on the randomised EORTC GCG (Gynaecological Cancer Group) trial, interval debulking by an experienced surgeon improves survival in some patients who did not undergo optimal primary debulking surgery. Based on the GOG (Gynecologic Oncology Group) 152 data, interval debulking surgery does not seem to be indicated in patients who underwent primarily a maximal surgical effort by a gynaecological oncologist. Open laparoscopy is probably the most valuable tool for evaluating the operability primarily or at the time of interval debulking surgery. In retrospective analyses, neoadjuvant chemotherapy followed by interval debulking surgery does not seem to worsen prognosis compared to primary debulking surgery followed by chemotherapy. However, we will have to wait for the results of the EORTC-GCG/NCI (National Cancer Institute) Canada randomised trial to know whether neoadjuvant chemotherapy followed by interval debulking surgery is as good as primary debulking surgery in some or all stage IIIc and IV patients. The most suitable candidates for secondary debulking surgery are those who had an initial complete response to chemotherapy, a long treatment-free interval (e.g. more than 12 months), and resectable disease (without diffuse carcinomatosis).