The role of cytoreductive surgery in advanced-stage ovarian cancer: a systematic review (original) (raw)
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Gynecologic Cancers - Basic Sciences, Clinical and Therapeutic Perspectives, 2016
Ovarian cancer is one of the commonest malignancy in women worldwide, and is the most lethal of all the gynaecological malignancies. Ovarian cancer often presents at an advanced stage, with the involvement of the peritoneal surface either at the initial diagnosis or at recurrence. Despite the advances made in the surgical techniques and chemotherapeutic options regarding agents, schedule, and route of administration, majority of the patients recur and eventually succumb to their disease. The change in the surgical approach supporting more radical and extensive surgical procedures, in a bid to attain optimal cytoreduction with no gross residual disease, has seen improvement in the survival, as has the use of intraperitoneal chemotherapy in combination with i.v. agents. Although peritoneal carcinomatosis has always been a poor prognostic factor, it ceases to be a factor of much importance if complete cytoreduction can be achieved. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) provide the combined benefits of surgical eradication and effective chemotherapy, and can be performed with acceptable morbidity and mortality. Further trials are being undertaken to examine its role in the primary, as well as recurrent settings of advanced ovarian cancer and to determine the ideal drug combinations and dosages. We aim to discuss the role of CRS and HIPEC in the treatment of ovarian cancer.
Cytoreductive surgery in ovarian cancer
Cancer Imaging, 2007
As the overall prognosis for patients with ovarian cancer is poor, the management of this condition should be restricted to expert multidisciplinary teams in gynaecological oncology. Apparent early stage ovarian cancer requires accurate and complete staging so that potential sites for metastases are not missed. Omitting adequate staging may have significant consequences including a negative impact on survival rates in young patients. The challenge with advanced ovarian cancer is to obtain a detailed appreciation of the extent of disease. This information allows treatment with primary chemotherapy if the cancer is considered to be inoperable and/or the general condition of the patient renders her unfit for appropriate surgery. Available data would suggest that a 5-year survival rate of 50% is only possible for those patients who have had complete cytoreduction of all tumour. Therefore, the best surgical option for patients with advanced ovarian cancer is a complete primary surgical procedure that achieves complete clearance of the abdominal cavity rather than optimal surgery that leaves tumour nodules up to 1 cm in diameter in situ in the patient.
Journal of Clinical Gynecology and Obstetrics, 2015
Background: The aim of the study was to evaluate the initial efficiency and security of maximal effort cytoreductive surgery in stages III and IV of ovarian cancer at a university hospital. Methods: Thirty-four patients with stage III and IV ovarian carcinoma underwent surgery between January 2013 and June 2014 in the University General Hospital of Castellon (Spain). Patients with primary and relapse ovarian cancer were included. The extent of disease, type of surgical technique, amount of tumor prior to surgery and amount of residual disease after surgery were recorded. To quantify the efficiency and the security of the procedure, the complete cytoreduction and the morbidity and the mortality rates were described. Results: Of the patients 26.4% received neoadjuvant chemotherapy. Complete cytoreductive surgery, without evident residual tumor at the end of the procedure, was obtained in 79% of patients and optimal cytoreductive surgery (CC0-CC1) in 91%. Surgical complications were found in 56% of patients and two deaths (6%) occurred attributable to surgery. The disease free interval was 15 months. Conclusions: This study confirms that with experienced multidisciplinary teams and in tertiary referral hospitals, 79% of complete cytoreduction surgery in advanced ovarian cancer can be achieved but they must be prepared to deal with a high rate of complications.
Case studies in surgery, 2015
The most common cause of primary ovarian malignancy is epithelial carcinoma, accounting for 95% of malignant ovarian neoplasia. The lifetime risk of epithelial ovarian cancer (EOC) is 1/70 females, representing the leading cause of gynecologic malignancy death. Due to its indolent clinical course, EOC tends to be diagnosed at an advanced stage, often resulting in unfavorable outcomes, since the stage at diagnosis is the most significant prognostic factor. So far the standard of care for ovarian cancer has been surgery followed by systemic chemotherapy. However, treatment with cytoreductive surgery, as described by Sugarbaker, and hyperthermic intraperitoneal chemotherapy (HIPEC) is another approach, showing promising results.
Ejso, 2009
Background: The present study reviews our 12-year results with cytoreductive surgery and HIPEC in patients with advanced primary and recurrent ovarian cancer. Methods: During the period from January 1995 to December 2007, 56 patients (31 with primary and 25 with recurrent epithelial ovarian cancer) underwent cytoreductive surgery and HIPEC (Doxorubicin intra-operatively, and cisplatin next 1e5 postoperative days) at our department. Results: 52 (92.8%) patients had no gross residual disease after the complete surgical procedure (Sugarbaker completeness of cytoreduction CC, score 0e1), and 4 patients had macroscopic residual disease (CC-2 or CC-3) Average PCI (peritoneal cancer index) was 13.4 (4e28). Mean follow-up was 56 months (range, 1e135). The median operation time was 279 min (range 190 AE 500 min). Median total blood loss was 850 mL (range 250 AE 1550 mL). The median survival time was 34.1 months for primary, 40.1 for recurrent ovarian cancer without statistically significance difference (p > 0.05) and median disease-free survival was 26.2 months. The PCI was equal or less than 12 in 31 patients and their median survival time was statistically significant longer than median survival time of months for the 25 patients with PCI greater then 12 (p < 0.01). Morbidity and mortality rate were 17.8% (10/56) and 1.8% (1/56). Conclusion: This series indicates that in the majority of patients with primary and recurrent advanced ovarian cancer, cytoreductive surgery combined with HIPEC can lead to a substantial increase in subsequent rates of disease-free and overall survival.
6 Controversial aspects of cytoreductive surgery in epithelial ovarian cancer
Baillière's Clinical Obstetrics and Gynaecology, 1989
Epithelial ovarian cancer is usually asymptomatic until it disseminates around the peritoneal cavity, so that about 70% of patients have advanced disease at initial presentation. Total surgical resection of all tumour is usually impossible for these patients, so that the surgical options are either biopsy only, limited surgery to include resection of the primary tumour, or aggressive cytoreductive surgery. Cytoreductive or debulking surgery is a procedure whereby surgically incurable tumour is partially removed in order to improve the effectiveness of subsequent therapy, usually chemotherapy or radiation. It contravenes traditional principles of cancer surgery because clear surgical margins are not always obtained. Hence, it has remained somewhat controversial, and has come under frequent criticism. Meigs was the first to suggest that as much tumour as possible should be removed in order to enhance the effect of postoperative irradiation (Meigs, 1935). Munnell (1968) reported an overall increase in survival of patients with ovarian cancer from 28% to 40% and concluded that this improvement was related to more frequent use of postoperative irradiation and more aggressive surgical resection of tumour. Munnell introduced the concept of the maximum surgical effort, but Griffiths was the first to quantify the surgical objective. Griffiths suggested that all tumour nodules should be reduced to 1.5 cm or less in diameter (Griffiths, 1975). Subsequently, both Hacker and van Lindert reported further enhancement of survival when all metastatic masses larger than 5 mm were resected (Hacker et al, 1983; van Lindert et al, 1984) (Figure 1). It has been conventional to refer to an 'optimal' cytoreductive operation as one which eliminates all tumour nodules having a diameter larger than 1.5cm. This convention allows comparison between different studies. Where centres have a particular interest and expertise in cytoreductive surgery, optimal cytoreduction is possible in about 85% of patients (Chen and Bochner, 1985; Heintz et al, 1986; Griffiths, 1987). Feasibility increases with the experience of the surgical team. On the basis of the results of three recent national cooperative ovarian cancer trials, it must be concluded that most patients with advanced ovarian
Recent surgical management of ovarian cancer
Journal of Obstetrics and Gynaecology Research, 2011
Ovarian cancer is the second most common gynecological malignancy in the USA, and the majority of patients with newly diagnosed ovarian cancer present with advanced-stage disease. The standard treatment of these patients involves primary cytoreduction followed by combination chemotherapy. As the evidence has accumulated regarding the benefit of surgical cytoreduction, and as the definition of optimal cytoreduction has evolved, the surgical techniques have expanded in order to achieve this goal. This article discusses the different facets of the surgical management of ovarian cancer, with a special emphasis on the most recent additions to our current knowledge.
Background:Complete cytoreductive surgery is the cornerstone of treating advanced ovarian cancer with platinum salt chemotherapy. The tumorresidue after maximal cytoreduction surgery is an essential prognostic factor for survival. The chronology of treatment is still debated, French and especially American recommendations place primary surgery as the standard and interval surgery as an option when initial surgery is not possible from the outset. The goal of resectability must be the same regardless of the option chosen, namely obtaining an infra-centimetric or ideally zero residue with a lower morbidity rate. Care must of course be discussed in a multidisciplinary consultation meeting.