Whenever possible, surgical removal of the ovaries and uterus is performed. Chemotherapy has an important part to play.

  • Except in the most specialised units, complete surgical removal of all deposits of advanced intraperitoneal ovarian cancer is rarely achieved. Some recommend "debaulking" followed by chemotherapy and a "second look laparotomy" to remove residual deposits.
    Ovarian cancer spreads early in the disease into the abdomen.
  • Ovarian cancer is the fifth most common cause of cancer-related death among women in the United States, although the median survival of patients has been increasing over the past few decades.0801
  • In patients with epithelial ovarian cancer, chemotherapy has increased survival. Platinum agents combined with taxanes have become standard treatment. Intraperitoneal chemotherapy has also increased survival.
  • Cytoreductive surgery to optimally debulk a tumor or, ideally, remove any gross disease has also been shown to increase survival.
    • Each 10% increase in cytoreduction correlates with a 5.5% increase in median survival. The ability to successfully perform optimal cytoreduction ranges from 20% to 90%. Many institutions have recently begun to perform aggressive/ultraradical procedures to achieve this result. Interval cytoreduction may also benefit patients whose initial surgery is suboptimal, especially if the first procedure was performed by a surgeon unfamiliar with the disease. Secondary cytoreduction can increase survival in patients with low-volume disease and a long disease-free interval. All of these procedures should be performed by a specialist trained in ovarian cancer surgery.
  • An en bloc resection of the tumor, according to surgical principle, is not possible in patients with high-stage ovarian cancer.
  • At surgery, large pelvic tumor lesions are found together with multiple tumor lesions involving the omentum, bowel, and mesentery together with a diffuse peritoneal carcinomatosis and diaphragmatic involvement.
  • A multimodality approach with cytoreductive surgery and taxol platinum-based chemotherapy is therefore the mainstay of treatment of advanced ovarian cancer.
  • The size of residual disease after surgery is one of the most important prognostic factors for survival. Patients with an optimal tumor cytoreduction (residual lesions smaller than 1 cm) have a significant longer survival (almost two times the median survival) than patients with larger residual lesions. This holds true even for patients with International Federation of Gynecology and Obstetrics (FIGO) stage IV disease.
  • Patients in whom all macroscopic tumor is resected do have the longest survival.
  • The 2-year survival of patients with a radical resection of all macroscopic tumors is 80%, in contrast to less than 22% for the patients with lesions larger than 2 cm.
  • An optimal primary cytoreductive surgery can generally be performed in 30% to 50% of patients.
  • Only in more experienced gynecologic oncology centers is the percentage as high as 85%, but sometimes at the cost of an increased morbidity and even mortality.
  • The worse prognosis of the patients with a suboptimal primary cytoreductive surgery can be improved by an interval cytoreductive surgery after platinum-containing induction chemotherapy.
  • The median survival and progression-free survivals are significantly lengthened by cytoreductive surgery.
  • After more than 5-years follow-up there is still a significant survival benefit: the 5-year survival of the surgery patients was 24% versus 13% for the no-surgery patients (P = 0.0032).
  • All patients, including those with unfavorable prognostic factors (stage IV disease, peritonitis carcinomatosis, or ascites at primary surgery), and even patients with stable disease after induction chemotherapy, seem to benefit from interval cytoreductive surgery.
  • The increase in progression-free survival and overall survival does outweigh the morbidity associated with interval debulking surgery, which is not different from those associated with primary surgery.0101

Cytoreductive surgery followed by platinum based systemic chemotherapy is an effective treatment for advanced ovarian epithelial carcinoma, resulting in up to 80% complete response (CR) rate; however only 30% of patients reaches 5-year survival.  An "open" intra-abdominal hyperthermic perfusion with 25 mg/m(2)/lt cisplatin of perfusate or 50 mg/m(2)cisplatin plus 15 mg/m(2)doxorubicin was carried out throughout the abdomino-pelvic cavity on 42 patients affected by peritoneal carcinomatosis from ovarian primary, soon after tumor removal en bloc with regional involved peritoneum. Clinical and oncologic data have been prospectively recorded on a dedicated database. RESULTS: Forty-two patients, submitted to peritonectomy, achieved no residual macroscopic disease in 83% of the cases. Hyperthermic chemoperfusion was performed in 95% of the patients. Major complications were observed in 21.4%, being directly correlated to the duration of the surgical procedure (p=0.03). The operative mortality was 4.7%. At a mean follow up of 22 months, the overall 3-year survival was 61.4%, with a median survival of 41 months. Careful selection of patients could reduce surgical risk and further improve survival.0901

New delivery systems for delivering chemotherapy are under development.0501

 

 


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