Surgical cytoreduction in ovarian cancer

The majority of ovarian cancer patients present with advanced-stage disease, for which the goal of surgery is not only to document the extent of disease but also to perform surgical cytoreduction or tumor debulking. Cytoreductive surgery for ovarian cancer is generally performed at the time of diagnosis, when it is referred to as primary cytoreduction. It is also performed during primary chemotherapy (interval cytoreduction) and after disease recurrence (secondary cytoreduction). Over the past 3 decades, numerous retrospective analyses have established the role of primary cytoreduction in the management of advanced-stage ovarian cancer. However, recent studies have reported that certain patients benefit from a neoadjuvant chemotherapeutic approach, in which chemotherapy is given to those with presumed advanced ovarian cancer prior to cytoreductive surgery. Although several theoretical advantages of this approach over primary cytoreduction have been reported, significant concerns remain. The role of neoadjuvant chemotherapy is being investigated in a randomized study currently being conducted by the European Organization for the Research and Treatment of Cancer (EORTC) and the National Cancer Institute of Canada. The benefit of interval cytoreduction was investigated in two randomized prospective trials conducted by the EORTC and the Gynecologic Oncology Group (GOG). Final results were somewhat conflicting, but both studies supported an extensive attempt at surgical cytoreduction during primary therapy. In the management of recurrent disease, the majority of retrospective studies demonstrate a benefit to secondary cytoreduction. The GOG is currently attempting to better define the role of secondary cytoreduction in a prospective, randomized trial.