Advanced ovarian cancer. Debulking and intervention surgery

Cytoreductive surgery is generally regarded as integral to the management of patients with advanced ovarian cancer, although definitive conclusions about its role have been plagued by the lack of randomized, prospective studies. With the availability of new information, the current status of cytoreductive surgery for epithelial ovarian cancer is reviewed.

Available literature was reviewed, including some data currently published in abstract form only.

Several non-randomized studies of primary cytoreduction have shown that optimal cytoreduction (usually defined as residual nodules < or = 1 cm diameter) can be achieved in the majority of cases, with acceptably low morbidity. Chemoresistant tumours will not benefit from cytoreduction, but these cannot be identified preoperatively. A recent EORTC randomized phase III trial examined the role of intervention cytoreduction after 3 cycles of chemotherapy for patients with > 1 cm residual disease following primary laparotomy. Patients with chemoresistant tumours, who progressed on therapy, were excluded from the study, while the remaining patients were randomized between intervention cytoreduction or 3 further cycles of chemotherapy. Seventy-five percent of patients were randomized. With follow-up data available on 278 patients, median progression-free interval and overall survival were prolonged by 5 and 6 months, respectively, in the surgical arm of the study (p = 0.01). The risk of progression and the overall risk of death were decreased by one third in patients in the surgical arm, and in the multivariate analysis, intervention surgery was an independent prognostic factor for progression-free and overall survival.

The EORTC study of intervention cytoreduction is the first phase III trial ever completed to evaluate the role of cytoreductive surgery in advanced ovarian cancer. The conclusions clearly demonstrate the importance of adequate surgery in the management of such patients.