*In selected cases of Stage IIIc/IV disease, neoadjuvant chemotherapy may be given, and then an interval cytoreductive surgery is performed after 3 cycles. +Chemotherapy depends on whether platinum-sensitive or platinum-resistant. (Modified from Berek JS, Hacker NF. Berek & Hacker’s Gynecologic Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:460, with permission.)
CHAPTER 37 Ovarian, Fallopian Tube, and Peritoneal Cancer
Figure 37.11 Extensive ovarian carcinoma involving the bladder, rectosigmoid, and ileocecal area. (Redrawn from Heintz APM, Berek JS. Cytoreductive surgery for ovarian carcinoma. In: Piver MS, ed. Ovarian malignancies. Edinburgh, UK: Churchill Livingstone, 1987:134, with permission.) (Fig. 37.11). In a minority of patients, most or all of the disease is confined to the pelvic viscera and the omentum, so that removal of these organs will result in extirpation of all gross tumor, a situation that is associated with a reasonable chance of prolonged progression-free survival.
The removal of bulky tumor masses may reduce the volume of ascites present. Often, ascites will disappear after removal of the primary tumor and a large omental “cake.” Removal of the omental cake may alleviate the nausea and early satiety that many patients experience. Removal of intestinal metastases may restore adequate intestinal function and improve the overall nutritional status of the patient, thereby facilitating the patient’s ability to tolerate subsequent chemotherapy.
A large, bulky tumor may contain areas that are poorly vascularized, and these areas will be exposed to suboptimal concentrations of chemotherapeutic agents. Similarly, these areas are poorly oxygenated, so that radiation therapy, which requires adequate oxygenation to achieve maximal cell kill, will be less effective. Surgical removal of these bulky tumors may eliminate areas that could be relatively resistant to radiation and chemotherapeutic treatment.
Larger tumor masses tend to be composed of a higher proportion of cells that are either non-dividing or in the “resting” phase (i.e., G0 cells, which are essentially resistant to the therapy). A low growth fraction is characteristic of bulky tumor masses, and cytoreductive surgery can result in smaller residual masses with a relatively higher growth fraction.
Goals of Cytoreductive Surgery The principal goal of cytoreductive surgery is removal of all of the primary cancer and, if possible, all metastatic disease. If resection of all metastases is not feasible, the goal is to reduce the tumor burden by resection of all individual tumors to an optimal status. Griffiths initially proposed that all metastatic nodules should be reduced to less
Figure 37.12 Survival of patients with stage IIIC epithelial ovarian cancer based on the maximal size of residual tumor after exploratory laparotomy and tumor resection. (From Heintz APM, Odicino F, Maisonneuve P, et al. Carcinoma of the ovary. Twenty-sixth annual report of the results of treatment of gynaecological cancer. Int J Gynecol Oncol 2006;95(suppl 1):S161–S192, with permission.) than 1.5 cm in maximal diameter and showed that survival was significantly longer in patients for whom this was achieved (144).