Resection of Other Metastases Other large masses of tumor located on the parietal peritoneum should be removed, particularly if they are isolated masses and their removal will permit optimal cytoreduction. Resection of extensive disease from the surfaces of the diaphragm is neither practical nor feasible, although solitary metastases may be resected, the diaphragm sutured, and a chest tube placed for a few days (157,158). The use of the Cavitron Ultrasonic Surgical Aspirator (CUSA) and the argon beam coagulator may facilitate resection of small tumor nodules, especially those on ﬂat surfaces (159,160).
There was no randomized prospective study performed to define the value of primary cytoreductive surgery, but all retrospective studies indicate that the diameter of the largest residual tumor nodule before the initiation of chemotherapy is significantly related to progression-free survival in patients with advanced ovarian cancer (163). Quality of life may be significantly enhanced by removal of bulky tumor masses from the pelvis and upper abdomen (166).
An analysis of the retrospective data indicates that, when performed by gynecologic oncologists, successful operations are feasible in 70% to 90% of patients (152,153). Major morbidity is approximately 5% and operative mortality is 1% (156,161,162). Intestinal resection in these patients does not appear to increase the overall morbidity caused by the operation (156).
In a meta-analysis of 81 studies of women who underwent cytoreductive surgery for advanced ovarian cancer, Bristow et al. documented that the extent of debulking correlated with incremental benefits in survival (i.e., the greater the percentage of tumor reduction, the longer the survival). Each 10% increase in cytoreduction equaled a 5.5% increase in median survival (163). Women whose cytoreduction was greater than 75% of their tumor burden had a median survival of 33.9 months compared with 22.7 months for women whose tumors were cytoreduced less than 75% (p < 0.001). The performance of a pelvic and para-aortic lymphadenectomy in patients with stage III disease does not prolong survival, based on the results of a large prospective, randomized trial (164).
A prospective randomized study of “interval” cytoreductive surgery was carried out by the European Organisation for the Research and Treatment of Cancer (EORTC). Interval surgery was performed after three cycles of platinum-combination chemotherapy in patients whose primary attempt at cytoreduction was suboptimal. The initial surgery for most of these patients was not an aggressive attempt to debulk their tumors. Patients in the surgical arm of the study demonstrated a survival benefit when compared with those who did not undergo interval debulking (165). The risk of mortality was reduced by more than 40% in the group that was randomized to the debulking arm of the study. Based on these data, the performance of a debulking operation as early as possible in the course of the patient’s treatment should be considered the standard of care (166).
A prospective phase III study of interval cytoreductive surgery was conducted by the GOG; the patients entered on the trial had a maximal attempt at tumor resection at their initial surgery (167). The randomized findings showed no difference between the patients who had an additional attempt at debulking after three cycles of chemotherapy compared with those who did not. The median survival of the 216 women who underwent interval cytoreduction was 32 months compared with 33 months for the 209 women who did not undergo surgical cytoreduction.