The primary surgical treatment for stage I epithelial ovarian cancer is surgical, and patients should undergo total abdominal hysterectomy, bilateral salpingo-oophorectomy, and surgical staging (132,133). In certain circumstances, a unilateral salpingo-oophorectomy may be performed. Based on the findings at surgery and the pathologic evaluation, patients with stage I ovarian cancer can be grouped into low-risk and high-risk categories (Table 37.3).
Table 37.3 Prognostic Variables in Early-Stage Epithelial Ovarian Cancer
Modified from Berek JS, Hacker NF. Berek & Hacker’s Gynecologic Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:458,with permission.
Fertility Preservation in Early-Stage Ovarian Cancer For patients who underwent a thorough staging laparotomy and who have no evidence of spread beyond the ovary, abdominal hysterectomy and bilateral salpingo-oophorectomy are appropriate therapy. The uterus and the contralateral ovary can be preserved in women with stage IA, grade 1 to 2 disease who desire to preserve fertility. The conditions of the women should be monitored carefully with routine periodic pelvic examinations and determinations of serum CA125 levels. Generally, the other ovary and the uterus are removed at the completion of childbearing.
Guthrie et al. studied the outcome of 656 patients with early-stage epithelial ovarian cancer (140). No untreated patients who had stage IA, grade 1 cancer died of their disease; thus, adjuvant radiation and chemotherapy are unnecessary. Furthermore, the Gynecologic Oncology Group (GOG) carried out a prospective, randomized trial of observation versus melphalan for patients with stage IA and IB, grade 1 or 2 disease (114). Five-year survival for each group was 94% and 96%, respectively, confirming that no further treatment is needed for such patients.
Patients who have more poorly differentiated disease or who have malignant cells, either in ascites ﬂuid or in peritoneal washings, must undergo complete surgical staging (3). The surgery should include the performance of a hysterectomy and bilateral salpingo-oophorectomy in addition to the staging laparotomy. Although the optimal supportive therapy for these patients is not known, most patients are treated with chemotherapy, as outlined below.
The surgical management of all patients with advanced-stage disease is approached in a similar manner, with modifications made in response to the overall status and general health of the patient and the extent of residual disease present at the time treatment is initiated. A treatment scheme is outlined in Figure 37.10. Most patients subsequently receive combination chemotherapy for an empiric number of cycles.
If the patient is medically stable, she should undergo cytoreductive surgery to remove as much of the tumor and its metastases as possible (144–171). The operation to remove the primary tumor and the associated metastatic disease is referred to as debulking or cytoreductive surgery. The operation typically includes the performance of a total abdominal hysterectomy and bilateral salpingo-oophorectomy, along with a complete omentectomy and resection of any metastatic lesions from the peritoneal surfaces or from the intestines. The pelvic tumor often directly involves the rectosigmoid colon, the terminal ileum, and the cecum
Primary cytoreductive surgery* Optimal debulking  microscopic or <1 cm residual Nonoptimal debulking or s/p neoadjuvant chemotherapy Chemotherapy 3 cycles Chemotherapy 3–5 cycles Chemotherapy 6–8 cycles Consider interval surgical cytoreduction No clinical evidence of disease More chemotherapy, experimental protocols, or palliative care Progressive disease Progressive disease Second-line chemotherapy+ Observation vs. maintenance treatment
Figure 37.10 Treatment scheme for patients with advanced-stage ovarian cancer.