Surgical cytoreduction of advanced-stage ovarian cancer has long been considered an important tenet of effective management of this disease. Although the sequence of chemotherapy and surgical intervention is debated, there is broad consensus that integration of the two modalities represents the best initial strategy for women with metastatic disease. Retrospective, case-cohort and meta-analysis reports have demonstrated a strong prognostic link between degree of postoperative residual disease and objective clinical and pathological complete response rates, progression-free survival (PFS) and overall survival.1 This relationship is most discriminative between patients with no detectable residual disease, so-called R0 resection, and those with any measure of residual disease.2, 3 Reports show incremental survival benefits among patients with residual disease volumes under 1 cm; however, most studies report limited benefit from a debulking effort if the residual disease cannot be reduced to less than 1 cm.4 As a consequence of these observations, the metric for 'optimal' surgical cytoreduction was defined as no tumour nodules greater than 1 cm.2, 3, 5, 6 However, on the basis of recent data,7 we feel that a strong case can be made for raising the bar for optimal cytoreduction to R0, given the robust prognostic value, lower prevalence, and unambiguous assignment associated with this approach after surgery. Moreover, a personalized surgical approach is desirable to enable rational decision-making with regard to the timing of surgery. We provide a brief overview of the historical progression of primary cytoreduction and definitions of 'optimal' residual disease, highlight current gaps in our knowledge in this regard, and present logical suggestions for personalized surgical approaches for women with advanced-stage ovarian cancer.
24-02-2015 | Ovarian cancer | Article
A framework for a personalized surgical approach to ovarian cancer
Abstract
The standard approach for the treatment of advanced-stage ovarian cancer is upfront cytoreductive surgery followed by a combination of platinum-based and taxane-based chemotherapy. The extent of residual disease following upfront cytoreductive surgery correlates with objective response to adjuvant chemotherapy, rate of pathological complete response at second-look assessment operations, and progression-free survival and overall survival. Contemporary data and meta-analyses indicate a correlation between volume of residual disease and patient outcome, with those patients undergoing complete gross resection having the best outcomes. Thus, attention has focused on surgical efforts to remove as much disease as possible with the metric of 'optimal' cytoreduction being R0 disease. Because patients with R0 resection seem to have the best overall outcomes, preoperative or intraoperative assessment to avoid unnecessary primary debulking surgery has become common. The use of serum CA-125 levels, physical examination and CT imaging have lacked accuracy in determining if disease can be optimally debulked. Therefore, an algorithm that identifies patients in whom complete gross resection at primary surgery is likely to be achieved would be expected to improve patient survival. We discuss contemporary definitions of 'optimal' residual disease, and opportunities to personalize surgical therapy and improve the quality of surgical care.
Nat Rev Clin Oncol 2015; 12: 239–245. doi: 10.1038/nrclinonc.2015.26
Subject terms: Cancer therapy • Ovarian cancer • Prognosis • Surgical oncology