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{{Ovarian cancer}}
{{Ovarian cancer}}
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==Overview==
==Overview==
[[Surgery]] is the preferred treatment and is frequently necessary to obtain a tissue specimen for differential [[diagnosis]] via its [[histology]]. Surgery performed by a specialist in [[gynecologic oncology]] usually results in an improved result. Improved survival is attributed to more accurate staging of the disease and a higher rate of aggressive surgical excision of tumor in the abdomen by gynecologic oncologists as opposed to general gynecologists and general surgeons.
[[Surgery]] is the preferred [[treatmen]]<nowiki/>t and is frequently necessary to obtain a tissue specimen for differential [[diagnosis]] via its [[histology]]. [[Surgery]] performed by a specialist in [[gynecologic oncology]] usually results in an improved result. Improved survival is attributed to more accurate staging of the disease and a higher rate of aggressive [[surgical]] [[excision]] of [[tumor]] in the [[abdomen]] by [[Gynecologic oncologist|gynecologic oncologists]] as opposed to general [[Gynecologist|gynecologists]] and general [[surgeons]].


==Surgical Therapy==
==Surgical Therapy==
The type of surgery depends upon how widespread the cancer is when diagnosed (the cancer stage), as well as the presumed type and grade of cancer. The surgeon may remove one (unilateral oophorectomy) or both ovaries (bilateral oophorectomy), the fallopian tubes (salpingectomy), and the uterus (hysterectomy). For some very early tumors (stage 1, low grade or low-risk disease), only the involved ovary and fallopian tube will be removed (called a "unilateral salpingo-oophorectomy," USO), especially in young females who wish to preserve their fertility. In advanced [[malignancy]], where complete resection is not feasible, as much tumor as possible is removed (debulking surgery). In cases where this type of surgery is successful (i.e. < 1 cm in diameter of tumor is left behind ["optimal debulking"]), the prognosis is improved compared to patients where large tumor masses (> 1 cm in diameter) are left behind.  [[Minimally invasive]] surgical techniques may facilitate the safe removal of very large (greater than 10 cm) tumors with fewer complications of surgery.<ref>{{cite journal
| author = Ehrlich PF, Teitelbaum DH, Hirschl RB, Rescorla F
| title = Excision of large cystic ovarian tumors: combining minimal invasive surgery techniques and cancer surgery--the best of both worlds.
| journal = J. Pediatr. Surg.
| volume = 42
| issue = 5
| pages = 890-3
| year = 2007
| pmid = 17502206
| doi = 10.1016/j.jpedsurg.2006.12.069
| issn =
}}</ref>


 
Surgical managements depends on the status of the patient, grading and staging of the tumor: <ref name="pmid11870167">{{cite journal| author=Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ| title=Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis. | journal=J Clin Oncol | year= 2002 | volume= 20 | issue= 5 | pages= 1248-59 | pmid=11870167 | doi=10.1200/JCO.2002.20.5.1248 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11870167  }}</ref><ref name="pmid16714056">{{cite journal| author=Chi DS, Eisenhauer EL, Lang J, Huh J, Haddad L, Abu-Rustum NR et al.| title=What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? | journal=Gynecol Oncol | year= 2006 | volume= 103 | issue= 2 | pages= 559-64 | pmid=16714056 | doi=10.1016/j.ygyno.2006.03.051 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16714056  }} </ref><ref name="pmid23747291">{{cite journal| author=Chang SJ, Hodeib M, Chang J, Bristow RE| title=Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis. | journal=Gynecol Oncol | year= 2013 | volume= 130 | issue= 3 | pages= 493-8 | pmid=23747291 | doi=10.1016/j.ygyno.2013.05.040 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23747291  }} </ref><ref name="pmid7835815">{{cite journal| author=Hoskins WJ| title=Epithelial ovarian carcinoma: principles of primary surgery. | journal=Gynecol Oncol | year= 1994 | volume= 55 | issue= 3 Pt 2 | pages= S91-6 | pmid=7835815 | doi=10.1006/gyno.1994.1346 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7835815  }} </ref><ref name="pmid8305389">{{cite journal| author=Redman CW, Warwick J, Luesley DM, Varma R, Lawton FG, Blackledge GR| title=Intervention debulking surgery in advanced epithelial ovarian cancer. | journal=Br J Obstet Gynaecol | year= 1994 | volume= 101 | issue= 2 | pages= 142-6 | pmid=8305389 | doi=10.1111/j.1471-0528.1994.tb13080.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8305389  }} </ref><ref name="pmid16876853">{{cite journal| author=Eisenkop SM, Spirtos NM, Lin WC| title="Optimal" cytoreduction for advanced epithelial ovarian cancer: a commentary. | journal=Gynecol Oncol | year= 2006 | volume= 103 | issue= 1 | pages= 329-35 | pmid=16876853 | doi=10.1016/j.ygyno.2006.07.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16876853  }} </ref><ref name="pmid7845426">{{cite journal| author=van der Burg ME, van Lent M, Buyse M, Kobierska A, Colombo N, Favalli G et al.| title=The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer. | journal=N Engl J Med | year= 1995 | volume= 332 | issue= 10 | pages= 629-34 | pmid=7845426 | doi=10.1056/NEJM199503093321002 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7845426  }} </ref><ref name="pmid15590951">{{cite journal| author=Rose PG, Nerenstone S, Brady MF, Clarke-Pearson D, Olt G, Rubin SC et al.| title=Secondary surgical cytoreduction for advanced ovarian carcinoma. | journal=N Engl J Med | year= 2004 | volume= 351 | issue= 24 | pages= 2489-97 | pmid=15590951 | doi=10.1056/NEJMoa041125 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15590951  }} </ref>
Early-Stage Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment
*Early-Stage [[Ovarian]] Epithelial, [[Fallopian tube]], and Primary [[Peritoneal]] Cancer  
Treatment options:
**If the [[tumor]] is well differentiated or moderately well differentiated, [[surgery]] alone may be adequate [[treatment]] for patients with stage IA and IB disease.
 
**Surgery should include [[hysterectomy]], [[bilateral]] [[salpingo-oophorectomy]], and omentectomy. Additionally, the undersurface of the [[diaphragm]] should be visualized and biopsied
If the tumor is well differentiated or moderately well differentiated, surgery alone may be adequate treatment for patients with stage IA and IB disease. Surgery should include hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. Additionally, the undersurface of the diaphragm should be visualized and biopsied; pelvic and abdominal peritoneal biopsies and pelvic and para-aortic lymph node biopsies are required and peritoneal washings should be obtained routinely. In selected patients who desire childbearing and have grade I tumors, unilateral salpingo-oophorectomy may be associated with a low risk of recurrence.
**[[Pelvic]] and [[abdominal]] [[peritoneal]] [[biopsies]] and [[pelvic]] and [[Paraaortic lymph nodes|paraaortic lymph node]] biopsies are required and [[peritoneal]] washings should be obtained routinely.  
If the tumor is grade III, densely adherent, or stage IC, the chance of relapse and death from ovarian cancer is as much as 30%. Clinical trials evaluating the following treatment approaches have been performed:
**In selected patients who desire childbearing and have grade I [[tumors]], unilateral [[salpingo-oophorectomy]] may be associated with a low risk of recurrence.
Intraperitoneal P-32 or radiation therapy.
*Primary surgical cytoreduction.
Systemic chemotherapy based on platinums alone or in combination with alkylating agents.
**Patients diagnosed with stage III and stage IV disease are treated with [[surgery]] and [[chemotherapy]]; however, the outcome is generally less favorable for patients with stage IV disease.  
Systemic chemotherapy based on platinums with paclitaxel.
**The role of surgery for patients with stage IV disease is unclear, but in most instances, the bulk of the disease is [[Intra-abdominal|intra-abdominal,]] and surgical procedures similar to those used in the management of patients with stage III disease are applied.  
 
**The options for [[intraperitoneal]] (IP) regimens are also less likely to apply both practically (as far as inserting an IP catheter at the outset) and theoretically (aimed at destroying [[microscopic]] disease in the [[peritoneal cavity]]) in patients with stage IV disease.
Primary surgical cytoreduction
*Advanced-Stage Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer
 
**[[Surgery]] has been used as a therapeutic modality and also to adequately stage the disease.  
Patients diagnosed with stage III and stage IV disease are treated with surgery and chemotherapy; however, the outcome is generally less favorable for patients with stage IV disease. The role of surgery for patients with stage IV disease is unclear, but in most instances, the bulk of the disease is intra-abdominal, and surgical procedures similar to those used in the management of patients with stage III disease are applied. The options for intraperitoneal (IP) regimens are also less likely to apply both practically (as far as inserting an IP catheter at the outset) and theoretically (aimed at destroying microscopic disease in the peritoneal cavity) in patients with stage IV disease.
**[[Surgery]] should include total [[abdominal]] [[hysterectomy]] and [[bilateral]] [[salpingo-oophorectomy]] with omentectomy and [[debulking]] of as much gross [[tumor]] as can safely be performed. While primary cytoreductive surgery may not correct for [[biologic]] characteristics of the [[tumor]], considerable evidence indicates that the volume of disease left at the completion of the primary surgical procedure is related to patient survival.
 
*Adjuvant Therapy
Advanced-Stage Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment
**For patients unable to undergo surgery, or for those with greater than 1 cm residual disease following surgery, IV [[chemotherapy]] is the standard.  
Surgery has been used as a therapeutic modality and also to adequately stage the disease. Surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as can safely be performed. While primary cytoreductive surgery may not correct for biologic characteristics of the tumor, considerable evidence indicates that the volume of disease left at the completion of the primary surgical procedure is related to patient survival.[1] A literature review showed that patients with optimal cytoreduction had a median survival of 39 months compared with survival of only 17 months in patients with suboptimal residual disease.
**The foundation is the [[platinum]] agents: [[cisplatin]], or its second-generation analog, [[carboplatin]], given either alone or in combination with other drugs.
 
Adjuvant Therapy
 
For patients unable to undergo surgery, or for those with greater than 1 cm residual disease following surgery, IV chemotherapy is the standard. The foundation is the platinum agents: cisplatin, or its second-generation analog, carboplatin, given either alone or in combination with other drugs. Trials by various cooperative groups in the subsequent two decades addressed issues of optimal dose-intensity [13-15] for both cisplatin and carboplatin,[16] schedule,[17] and the equivalent results obtained with either of these platinum drugs, usually in combination with cyclophosphamide.[18] With the introduction of the taxane paclitaxel, two trials confirmed the superiority of cisplatin combined with paclitaxel to the previous standard of cisplatin plus cyclophosphamide; however, two trials that compared the agent with either cisplatin or carboplatin as a single agent failed to confirm such superiority in all outcome parameters (i.e., response, time-to-progression, and survival) (see Table 2).
 
Nevertheless, for patients with ovarian cancer, the combination of cisplatin or carboplatin and paclitaxel has been used as the initial treatment (defined as induction chemotherapy) for several reasons:
 
GOG-132 was regarded by many as showing that sequential treatment with cisplatin and paclitaxel was equivalent to the combination because many patients crossed over before progression; moreover, the cisplatin-only arm was more toxic because it utilized a 100 mg/m2 dose.
The Medical Research Council (MRC-ICON3) study, while having fewer early crossovers, could be interpreted similarly in regard to the impact on survival of sequential treatment.
Data from MRC-ICON4 have shown a survival advantage for patients treated with the combination treatment regimen versus those treated with single-agent carboplatin upon recurrence (see Table 2).
In past trials, single-agent platinums were not superior to platinum combined with an alkylating agent; therefore, the explanation of a detrimental effect of cyclophosphamide is unlikely.


==References==
==References==
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Latest revision as of 15:55, 13 September 2019

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: , Huda A. Karman, M.D.

Overview

Surgery is the preferred treatment and is frequently necessary to obtain a tissue specimen for differential diagnosis via its histology. Surgery performed by a specialist in gynecologic oncology usually results in an improved result. Improved survival is attributed to more accurate staging of the disease and a higher rate of aggressive surgical excision of tumor in the abdomen by gynecologic oncologists as opposed to general gynecologists and general surgeons.

Surgical Therapy

Surgical managements depends on the status of the patient, grading and staging of the tumor: [1][2][3][4][5][6][7][8]

  • Early-Stage Ovarian Epithelial, Fallopian tube, and Primary Peritoneal Cancer
  • Primary surgical cytoreduction.
    • Patients diagnosed with stage III and stage IV disease are treated with surgery and chemotherapy; however, the outcome is generally less favorable for patients with stage IV disease.
    • The role of surgery for patients with stage IV disease is unclear, but in most instances, the bulk of the disease is intra-abdominal, and surgical procedures similar to those used in the management of patients with stage III disease are applied.
    • The options for intraperitoneal (IP) regimens are also less likely to apply both practically (as far as inserting an IP catheter at the outset) and theoretically (aimed at destroying microscopic disease in the peritoneal cavity) in patients with stage IV disease.
  • Advanced-Stage Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer
    • Surgery has been used as a therapeutic modality and also to adequately stage the disease.
    • Surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as can safely be performed. While primary cytoreductive surgery may not correct for biologic characteristics of the tumor, considerable evidence indicates that the volume of disease left at the completion of the primary surgical procedure is related to patient survival.
  • Adjuvant Therapy
    • For patients unable to undergo surgery, or for those with greater than 1 cm residual disease following surgery, IV chemotherapy is the standard.
    • The foundation is the platinum agents: cisplatin, or its second-generation analog, carboplatin, given either alone or in combination with other drugs.

References

  1. ↑ Bristow RE, Tomacruz RS, Armstrong DK, Trimble EL, Montz FJ (2002). "Survival effect of maximal cytoreductive surgery for advanced ovarian carcinoma during the platinum era: a meta-analysis". J Clin Oncol. 20 (5): 1248–59. doi:10.1200/JCO.2002.20.5.1248. PMID 11870167.
  2. ↑ Chi DS, Eisenhauer EL, Lang J, Huh J, Haddad L, Abu-Rustum NR; et al. (2006). "What is the optimal goal of primary cytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)?". Gynecol Oncol. 103 (2): 559–64. doi:10.1016/j.ygyno.2006.03.051. PMID 16714056.
  3. ↑ Chang SJ, Hodeib M, Chang J, Bristow RE (2013). "Survival impact of complete cytoreduction to no gross residual disease for advanced-stage ovarian cancer: a meta-analysis". Gynecol Oncol. 130 (3): 493–8. doi:10.1016/j.ygyno.2013.05.040. PMID 23747291.
  4. ↑ Hoskins WJ (1994). "Epithelial ovarian carcinoma: principles of primary surgery". Gynecol Oncol. 55 (3 Pt 2): S91–6. doi:10.1006/gyno.1994.1346. PMID 7835815.
  5. ↑ Redman CW, Warwick J, Luesley DM, Varma R, Lawton FG, Blackledge GR (1994). "Intervention debulking surgery in advanced epithelial ovarian cancer". Br J Obstet Gynaecol. 101 (2): 142–6. doi:10.1111/j.1471-0528.1994.tb13080.x. PMID 8305389.
  6. ↑ Eisenkop SM, Spirtos NM, Lin WC (2006). ""Optimal" cytoreduction for advanced epithelial ovarian cancer: a commentary". Gynecol Oncol. 103 (1): 329–35. doi:10.1016/j.ygyno.2006.07.004. PMID 16876853.
  7. ↑ van der Burg ME, van Lent M, Buyse M, Kobierska A, Colombo N, Favalli G; et al. (1995). "The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer". N Engl J Med. 332 (10): 629–34. doi:10.1056/NEJM199503093321002. PMID 7845426.
  8. ↑ Rose PG, Nerenstone S, Brady MF, Clarke-Pearson D, Olt G, Rubin SC; et al. (2004). "Secondary surgical cytoreduction for advanced ovarian carcinoma". N Engl J Med. 351 (24): 2489–97. doi:10.1056/NEJMoa041125. PMID 15590951.


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