What is Cytoreductive (Debulking) Surgery?
Cytoreductive surgery, also called debulking surgery, is a comprehensive surgical procedure aimed at removing the primary ovarian cancer and all visible metastatic disease, with the goal of achieving complete resection of all macroscopic tumor or, at minimum, reducing residual disease to less than 1 cm in diameter. 1
Primary Goal and Definition
The fundamental objective is complete removal of all gross visible disease, as this approach has been definitively shown to improve overall survival and progression-free survival in patients with advanced ovarian cancer. 1 The extent of residual disease after surgery is one of the most powerful prognostic determinants—more influential than even FIGO stage itself. 1
Evolution of "Optimal" Cytoreduction
- Historical definition (1970s): Reduction to ≤2 cm maximum diameter of individual tumor aggregates 1
- Current standard: Reduction to ≤1 cm diameter of residual disease 1
- Modern goal: Complete macroscopic tumor clearance with no residual visible disease 1
Survival Impact
Each 10% increase in maximal cytoreduction correlates with a 5.5% increase in median survival time. 1 Specifically:
- Median survival with 75% cytoreduction: 37 months 1
- Median survival with 25% cytoreduction: 23 months 1
- Median survival doubles from 17 to 39 months with aggressive optimal cytoreduction 1
Standard Surgical Components
Core Procedures 1
- Total abdominal hysterectomy and bilateral salpingo-oophorectomy
- Omentectomy (removal of all involved omentum)
- Peritoneal washings/ascites collection for cytologic examination
- Resection of all suspicious or enlarged lymph nodes
- Multiple peritoneal biopsies from all abdominal fields
Extended Procedures for Complete Cytoreduction 1
When necessary to achieve complete tumor removal, the following may be performed:
- Bowel resection (required in 30-40% of cases) 2
- Diaphragm or peritoneal surface stripping
- Splenectomy
- Partial hepatectomy
- Radical pelvic dissection
- Cholecystectomy
- Partial gastrectomy or cystectomy
- Ureteroneocystostomy
- Distal pancreatectomy
- Appendectomy (especially for mucinous histology) 1
Clinical Indications
Primary Cytoreduction
Recommended as initial treatment for patients with clinical stage II, III, or IV ovarian cancer. 1 This represents the standard approach in the United States and should be performed by a gynecologic oncologist, as specialist training significantly improves cytoreduction rates without increasing morbidity. 1
Alternative Timing: Neoadjuvant Chemotherapy with Interval Cytoreduction
May be considered for patients with bulky stage III-IV disease who are poor surgical candidates, including those with:
A randomized phase III trial (EORTC-GCG/NCIC CTG) demonstrated equivalent median overall survival (29-30 months) between neoadjuvant chemotherapy followed by interval debulking versus upfront primary surgery, with fewer complications in the neoadjuvant arm. 1 However, upfront debulking surgery remains the preferred treatment in the United States due to concerns about lower overall survival compared to US trials (50 months with primary surgery). 1
Important Caveats
- Surgery must be performed at specialized centers with adequate infrastructure and by gynecologic oncologists trained in aggressive cytoreductive techniques 1
- Pathologic diagnosis must be confirmed (via FNA, biopsy, or paracentesis) before initiating neoadjuvant chemotherapy 1
- The value of systematic lymphadenectomy in advanced disease remains controversial; currently, only bulky lymph nodes should be removed as part of achieving maximum cytoreduction 1
- "Second look" surgery after treatment completion is obsolete and should not be performed 1
Recurrent Disease Setting
In recurrent ovarian cancer, secondary or tertiary cytoreduction may benefit highly selected patients only when complete tumor resection can be achieved. 1 Favorable prognostic factors include complete resection at first surgery, good performance status, and absence of ascites. 1