What is the treatment for cancer of the tubo-ovarian?

Treatment of Tubo-Ovarian Cancer

Tubo-ovarian cancer (including fallopian tube and primary peritoneal cancers) should be treated identically to epithelial ovarian cancer, with primary cytoreductive surgery followed by platinum-based combination chemotherapy. 1

Primary Surgical Management

Standard Surgical Approach

All patients with suspected tubo-ovarian cancer should undergo comprehensive surgical staging and maximal cytoreductive surgery performed by a gynecologic oncologist (Category 1 recommendation). 1

The standard surgical procedure includes: 1

• Total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO) via paramedian or midline incision 1, 2
• Complete infracolic omentectomy 1
• Appendectomy (mandatory for all cases, especially mucinous histology) 1
• Pelvic and para-aortic lymph node assessment with resection of suspicious/enlarged nodes 1
• Peritoneal biopsies from multiple sites including diaphragm, paracolic gutters, bladder peritoneum, and pelvic cul-de-sac 1
• Ascites collection or peritoneal washings for cytologic examination 1

Cytoreductive Surgery Goals

The primary surgical goal is complete resection of all visible disease (R0 resection), which doubles median survival from 17 to 39 months compared to suboptimal cytoreduction. 1

• Optimal cytoreduction is defined as residual disease <1 cm, though complete macroscopic resection (R0) is strongly preferred 1
• Each 10% increase in maximal cytoreduction correlates with a 5.5% increase in median survival 1
• Surgical procedures may include bowel resection (avoiding permanent colostomy when possible), diaphragm stripping, splenectomy, or other organ resections to achieve complete cytoreduction 1

Fertility-Sparing Surgery (Early Stage Only)

For young patients with stage IA disease who desire fertility preservation: 1

• Unilateral salpingo-oophorectomy with preservation of uterus and contralateral ovary may be considered for stage IA, grade 1-2, non-clear cell tumors 1
• Comprehensive surgical staging must still be performed as approximately 30% of patients are upstaged with complete staging 1
• Hysteroscopy and endometrial curettage are mandatory 1

Neoadjuvant Chemotherapy Approach

Neoadjuvant chemotherapy (NACT) with interval debulking surgery (IDS) should be considered for patients who are poor surgical candidates or when optimal cytoreduction appears unlikely at primary surgery. 1

Indications for NACT include: 1

• Advanced age, frailty, or poor performance status
• Significant medical comorbidities
• Advanced disease unlikely to be optimally cytoreduced at primary surgery

The NACT regimen consists of: 1

• 3-4 cycles of upfront platinum-based chemotherapy
• Interval debulking surgery with goal of maximal cytoreduction
• 3-4 additional cycles of postoperative chemotherapy

Systemic Chemotherapy

First-Line Chemotherapy

All patients except those with stage IA grade 1 tumors require adjuvant platinum-based combination chemotherapy. 1, 3

Standard regimens: 3, 4

• Carboplatin (300-360 mg/m² IV) plus paclitaxel every 3-4 weeks
• 6-8 cycles total for advanced disease (stage II-IV) 1
• 3 cycles may be adequate for stage I disease (excluding stage IA grade 1) 1
• Carboplatin can be dosed using AUC formula to account for renal function 3

Maintenance Therapy

Following completion of primary chemotherapy, most patients with advanced-stage disease should receive maintenance therapy with bevacizumab and/or PARP inhibitors. 4

• Patients with BRCA-related gene variants achieve approximately 70% 5-year survival with PARP inhibitor maintenance 4
• Bevacizumab (anti-angiogenesis monoclonal antibody) is an established maintenance option 4

Stage-Specific Outcomes

Early-Stage Disease (Stage I-II)

• 5-year overall survival: 70-95% with surgery and adjuvant chemotherapy 4
• Stage IA grade 1 tumors may be observed without chemotherapy 1

Advanced-Stage Disease (Stage III-IV)

• 5-year overall survival: 10-40% overall 4
• 70% 5-year survival for BRCA-variant patients receiving PARP inhibitors 4
• Approximately 75% experience recurrence within 2 years despite 80% initial remission rate 4

Critical Pitfalls to Avoid

Surgery must be performed by a gynecologic oncologist as this significantly improves outcomes (Category 1 evidence). 1

Incomplete staging is a major error - if initial surgery was inadequate, restaging laparotomy should be performed as soon as possible. 1

Do not use aluminum-containing needles or IV sets with carboplatin as this causes precipitate formation and loss of potency. 3

Avoid permanent colostomy when performing bowel resection for cytoreduction. 1

For mucinous tumors, appendectomy is absolutely mandatory as 8% have appendiceal involvement and primary appendiceal cancer frequently mimics ovarian cancer. 1