What is the optimal first‑line and overall management for an adult woman with a high‑grade ovarian carcinoma, FIGO stage IVB?

Management of Stage IVB High-Grade Ovarian Carcinoma

For a woman with stage IVB high-grade ovarian carcinoma, maximal surgical cytoreduction followed by carboplatin (AUC 5-7.5) plus paclitaxel (175 mg/m² over 3 hours) every 3 weeks for 6 cycles is the standard treatment approach, with neoadjuvant chemotherapy followed by interval debulking surgery reserved for patients who cannot achieve optimal cytoreduction at initial surgery. 1

Surgical Approach Decision Algorithm

Primary Debulking Surgery (PDS) Candidates

Young patients with good performance status, pleural effusion or parenchymal metastases as the only sites of disease outside the abdominal cavity, small volume metastases, and no major organ dysfunction should undergo upfront maximal cytoreductive surgery. 2, 1

• Surgery must include total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and staging biopsies with the explicit goal of achieving no residual disease 2, 1
• Patients with stage IV disease obtain a survival advantage from maximal surgical cytoreduction at initial laparotomy, though this has not been tested in randomized trials 2, 1
• Research data support this approach: patients achieving optimal primary surgery had median survival of 22.9-27.1 months compared to only 15.1 months for those without cytoreductive surgery 3

Neoadjuvant Chemotherapy (NACT) Followed by Interval Debulking Surgery (IDS)

If initial maximal cytoreduction cannot be achieved due to extensive disease burden or patient factors, confirm diagnosis by biopsy and administer neoadjuvant chemotherapy. 2, 1

• IDS should be performed after 3 cycles of chemotherapy in patients responding to treatment or showing stable disease, followed by 3 additional cycles 2, 1
• Available data suggest survival outcomes may be inferior to successful primary surgery followed by chemotherapy, though one study showed patients receiving NACT followed by surgery had median survival of 45.5 months 2, 3
• Population-based data demonstrate no differences in overall survival between PDS, IDS, and delayed primary surgery groups when no residual tumor is achieved 4

Standard Chemotherapy Regimen

The chemotherapy backbone is carboplatin AUC 5-7.5 plus paclitaxel 175 mg/m² administered over 3 hours every 3 weeks for 6 cycles. 2, 1

• Patients should receive optimal doses based on measured glomerular filtration rate (GFR) and actual body weight; dose reductions for obesity are discouraged 2
• This regimen applies whether given as primary treatment after PDS or as neoadjuvant therapy before IDS 2, 1
• Intraperitoneal chemotherapy should be considered an option in centers with expertise, particularly for patients optimally cytoreduced 2, 1

Response Monitoring

CA-125 Surveillance

Measure serum CA-125 before each cycle of chemotherapy, as levels correlate with tumor response and survival. 2, 1

Imaging Strategy

• For patients with abnormal CT scans at baseline, repeat imaging after cycle 6 unless CA-125 levels are not falling, which warrants earlier CT scanning 2, 1
• Patients with normal baseline CT scans do not require further imaging unless clinical or biochemical progression occurs 2, 1
• An interim CT scan after 3 cycles should be obtained for CA-125-negative patients or when considering interval debulking surgery 2, 1

Maintenance and Extended Therapy Considerations

Current data do not strongly support maintenance/consolidation treatment beyond 6 cycles. 2, 1

• Data for 12 months of paclitaxel maintenance may be discussed with patients regarding potential improvement in progression-free survival, especially in patients with low CA-125 concentrations 2, 1
• Patients with partial response or elevated CA-125 after 6 cycles but continuing evidence of response can receive 3 additional cycles of the same chemotherapy 2, 1

Critical Pitfalls to Avoid

Second-Look Surgery Has No Role

"Second-look" surgery following completion of chemotherapy in patients whose disease appears to be in complete remission shows no evidence of survival benefit and should only be undertaken as part of a clinical trial. 2, 1

Suboptimal Surgery Is Harmful

• Attempting surgical resection when optimal cytoreduction (no residual disease or minimal residue) cannot be achieved delays chemotherapy without survival benefit 1, 5
• The extent of surgery (radical vs. standard) significantly impacts survival, with no residual tumor remaining the primary objective regardless of surgical timing 4
• Research demonstrates that patients treated without cytoreductive surgery had significantly worse median survival (15.1 months) compared to those with any form of debulking surgery 3

Stage-Specific Prognostic Considerations

• Recent research suggests stage IVA (pleural effusion) may have worse prognosis than stage IVB (parenchymal/extra-abdominal metastases), with median OS of 31 vs. 45 months respectively 6
• Initial pleural involvement appears to be a poor prognostic factor with median OS of 35 months versus 49 months for patients without pleural involvement 6