From the Guidelines
Cytoreductive surgery should be performed by a gynecologic oncologist and aimed at achieving optimal cytoreduction, with residual tumor nodules less than 1 cm in maximum diameter or thickness, as this has been shown to be associated with a significantly increased overall survival and progression-free survival 1. The primary goal of cytoreductive surgery is to reduce the overall tumor burden, which can improve the effectiveness of subsequent treatments like chemotherapy or radiation. This procedure is most commonly used for cancers that spread within body cavities, such as ovarian cancer, colorectal cancer with peritoneal metastases, and certain gastrointestinal cancers. Some key points to consider when performing cytoreductive surgery include:
- The surgical approach should be comprehensive, including a total abdominal hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and lymphadenectomy of suspicious or enlarged nodes 1.
- The procedure may involve removing portions of affected organs, tissues, or the peritoneum, and extensive resection of upper abdominal ovarian metastases is recommended for patients who can tolerate this surgery 1.
- Minimally invasive procedures may be used to assess whether cytoreductive surgery is feasible and to achieve cytoreduction in select patients 1.
- Optimal cytoreduction is defined as total macroscopic tumor clearance with no residual visible disease, and patients with suboptimally debulked stage IIB–IIIB tumors have a worse outcome than those with completely debulked stage IIIC tumors 1. The effectiveness of cytoreductive surgery depends on achieving optimal cytoreduction, and patients should be aware that this is a complex, lengthy procedure with significant recovery time and potential complications, but it offers meaningful survival benefits for appropriately selected patients with certain advanced cancers when performed by experienced surgical teams. It is also important to note that neoadjuvant chemotherapy may be considered for patients with bulky stage III to IV disease who are not surgical candidates, and the use of primary chemotherapy with interval surgery is becoming more widely accepted and is offered to patients with poor performance status at presentation, low albumin levels, and in those with very extensive tumor dissemination 1.
From the Research
Cytoreductive Surgery Overview
- Cytoreductive surgery is a cornerstone of treatment for advanced ovarian cancer, offering the best chances for overall survival when optimal cytoreduction is achieved 2.
- The goal of cytoreductive surgery is to achieve complete gross resection of all visible macroscopic disease, which is associated with significant survival benefits in patients with advanced ovarian cancer 3, 4.
Predicting Optimal Cytoreduction
- Clinicopathological and radiological models for predicting optimal resectability have not been universally applicable, and more research is needed to devise a set of uniform criteria to predict ovarian cancer resectability among different patient populations 2.
- The rates of optimal cytoreduction vary among surgeons, and a universally applicable clinical model that can predict which patients will undergo optimal cytoreduction remains elusive 2.
Primary vs Interval Cytoreductive Surgery
- Primary cytoreductive surgery and interval cytoreductive surgery are viable treatment options for patients with advanced ovarian cancer, with the choice of approach depending on factors such as disease extent and patient comorbidities 5.
- Some ovarian cancer histotypes, such as low-grade serous and mucinous carcinomas, may be less responsive to neoadjuvant chemotherapy and may benefit from primary cytoreduction with maximal surgical effort 5.
Advanced Surgical Techniques
- The introduction of hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) combined with complete cytoreductive surgery is a promising approach for advanced-stage disease, as well as for recurrent cases 6.
- Extra-abdominal cytoreductive techniques, such as resection of disease within the intrathoracic and inguinal regions, can be safe and feasible in properly selected patients and may benefit appropriately selected patients 3.
Importance of Specialized Centers
- The treatment of ovarian cancer should be performed by an expert oncological surgeon or gynecological oncologist in specialized centers, as clinical and surgical decisions may affect the prognosis 4.