Cytoreductive Surgery Goals in Advanced Ovarian Cancer

Thomas C. Krivak, MD:The benefits of cytoreductive surgery—you know for an ovarian cancer optimal outcome, we want a good surgery and response to chemotherapy. And the goals of surgery, I think, are [2-fold]. One is you want to get a full disease assessment, [because] the [CT; computed tomography] scan, PET [positron emission tomography] scan, [and] MRI [magnetic resonance imaging], they’re not going to tell you the whole story. So you want to be able to get into a person’s abdomen and see and visualize exactly how much tumor she has and where it’s located. And then the goal of surgery, once you assess that, is really to resect all visible disease that you can see or feel. Whether it’s in the omentum, the spleen, the liver, on the diaphragm, down in the pelvis.

So with a lot of patients [who] we’ll see with advanced-stage ovarian cancer, especially with the high CA 125 [test], patients who have multiple peritoneal nodules [will] have a lot of tumor potentially on the liver, on the diaphragm. They’ll require diaphragm strippings. At times they’ll require small bowel resections as well as large bowel resection—[even if] it’s a rectosigmoid colectomy, because the ovaries are down in the pelvis, so at times you may find patients who have cancer on their ovaries, cancer on their uterus, as well as down low in the pelvis surrounding the colon. And you still want to be able to go after and surgically resect all that disease, so when you complete your surgery, you can inspect the small intestine, you can inspect the large intestine—whatever residual surfaces that are remaining to ensure that there’s no residual disease.

We always like to think that the earlier you do the surgery, the better the outcomes. And, again, there’s different philosophies on how to do this. How I was trained and I think a lot of people think is, you want to go ahead and start with primary debulking surgery. You want to operate people [and] patients as early as you can. You want to make sure and get them to microscopic disease. Sometimes we call that R0. Sometimes people call it R1. But the bottom line is that I think it’s in the description of what you leave. You can say that I surgically resected all the disease on the diaphragm, the liver, the spleen, down in the pelvis—there is no evidence of disease left; [it’s] basically microscopic. That should be the goal: to try to get the patients to [have] no residual disease.

Again, you always have to temper your surgeries. This patient was 70, she was healthy, so you can be a little more aggressive. But at times you may have somebody who’s 75 who has multiple medical comorbidities in that your operation time may lead to, you know, deconditioning. There are studies out there that try to look at other risk factors such as preoperative albumin to try to help stratify, you know, how aggressive you should be with your surgery. And then when you think you may need to [be] aggressive with the surgery, consider doing chemotherapy—so neoadjuvant chemotherapy—to chemically cytoreduce these patients to go ahead and get them prepared, so you can do an optimal cytoreduction after 3 or 4 cycles of chemotherapy.

I think when you look at patients with this advanced-stage disease, some patients will get primary debulking [and] neoadjuvant chemotherapy as well. And where you do the neoadjuvant chemotherapy, some patients will get 3 cycles of chemotherapy, some people will get 4 cycles of chemotherapy. That’s going to be up to the physician to see how those patients are responding to their treatment. And again, there’s a study out of Canada that looked at using primary cytoreductive surgery followed by—or, I’m sorry, neoadjuvant chemotherapy followed by debulking surgery. And then actually using a combination of intraperitoneal intravenous chemotherapy.

In this patient who [is] 70 years young, has stage IV disease, [and] was not optimally cytoreduced, she was not a candidate really for a combination intravenous intraperitoneal chemotherapy, but there are many different ways we can approach these patients to try to get them through their surgery as well as their chemotherapy.

When I see folks, when I see patients in the office, I tell them, you know, it’s a step-wise process. You want to get a good diagnosis, get them through their surgery, start chemotherapy, get them through their chemotherapy, and really the goal should be to get the patients into remission. Remission is defined as no evidence of disease-based by [CT] scans, CA 125s in [a] physical exam. So to me we see the patients, we give them the differential diagnosis, we plan their treatment—whether it’s surgery followed by chemotherapy or neoadjuvant chemotherapy. And then we want to get them into a complete remission—that should be our goal.

Transcript edited for clarity.

Case: A 70-Year-Old Woman Presenting With Advanced Ovarian Cancer

H & P:

• A 70-year-old woman presents for evaluation of left-ovary mass discovered during a recent pelvic exam. She reports abdominal tenderness, urinary symptoms, and a “bloated” or “full” feeling, despite normal diet and bowel movements
• Postmenopausal, no children
• PE: reveals a woman of low normal weight (BMI = 19 kg/m²) with hypertension; abdomen is distended and shows dullness to percussion
  • BP = 135/80 mm Hg on metoprolol
  • Fasting glucose = 95 mg/dL
  • LDL = 90 mg/dL

Imaging

• CT with contrast of pelvis, abdomen, and chest reveals multiple peritoneal lesions and spread to outside of liver
• Malignant ascites present

Biopsy and labs:

• Pathology: high-grade epithelioid adenosarcoma, ovarian primary
• BRCA1/2status: unknown
• CA-125: 656 U/mL

Treatment

• She underwent hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and tumor debulking; residual disease after cytoreduction: 1.25 cm
• Diagnosis: stage IV ovarian cancer, grade 3
• Started on carboplatin and paclitaxel plus bevacizumab; achieved a partial response
• She was continued on maintenance bevacizumab

Follow up:

• Follow up imaging at 6 months showed disease progression in the liver
• She was started on paclitaxel plus bevacizumab