Dennis S. Chi, MD

Cytoreductive Surgery Is the Best Way to Affect Survival Outcomes

The majority of ovarian cancer patients present with advanced-stagedisease, for which the goal of surgery is not only to document the extentof disease but also to perform surgical cytoreduction or tumordebulking. Cytoreductive surgery for ovarian cancer is generally performedat the time of diagnosis, when it is referred to as primarycytoreduction. It is also performed during primary chemotherapy (intervalcytoreduction) and after disease recurrence (secondarycytoreduction). Over the past 3 decades, numerous retrospective analyseshave established the role of primary cytoreduction in the managementof advanced-stage ovarian cancer. However, recent studies havereported that certain patients benefit from a neoadjuvant chemotherapeuticapproach, in which chemotherapy is given to those with presumedadvanced ovarian cancer prior to cytoreductive surgery. Althoughseveral theoretical advantages of this approach over primarycytoreduction have been reported, significant concerns remain. Therole of neoadjuvant chemotherapy is being investigated in a randomizedstudy currently being conducted by the European Organizationfor the Research and Treatment of Cancer (EORTC) and the NationalCancer Institute of Canada. The benefit of interval cytoreduction wasinvestigated in two randomized prospective trials conducted by theEORTC and the Gynecologic Oncology Group (GOG). Final resultswere somewhat conflicting, but both studies supported an extensiveattempt at surgical cytoreduction during primary therapy. In the managementof recurrent disease, the majority of retrospective studies demonstratea benefit to secondary cytoreduction. The GOG is currentlyattempting to better define the role of secondary cytoreduction in aprospective, randomized trial.

One of the cornerstones of gynecologic cancer surgery is the assessment and removal of the retroperitoneal lymph nodes. Numerous reports have demonstrated that, when performed by highly skilled individuals, laparoscopic