**5. Quality of Life**

*Ovarian Cancer - Updates in Tumour Biology and Therapeutics*

area, if aiming for complete cytoreduction.

had no lymphadenectomy [61].

**Figure 8** illustrates the opening of the right pelvic side wall.

Surgical debulking in ovarian cancer (especially for advanced disease) has traditionally been performed via an open abdominal route. Laparoscopy in advanced ovarian cancer has mostly been used to explore the feasibility of a complete surgical resection [30]. However, there are a few recent studies in the literature, which report complete response to chemotherapy and no gross residual disease after a laparoscopic approach. In the past, concern about the use of laparoscopy included inadequate radicality, the risk of vaginal and/or port site metastasis secondary to

tumour resection at the PH, moreover the resection of PH disease was effective, significantly contributing to a 90% rate of achieving R0. Raspagliese et al. [33, 60], along with this study [33] highlight the importance of routinely exploring the PH

The excision of lymph nodes beyond abdomen and pelvis is controversial, however leaving an enlarged/bulky lymph node despite all other maximal cytoreductive efforts, may mean that no residual disease status was not achieved. Removal of the cardio-phrenic lymph nodes has to be assessed on individual circumstances and localization of the lymph nodes. In the circumstance, that an enlarged pericardiac lymph node is noted, and the gynaecological oncologist is not trained or confident in removing it, then cardiothoracic expertise would be required in order to achieve complete cytoreduction. The Lion study intraoperatively randomly assigned 647 patients with newly diagnosed advanced ovarian cancer (Stage IIB to IV) who had undergone macroscopically complete resection and had normal lymph nodes (both before and during surgery) to either undergo or not undergo lymphadenectomy. In total, 323 had lymphadenectomy whilst 324 did not. The median overall survival was 69.2 months in the non-lymphadenectomy group and 65.5 months in the lymphadenectomy group. The median progression-free survival was 25.5 months in both groups. Postoperative complications were more prevalent in the lymphadenectomy group. Therefore, the Lion study concluded that systematic pelvic and para-aortic lymphadenectomy in patients with advanced ovarian cancer, was not associated with longer overall or progression-free survival but was associated with a higher incidence of postoperative complications, when compared with those who

**102**

**Figure 8.**

*Right pelvic side wall- exposure of lumbosacral and obturator fossae.*

The Quality of Life (QoL) needs to be assessed after such a major and long surgery, which sometimes lasts up to ten hours. QoL questionnaires were sent out to the patients in the Lion study [61]. At the time of discharge, most patients had a poor quality of life, but this improved at follow up (at the end of chemotherapy).

An ultra-radical surgery with the aim of leaving no residual disease (R0) is not successful if the approach to the patient is not holistic; an assessment of whether the patient's quality of life could be improved has to be performed. This surgery should be offered to suitable patients only. Du Bois et al. demonstrated in their study that the benefit was exclusively seen in patients with complete resection (R0) indicating the importance of both the optimal selection of the patients, and of centres with expertise and a high chance of achieving R0 [26, 67, 68].

In ovarian cancer surgery, a multidisciplinary approach is required for successful cytoreductive surgery, keeping the patient at the centre of care.
