8. Conclusions

The reader should exercise caution in interpreting results from studies for two key reasons; each study will use a different protocol for the index test of interest and secondly the assess-

Several studies have demonstrated that preoperatively raised level of CA125 and HE4 can predict suboptimal debulking [33–35]. Indeed higher platelet count, lower lymphocyte count or higher ratio of platelet to lymphocyte count can predict suboptimal debulking in advanced

Functional imaging such as diffusion weighted MRI and PET-CT are rapidly evolving. The key aspect for imaging should be able to identify the rate limiting steps in relation to cytoreductive surgery. Diseases on small bowel mesentry and bowel serosa are consistently the rate limiting steps in delivering microscopic clearance of the disease. At present there is significant interest in diffusion weighted MRI and a prospective imaging study is underway to delineate the role of multiplanar MRI with CT as compared with standard CT alone in guiding decision making process (ISRCTN51246892). In a recent paper, the dwMRI appears to perform very well in predicting disease map [38]. The role of CT on its own in predicting resectability provides does not provide a consistent acceptable answer particularly as the current standard of 'optimal'

Laparoscopic assessment can be useful adjunct in patient selection. One must acknowledge that a laparoscopic assessment can only provide information regarding the intraperitoneal disease. Fagotti and colleagues have accomplished a body of work regarding the role of laparoscopy in advanced ovarian cancer. Studies have consistently shown that small bowel and its mesentry are common site for the residual disease [27, 31, 42]. Petrillo et al. de on laparoscopic assessment, where unresectability is indicated by a predictive score of greater

It is likely that a combination of metabolic analysis and morphologic characteristics will

In the United Kingdom, the chief medical officer, Professor Dame Sally Davies recommended that 'the Royal College of Obstetricians and Gynaecologists should make sure that subspecialist training in gynaecological oncology equips doctors to perform optimal surgery for

Both modifiable (technical skills, organisation of care) and constitutional (e.g. age, biology, functional status) factors need to be addressed if we are to make incremental improvements in

One approach to this could frame any death from ovarian cancer as an 'error'. With such an approach one can adopt a sophisticated approach to addressing the modifiable factors [44, 45]. Vincent and colleagues articulated seven levels at which an error should be tackled. These are

enhance non-invasive prediction of resectability in the medium future.

gynaecological cancers and reduce mortality from ovarian cancer' [43].

ment of residual disease is not without bias [32].

242 Ovarian Cancer - From Pathogenesis to Treatment

debulking is nil visible disease [39–41].

7. Optimising cytoreductive surgery

the outcomes for our patients.

ovarian cancer [36, 37].

than 8 [31].

At present the grade A evidence reveals no significant difference in the 5 year survival amongst patients receiving either primary or interval debulking surgery for ovarian cancer. It must be borne in mind that the evidence base is not without significant criticism. It is likely that on-going surgical and medical trials in ovarian cancer will alter our management of this heterogeneous entity. Clinicians will appreciate that given the morbidity of cytoreductive surgery, development of this service requires appropriate governance structure.

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How to optimise surgery: will involve better characterisation of the disease through molecular stratification, better selection of patients in terms of physiological fitness (so reduce complications), continued training of surgeons & teams, centralization of service for those who would be best suited for maximal effort surgery.
