7. Chemotherapy or surgery as initial treatment for ROC

In an early study [43], a less favourable outcome from secondary surgical cytoreduction was reported if this was preceded by second-line chemotherapy. This was not found in a later study [56] on a small number of patients. However, if second-line chemotherapy has been given and there has been disease progression, in general there would be a greater reluctance to operate. This sequence of management of initial chemotherapy has been proposed as a means to case select for secondary cytoreduction as only those showing a response should undergone surgery. Bulky disease has been considered an adverse factor in those undergoing surgery for ROC, but only in a few reports; Eisenkop et al. [43, 44] reported on patients with tumour mass more than and less than 10 cm and Onda et al. reported [45] a poorer outcome from surgery with tumour masses greater than 6 cm. Perhaps not surprising that amongst all patients treated initially with chemotherapy for ROC, those who do better are those who also have more favourable factors for surgery—such as longer DFI, good performance status and small volume disease. As with surgery, predictive models for response and outcome for patients treated with chemotherapy for ROC have been described. In the model proposed by Lee et al. [22], CA125 level (≤ 100 IU/l or > 100 IU/l) was assessed as was largest tumour size (<5 cm or >5 cm) but the role of secondary cytoreductive surgery was not assessed. Different managements of ROC may be appropriate in a particular patient but in patients with favourable factors, secondary cytoreductive surgery (with or without chemotherapy) results in a better outcome (overall survival) than chemotherapy alone [24, 30, 33], although level I evidence on overall survival benefit is awaited [49]. In a large retrospective study on ROC in which patients were treated with chemotherapy alone or with cytoreductive surgery and chemotherapy, the latter group had improved overall survival, but only in those with no residual disease or smaller volume residual disease [57].

there is likely to be a significant selection bias in the surgical studies on ROC [52]. Most reports have not addressed quality of life (QoL) issues, but in one report [27], no difference was found to be in QoL in patients with ROC who had chemotherapy alone and those who had surgery and

This subgroup of patients has a poor prognosis and more recently bevacizumab has been used as part of second-line treatment. With the associated operative morbidity and possible negative impact on QoL of major surgery in these patients, there has been understandable reluctance both from surgeons and patients to undertake surgery. Where there has been initial suboptimal cytoreduction the surgical goal of complete CSC is rarely achieved, if one extrapolates from the results of Rose et al. [53] in primary disease. A key finding in that study was the training and skill of the surgeon who performed the primary surgery—a gynaecological oncologist whose goal was complete cytoreduction, or a non-specialist surgeon. Case selection for surgery in ROC is also influenced by the patient's performance status, the number of and sites of metastasis and in these cases obtaining the operative report from the initial surgery is often instructive. The practice in the UK is more towards non-surgical management of recurrent disease in platinum-resistant cases. A more common clinical situation is the patient with persistent but stable disease after primary treatment, in whom the disease progresses. In these patients, elective surgery with the goal of achieving complete clearance of disease is most unlikely to be achieved if the original surgery by a gynaecological oncologist was suboptimal

6. SCS in platinum-resistant recurrent ovarian cancer

and in such cases the recommended treatment is second-line chemotherapy.

the patient is symptomatic are important considerations.

7. Chemotherapy or surgery as initial treatment for ROC

Nevertheless, there are some patients who were disease free at completion of treatment for primary disease and have recurrent disease at one or a few sites within 6 months of completing treatment and in whom secondary cytoreductive surgery may be an option [41, 54, 55] and may enhance the otherwise limited response to chemotherapy. Whether or not there is a role for initial laparoscopic assessment is unclear and practices vary. Treatment alternatives must be discussed including palliative care [15]. In other clinical situations, a decision may be made to operate on a patient to remove a large mass that is symptomatic even if CSC cannot be

A less common EOC is the low grade serous carcinoma, which typically is less chemosensitive and runs a more indolent course than the high grade serous carcinoma. Often in recurrent disease, there is calcification which can render surgical resection more difficult. Given these usual clinical features there more often is recourse to secondary cytoreductive surgery [56]. This is an individual decision and the pace of growth of the tumour site(s) and whether or not

In an early study [43], a less favourable outcome from secondary surgical cytoreduction was reported if this was preceded by second-line chemotherapy. This was not found in a later

chemotherapy.

282 Ovarian Cancer - From Pathogenesis to Treatment

achieved or warranted.
