6. SCS in platinum-resistant recurrent ovarian cancer

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

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 achieved or warranted.

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 the patient is symptomatic are important considerations.
