11. Surgery for second recurrence and beyond

There are fewer reports on the role of surgery for second, third, etc. relapse of EOC. Intuitively the factors that are important in surgical decision making for first recurrence should also be important in surgical decision making in patients with second and subsequent recurrence. It is clear too that if surgery is contemplated for such relapses the patients are highly selected and more often than not surgical intervention will be for palliation (e.g. bowel obstruction) rather than for complete cytoreduction. More usually in clinical practice patients with second and subsequent relapse will be treated with chemotherapy or other drug therapy. The paucity of cases and reports on tertiary cytoreduction emphasises the uncommon clinical scenario of a patient with second relapse of EOC undergoing surgery. In a multi-centre retrospective review of 406 patients [84], based over a 16-year period, it was reported that residual tumour after secondary and tertiary surgery was an important prognostic factor and surgical outcome was compromised by ascites and upper abdominal disease. Avras et al. [85] reported that the surgical goal, as with first recurrence, should be complete cytoreduction as this improved overall survival. The usual factors to be considered for surgery in recurrent disease with the goal of complete cytoreduction, such as disease-free interval, were reported but they also found an association with increased size of recurrent disease and reduced benefit from surgery. Another report highlighted the importance of case selection and maximixing cytoreduction [86]. No QoL data were presented in these papers.

teratoma syndrome. The more usual indication for surgery is to remove a symptomatic mass or a growing mass that is causing pressure symptoms (the growing teratoma syndrome). In such cases, the focus of surgery in the typical young patient, with fertility preservation necessary, is not complete cytoreduction but resection of the symptomatic mass. A less common clinical problem is of peritoneal disease with mature glial tissue—gliomatosis peritoneii, which most often has a very indolent course. Typically the initial primary surgery has been fertility preserving. With relapsed disease, which may be in the pelvis or disseminated, including involvement of the retroperitoneal lymph nodes, it is important to determine whether the relapsed disease is mature or immature teratoma, and although both pathologies may be present the more common is mature teratoma [93]. For gliomatosis peritoneii, which is of different grades, surgery should be in symptomatic patients only, the goal is palliation and not complete cytoreduction, which is most often not feasible. When secondary surgery is undertaken for recurrent disease the reproductive organs should be preserved if possible (including the uterus). The surgical goal is cytoreduction with fertility preservation, and it is reasonable to leave small volume disease on

Surgery for Recurrent Ovarian Cancer http://dx.doi.org/10.5772/intechopen.71587 287

Most patients with OC present with late stage disease and most are destined to develop recurrence and to die of disease. Consideration needs to be given as to how recurrence is diagnosed and whether the patient is asymptomatic or symptomatic. The majority of data on ROC is from studies on EOC, but the role of secondary surgery is influenced by the histologic subtypes of OC. Patients treated with second-line chemotherapy tend to have less favourable features than those treated initially with surgery. In non-randomised studies, where there is likely selection bias, usually showed a benefit in overall survival from secondary cytoreductive surgery compared to chemotherapy alone. Consistently non-randomised studies report that the benefit of surgery in terms of DFI and survival is seen only in patients with complete surgical cytoreduction. Only one of three current randomised trials has reported preliminary data which show a benefit from surgery and data on overall survival are awaited. As complete surgical cytoreduction at primary surgery is an important factor in improved outcome from primary treatment and from secondary treatment, patients with primary OC should be managed in specialist units where complete cytoreduction is achieved in the majority of patients. There may be a benefit from ip chemotherapy or HIPEC following cytoreductive surgery for

the one remaining ovary.

ROC but level one evidence is needed.

Address all correspondence to: dbarton@sgul.ac.uk

The Royal Marsden Hospital, London, United Kingdom

Author details

Desmond PJ Barton

13. Conclusion
