1. Introduction

The hallmarks of cancer include (1) the potential for dissemination of cancer cells to adhere to distant sites and establish tumour growth—metastases and (2) the potential to recur following

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited.

primary or subsequent treatments. Frequently these develop together and herald relentless progression until the patient succumbs to disease. For all cancers, these processes show a greater propensity with higher stage (or TNM) of disease at presentation. Furthermore, it is known that certain types or subtypes of a given cancer have a greater or lesser tendency to metastasise and recur than others.

(SLL) in OC, which is no longer recommended. Unlike most other recurrent gynaecological cancers where typically histologic confirmation of recurrence is required before treatment, this

Surgery for Recurrent Ovarian Cancer http://dx.doi.org/10.5772/intechopen.71587 273

Essentially all OC patients receive platinum-based chemotherapy as part of primary treatment and some concepts are used to help stratify and compare managements of recurrent cancer. These include (1) platinum-sensitive and platinum-resistant disease [6] and (2) platinum-free interval (the interval between date of last platinum dose and date of relapse, PFI) and (3) progression-free survival (PFS). The definition of platinum sensitive and platinum resistant is somewhat arbitrary, but clinically useful. There is an argument that surgical trials might instead focus on date of last treatment (treatment-free interval (TFI)), and date of last operation rather than response to platinum or PFI [7]. Platinum-sensitive OC is defined as disease that is undetected at completion of primary treatment with platinum and which is undetectable for at least 6 months after completion of platinum-based chemotherapy; platinum-resistant disease is ovarian cancer that is detected within 6 months of completion of platinum-based chemotherapy. Other terms used in reports on recurrent cancer are time to first subsequent treatment and intervention-free interval. It is not clear what impact the use of maintenance therapy as an extension of primary

Recurrence is documented clinically, and/or by tumour marker levels and/or radiologically and in different clinical units the policy of post-treatment surveillance is variable. The clinical determination of relapse may be in an asymptomatic or symptomatic patient, and rarely OC patients may present acutely, for example, with bowel obstruction. Indeed, previously treated OC patients who develop bowel obstruction almost always have (recurrent) disease as the

Recurrence may be suspected from the patient's history—symptoms include weight loss, weight gain (e.g. from ascites), leg swelling (unilateral or bilateral), dyspnoea, pelvic pressure symptoms and loss of appetite. More unusual symptoms relate to the paraneoplastic syndrome including features associated with hypercalcaemia, myositis, erythema nodosum and herpes zoster. Less commonly patients have haematuria, vaginal or rectal bleeding. The patient

The clinical examination, which should include assessment of the lymph nodes, abdominal and pelvic examination and recto-vaginal examination, may be normal. If the patient presents more acutely, for example with dyspnoea or evidence of bowel obstruction, there are usually

Unless clinically indicated, the usual test off treatment is to measure the serum tumour marker(s). The evidence that this is useful clinically and contributes to more efficacious treatment and

cause, even if this is not suspected on tumour marker levels or on imaging.

is the exception in cases of ROC.

treatment will have on these definitions.

3.1. Clinical features

may of course be asymptomatic.

concerning clinical findings.

3.2. Blood results

3. Determination of recurrent ovarian cancer

The typical clinical picture of ovarian cancer (OC) is presentation with advanced stage disease in the post menopausal woman and despite advances in medical and surgical treatments, most patients will die of disease. While arguably the goal of primary treatment is cure, this applies to those with early stage disease but not for all subtypes. Data from CRUK [1] show that there were 7378 new cases of OC and 4128 deaths from OC in 2014. These deaths were in most cases due to recurrent disease rather than primary disease. Survival is also associated with lower patient age and the overall 5-year survival is about 35%; the 5-year survival for stages III and IV disease is about 20 and <5%, respectively [1]. The majority of data on ovarian cancer is based on epithelial ovarian cancer (EOC) and this review predominantly deals with recurrent EOC.
