1. Introduction

The surgical management of ovarian cancer has continued to evolve, particularly over the past 25 years.

The principles of cytoreductive surgery have been applied to not only the pelvic cavity but also within the abdominal and thoracic cavity. The 5 year survival for this cohort of patients has not significantly changed in the past 40 years. Presently clinical trials are examining the role of effective cytoreductive surgery (CRS) and combination chemotherapy (including antiangiogenesis inhibitors, PARP inhibitors and immunotherapy) in optimising therapy. These are likely to yield encouraging results in the next decade or two.

Imaging, role of lymphadenectomy and the management of recurrent ovarian cancer are discussed elsewhere in this book. This chapter will describe the rationale and outcomes associated with first line (either primary or interval) surgery for ovarian, tubal or primary

peritoneal cancer. A technical description of the operative steps and intra-peritoneal chemotherapy are outside the scope of this chapter.

Benefits of CRS include removal of poorly vascularised tissues (removing the pharmacological sanctuary) and excising the chemoresistant clones. Therefore the resulting absent or minimal

Surgical Management of Ovarian Cancer http://dx.doi.org/10.5772/intechopen.80891 237

As the concept of CRS became more widely embraced, the application became more aggressive. Disease on the diaphragm, large bowel, spleen or distal pancreas might have been considered unresectable are now readily resected. Patient selection for these ultraradical procedures is important. This was a concern for the doubters as it may be associated with greater risk of morbidity, delay in receiving chemotherapy as well as significant impact on the quality of life (QOL) [6–8]. Indeed it was felt that perhaps only those with smaller volume and earlier stage disease would benefit from aggressive CRS [5, 9]. However a structured approach to quality improvement through enhanced skills, team structure and commitment to CRS has been shown to improve extent of cytoreduction and hence overall median survival [10–12].

In an important meta-analysis, Bristow demonstrated that greater the volume reduction, greater the survival outcome [13]. In fact they revealed that for every 10% increase in nil residual disease, overall survival increased by 5.5% [13]. Similarly in a more recent metaanalysis of largely newer data in the platinum-taxane era, Chang et al. demonstrated that with each 10% increase in complete cytoreduction, the median overall survival improved by

Three limitations to ultra-radical debulking surgery remain absence of grade A evidence confirming that radical surgery is more efficacious than standard surgery, morbidity/mortality associated with radical CRS and surgery in non-expert centres will only yield nil residual disease in a relatively small proportion of patients [15]. The first two arguments are unlikely to be resolved but one can certainly use big data to resolve treatment pathways for patients

In early stage ovarian cancer, the disease is confined to the ovaries or the upper genital tract. Approximately 25% of ovarian cancer patients are diagnosed with stages 1 and 2. These women generally have an excellent prognosis, provided a full staging procedure has been performed. Proper staging allows identification of those who are truly early stage and those who might have more advanced disease. This will allow optimal recommendation regarding adjuvant chemotherapy for the apparent early stage patients [16]. The critical importance of proper staging is underlined by the long term (10 year) follow up data offered by the ICON 1 study [17]. In this study the 10 year survival varied between 56 and 78% depending on the

Table 1 enumerates the steps in comprehensive surgical staging of suspected ovarian cancer. Even in unilateral ovarian cancer, the risk of contralateral lymph node metastasis only, is 3.5%; this is in addition to the 9.7% risk of metastasis on both sides and the 8.3% risk of ipsilateral metastasis [18]. Indeed the risk of para-aortic lymph node metastasis only is 7.1% and the risk

2.3 months [14].

with advanced disease.

completeness of staging [17].

4. Management of early stage ovarian cancer

disease will have more favourable cell kinetics with regard to chemosensitivity [5].
