Primary Surgery for Advanced (Stage IIB-IV) Ovarian cancer Inclusion Criteria

Scottish Ovarian Cancer Forum: A Feasibility Pilot

Aims

• To achieve cytoreduction to zero macroscopic residual disease without compromising patient fitness for adjuvant chemotherapy
• Benefit:-Median overall survival is 45 months for patients achieving optimal debulking to zero with primary surgery. Subgroup analysis of EORTC 55971 and real-world analysis (Meyer et al.) suggest this group has an overall survival advantage to surgery rather than NACT and IDS but with an increase in operative mortality from 0.7 to 2.5%.

Inclusion Criteria

• Biopsy-proven high-grade advanced-stage ovarian cancer likely to be resectable to <1cm residual disease
• All biopsy-proven low-grade serous, low-grade endometrioid, clear cell or mucinous advanced-stage ovarian cancer (chemo resistant) should have primary surgery, not NACT
• All extra-abdominal metastases (stage IV) should be considered potential indications for NACT/IDS, not primary surgery, except for the following:
  • Isolated liver parenchymal lesion
  • Resectable inguinal lymph nodes
  • pleural fluid that contains cytologically malignant cells without proof of the presence of pleural tumours (IVA)
  • Resectable disease involving the anterior abdominal wall including port site metastases

(NB If excluded on the basis of multiple pulmonary metastasis then these should be histologically proven)

• In situations where supra-diaphragmatic lymph nodes of uncertain significance or borderline size are identified primary surgery can still be considered.

Exclusion Criteria

The following are contra-indications to primary resection :

• Diffuse deep infiltration of the root of small bowel mesentery
• Diffuse carcinomatosis of the small bowel involving such large parts that resection would lead to a short bowel syndrome (remaining bowel <1.5m)
• Diffuse involvement/deep infiltration of stomach/duodenum or head or middle part of pancreas
• Involvement of coeliac trunk, hepatic arteries, left gastric artery
• Central or multisegmental parenchymal liver metastases
• Patient characteristics
  • Impaired performance status and comorbidity that does not allow a maximal surgical effort to achieve a complete resection;
  • patients’ nonacceptance of potential supportive measures, such as blood transfusions or temporary stoma
  • Significant recent arterial or venous clot <3months e.g. CVA, PE

References

1. Which patients benefit most from primary surgery or neoadjuvant chemotherapy in stage IIIC or IV ovarian cancer? An exploratory analysis of the EORTC 55971 randomised trial. Van Meurs et al. Eur J Cancer 49:3191
2. Use and effectiveness of NACT for treatment of ovarian cancer. Meyer et al. JCO 2016
3. Cochrane review: Chemotherapy versus Surgery for Initial treatment in Advanced Ovarian Epithelial Cancer Cochrane Database of Systematic Reviews 2021.
4. Port-site metastases after open laparoscopy: a study in 173 patients with advanced ovarian carcinoma. Vergote I, Marquette S, Amant F et al. Int J Gynecol Cancer 2005; 15(5): 776–779
5. ESMO ESGO Consensus Guideline Colombo et al, Annals of Oncology 2019; 30: 672-705.