Ovarian Cancer: Primary Therapy

Surgery is often the treatment of choice for women with ovarian cancer. The goal of surgery is to confirm the diagnosis of ovarian cancer, to determine the extent of spread of the cancer, and to remove all of the cancer. Women with an ovarian cancer that appears to be defined to the ovary undergo a procedure called staging that is designed to detect microscopic spread of the cancer beyond the ovary. For those women with cancer that has spread beyond the ovary, surgical treatment is a procedure known as cytoreduction or debulking.

Women with ovarian cancer should undergo surgery by a gynecologic oncologist. Gynecologic oncologists are physicians who have received extended training in the surgical management of ovarian cancer and have expertise in both staging and debulking procedures. The gynecologic oncologists at Columbia University all have extensive experience with advanced surgical procedures for ovarian cancer. To provide the comprehensive care required to successfully undertake these procedures, we have developed the Center for Advanced Gynecologic and Pelvic Surgery at Columbia University. This center brings together world renowned specialists from a variety of disciplines to undertake the most complex pelvic operations as a team.

Staging Surgery

Women with an ovarian cancer that appears to be confined to the ovary typically undergo a surgery called a staging procedure. The goal of a staging surgery is to detect microscopic spread of the ovarian cancer outside of the ovary. Microscopic spread of cancer is detected in up to 30% of women who appear have no visible evidence of cancer outside of the ovary.

A staging procedure for ovarian cancer typically involves removal of both ovaries and fallopian tubes (bilateral salpingo-oophorectomy) along with the uterus (hysterectomy), lymph nodes in the pelvis (lymphadenectomy), the omentum that is fatty tissue that connects the intestines, the stomach, and the spleen (omentectomy), and biopsies of the lining of the abdominal cavity (peritoneal biopsies). Some young women with very early ovarian cancer may be candidates for fertility sparing surgery with preservation of the uterus and an uninvolved ovary. Women with non-epithelial ovarian tumors are also often candidates for fertility preserving surgery.

Debulking Surgery

Debulking surgery or cytoreduction is the surgical procedure performed in women with ovarian cancer that has spread from the ovary to the abdominal cavity. Debulking typically entails removal of both ovaries (bilateral salpingo-oophorectomy) and removal of the uterus (hysterectomy). In addition, any cancer nodules that have spread within the abdominal cavity are removed. This may require removal of a portion of the lining of the abdominal cavity (peritonectomy), removal of a portion of the small intestines or colon (colectomy), removal of the spleen (splenectomy), removal of the omentum (fatty tissue that sits on the intestines, omentectomy), removal of a portion of the diaphragm, or removal of a portion of the liver (partial hepatectomy).

The goal of debulking surgery is to remove as much cancer as possible. The amount of cancer that remains at the completion of debulking surgery is an important prognostic factor for women who undergo surgery; the larger amount of cancer that remains after surgery the shorter the survival for ovarian cancer. At the completion of surgery, women are classified as having either undergone an optimal or suboptimal cytoreduction. Optimal cytoreduction is defined as having no remaining areas after surgery. In contrast, suboptimal cytoreduction is defined as having cancer nodules >1 cm in size after surgery. The prognosis is substantially better in women who undergo optimal tumor cytoreduction compared to suboptimal cytoreduction.

Neoadjuvant Chemotherapy

In some women initial therapy for ovarian cancer may begin with chemotherapy. This strategy is known as neoadjuvant chemotherapy. Women treated with neoadjuvant chemotherapy typically receive several cycles of chemotherapy which is followed by surgery. Additionally chemotherapy is usually given after surgery.

The benefit of neoadjuvant chemotherapy is that it reduces the size of cancer nodules in the abdominal cavity thus making surgery less radical when it is performed. A number of scientific studies have shown that surgery is better tolerated and associated with fewer complications if chemotherapy is given first and that complete resection of the ovarian cancer is more likely in women who receive neoadjuvant chemotherapy. Additionally, multiple studies have shown that survival is similar for women who receive neoadjuvant therapy compared to primary surgery. It is essential that patients have the opportunity to discuss the merits of neoadjuvant chemotherapy versus upfront surgical cytoreduction.