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This lecture discusses critical aspects of surgery in ovarian cancer.
(1) Access to optimal state-of-the art quality of care: Not all patients have access to high-quality centers. The European Society of Gynaecological Oncology (ESGO) and other societies have expended energy on improving both training and optimizing center structures and visibility. Certification process, centralization, and participation in clinical trials are crucial factors in these quality initiatives.1
(2) Selecting the right strategy for the right patient: In general, the optimal (surgical) treatment strategy in advanced ovarian cancer patients should be based on the determination of operability and resectability. Operability relates to whether a patient is fit enough to tolerate radical surgery. Studies in this area identified prognostic factors such as advanced disease and/or high tumor dissemination, poor performance status, hypoalbuminemia, older age, and comorbidity as being associated with significantly higher postoperative morbidity and mortality.2–4 However, none of these factors alone can determine strategy. Several attempts have been undertaken to build a predictive score for frailty; however, so far none have been confirmed independently and could be generalized. Further research is necessary to identify the subgroup of patients who will not benefit from a radical approach due to either tumor biology or fragility/vulnerability and severe postoperative morbidity; these patients might be candidates for alternative treatment strategies such as neoadjuvant therapy. A strict selection of balancing risks and harms of extensive debulking surgery based on objective parameters and clinical experience is still to be developed.5
(3) Resectability: The huge impact of residual disease status on patients' prognosis has been demonstrated in several analyses (primary and interval debulking surgery) and the concept of extensive debulking surgery is considered a key part in the management of advanced ovarian cancer.6–8 Several attempts have been undertaken to accurately predict resectability and complete resection using techniques such as computed tomography (CT) and positron emission tomography (PET)-CT imaging, diffusion-weighted whole-body magnetic resonance imaging (MRI), video-assisted thoracic surgery (VATS), or laparoscopic evaluation in order to better predict the probability of complete resection.9 10 However, imaging alone is not sufficient to predict surgical outcome. The interaction of intrinsic (patient’s frailty) and extrinsic (surgical skills and equipment of center) aspects may add to the concept of resectability.
(4) Timing of surgery: There is still debate on the optimal timing of debulking surgery – before chemotherapy or after neoadjuvant chemotherapy. The EORTC and CHORUS trials have shown non-inferiority for neoadjuvant chemotherapy in mainly non-optimally operable patients with postoperative residuals in more than 80% of patients. The question as to whether neoadjuvant chemotherapy is also acceptable in patients with potentially resectable disease remains open and will hopefully be answered by the prospective randomized TRUST-trial. Today, the gold standard remains upfront debulking surgery if complete resection seems achievable and the patient’s preoperative workup demonstrated fitness and resilience for radical surgery.5
(6) Future trends: Optimizing structure of centers, centralization, and training/skills evaluation of new techniques offers a promising opportunity. Among them, the definition of the role of laparoscopy is a matter for research, as is the role of hyperthermic intraperitoneal chemotherapy (HIPEC). Another major factor is the approach to optimizing patients’ resilience and perioperative outcome with implementation of enhanced recovery after surgery (ERAS) programs. Finally, the management of complications should be a training focus as it is in the annual European Society of Gynaecological Oncology (ESGO)-supported ‘Master-of-Disaster’ workshop and symposium in Essen.
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Contributors Andreas du Bois gives this lecture. The accompanying text was written and approved by all the authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests AB reports personal fees from Roche; grants, personal fees, and non-financial support from Astra Zeneca; personal fees and non-financial support from Clovis; personal fees and non-financial support from Tesaro/GSK; personal fees from Pfizer; personal fees from Genmab; personal fees from Biocad, outside the submitted work. PH reports grants and personal fees from Astra Zeneca; grants and personal fees from Roche; personal fees from Sotio; grants and personal fees from Tesaro; personal fees from Stryker; personal fees from Zai Lab; personal fees from MSD; grants from public funding (DKH, DFG, EU); personal fees from Clovis; personal fees from Immunogen; grants and personal fees from GSK; grants from Boehringer Ingelheim; grants from Medac; grants from Genmab, outside the submitted work. BA reports personal fees and non-financial support from Roche; personal fees from Amgen; personal fees from AstraZeneca; personal fees and non-financial support from Tesaro/GSK; personal fees from Clovis; personal fees from Celgene; non-financial support from PharmaMar; personal fees and non-financial support from MSD; personal fees from Novartis, outside the submitted work.
Provenance and peer review Not commissioned; externally peer reviewed.