What Is the Optimal Goal of Primary Cytoreductive Surgery for Bulky Stage IIIC Epithelial Ovarian Carcinoma (EOC)?

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What constitutes “optimal” cytoreduction for women operated on for ovarian cancer remains uncertain. A majority of studies have employed a cutoff of 1–2 cm to define optimal cytoreduction. Recent studies suggest that removing all gross disease promotes disease-free survival compared to the current Gynecologic Oncology Group threshold of 1 cm or less of residual disease. This prospective database analysis reviewed the records of 465 patients with stage IIIC epithelial ovarian carcinoma (EOC) who had cytoreductive surgery in the years 1989–2003. All participants had bulky abdominal tumor, and maximal cytoreduction was attempted if technically possible. The patients, whose median age was 60 years, were followed up for a median of 38 months. Nearly all the patients received at least 6 cycles of platinum-based systemic chemotherapy.Univariate analysis showed age at the time of surgery and the preoperative platelet count to be significant continuous variables. Categorical variables with prognostic significance included the presence of ascites, the site of the largest tumor mass, extensive upper abdominal cytoreduction, and the extent of residual disease. Multivariate analysis confirmed age, the presence or absence of ascites, and the diameter of residual disease as being significant factors. Median survival was 106 months when there was no gross residual disease, and declined steadily as the amount of residual disease increased. Median survival was 34 months when patients were left with more than 2 cm of residual disease. The major distinctions with regard to survival rate were between no gross residual disease, 1 cm or less of gross disease, and more than 1 cm of residual disease. A trend toward improved survival was noted in patients left with 0.5 cm or less of residual disease compared with those retaining 0.6–1 cm of disease (Fig. 1).The investigators conclude from these findings that removing all evidence of gross stage IIIC EOC prolongs survival and is an appropriate goal of primary cytoreductive surgery. If complete gross resection is not feasible, as little residual tumor as possible should be left behind. An incremental decrease in residual disease below 1 cm can incrementally enhance overall survival.

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