SURGICAL THERAPY
Surgical removal of epithelial cancer that is confined to the ovary, followed by a full surgical staging procedure, may be adequate therapy. In other early-stage patients, some type of adjunctive treatment may be required. Epithelial ovarian cancer is categorized as early disease (stages I and II with no residual cancer) and advanced disease (stage II with residual cancer and stage III and stage IV cancer).
Table 10 provides a classification system for patients within broad categories. Early ovarian cancer can be divided into low-risk and high-risk disease. For properly staged low-risk epithelial ovarian cancer, survival is approximately 95% and no therapy has been shown to be more effective than surgical removal of the cancer. For patients who wish to continue childbearing, unilateral salpingo-oophorectomy is acceptable providing they had a full surgical staging procedure. Most authorities would recommend removal of the retained ovary when childbearing is complete.
High-risk cancer, however, requires adjuvant treatment with either irradiation or chemotherapy. With adjunctive therapy, survival rates for patients with high-risk cancer are 75-95%. In these patients, the role of conservative surgery is more controversial, although some oncologists will preserve childbearing capability in these women despite the requirement for adjunctive chemotherapy. These patients do not have the option of choosing irradiation as a therapeutic option because such therapy would destroy the retained ovary.
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Primary Cytoreductive Surgery. Reports in the late 1960s indicated improved survival in patients who had extensive surgical resection followed by whole-abdomen radiation. In a 1975 study, the exact residual diameter of tumors was recorded, and size was related to duration of survival. All of the study patients had been treated postoperatively with a single alkylating agent. The study reported a survival time of 39 months for patients with no residual tumors, 29 months for patients with residual tumors smaller than 0.5 cm in diameter, 18 months for patients whose tumors were 0.6-1.5 cm in diameter, and 11 months for patients with residual tumors larger than 1.5 cm. Since that report, many other reports have confirmed that patients whose tumors are reduced to small-volume disease are more likely to have a response to chemotherapy and the frequency of complete responses is greater. Overall response rates were 66.8% in patients with optimal residual disease compared with 53.3% in patients with suboptimal residual disease. The complete response rate was 42.7% in patients with optimal residual disease compared with 24% for patients with suboptimal residual disease.
A group of researchers evaluated 324 patients who had been entered in a Gynecologic Oncology Group study for patients with optimal (<1 cm) disease in an effort to define the benefit of cytoreductive surgery in relation to a variety of other prognostic factors. These investigators found that although cytoreductive surgery was an important factor in determining outcome, it was not the only significant factor. Also important was the age of the patient, the number of residual tumor nodules, and the grade of the tumor.