Page 6 - Guidelines Ovarian Surgery

SURGICAL MANAGEMENT FOR STAGE III-IV OVARIAN CANCER
(ALGORITHMS 2-3)

✓ Midline laparotomy is required to manage stage III-IV ovarian cancers.

A Complete resection of all visible disease is the goal of surgical management. Voluntary use of
incomplete surgery (upfront or interval) is discouraged.

✓ Criteria against abdominal debulking are:
• 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 short bowel syndrome (remaining bowel < 1.5 m),
• Diffuse involvement/deep infiltration of
− Stomach/duodenum (limited excision is possible), and
− Head or middle part of pancreas (tail of the pancreas can be resected);
• Involvement of truncus coeliacus, hepatic arteries, left gastric artery (coeliac nodes can be
resected).

✓ Metastatic (stage IVB) disease may be resectable. Central or multisegmental parenchymal liver
metastases, multiple parenchymal lung metastases (preferably histologically proven),
nonresectable lymph node metastases, and multiple brain metastases are not resectable.

A Primary surgery is recommended in patients who can be debulked upfront to no residual

tumour with a reasonable complication rate.

✓ Risk-benefit ratio is in favour of primary surgery when:
• There is no unresectable tumour extent
• Complete debulking to no residual tumour seems feasible with reasonable morbidity, taking
into account the patient’s status. Decisions are individualised and based on multiple
parameters4.
• Patient accepts potential supportive measures as blood transfusions or stoma.

A Interval debulking surgery should be proposed to patients fit for surgery with response or

stable disease compatible with complete resection.

✓ If a patient did not have the opportunity of surgery after 3 cycles, then a delayed debulking
after more than 3 cycles of neoadjuvant chemotherapy may be considered on an individual basis.

✓ A patient with inoperable tumour who progresses during neoadjuvant chemotherapy should
not be operated unless for palliative reasons that cannot be managed conservatively. Careful
review of pathology in serous adenocarcinoma (possible lowgrade) and additional workup in
mucinous adenocarcinoma (possible GI tract secondary) is recommended when applicable in
this circumstance.

4 Examples of potentially resectable extra-abdominal disease: Examples of resectable intra-abdominal parenchymal metastases:
• Inguinal or axillary lymph nodes, • Splenic metastases,
• Retrocrural or paracardiac nodes, • Capsular liver metastases,
• Focal parietal pleural involvement, • Single deep liver metastasis, depending on the location.
• Isolated parenchymal lung metastases.

6 • OVARIAN CANCER SURGERY - GUIDELINES •