Ovarian Cancer: Surgical Therapy

Epithelial ovarian cancer [S3 guideline]

Patients with genetic predisposition (healthy mutation carriers) to ovarian cancer.

  • Prophylactic bilateral salpingo-ovarectomy (PBSO; removal of the fallopian tube and ovary) after completed family planning results in an 80% to >90% risk reduction of developing ovarian cancer. Indication: women with a mutation in the BRCA1/2 gene and proven mutations in other high-risk genes, such as RAD 51C.

Patients with unilateral tumor stage FIGO IA, G1 or G2.

  • Fertility-preserving (fertility-preserving) surgery leaving the uterus (womb) and contralateral (“lying on the other side”) ovary is possible. Prerequisite is a staging (staging) of the entire abdomen with multiple biopsies (removal of a tissue sample) and a peritoneal lavage (abdominal lavage) after detailed risk disclosure.
  • Patients do not require adjuvant chemotherapy at this stage.

Early ovarian cancer (stage FIGO I-IIA).

  • Standard therapy consists of primary staging surgery via longitudinal laparotomy (longitudinal incision) with the goal of macroscopically complete tumor resection. This includes:
    • Inspection and palpation (viewing and palpation) of the entire abdominal cavity (abdominal cavity).
    • Peritoneal cytology (cell examination of cells of the peritoneum).
    • Biopsies (tissue sampling) from all abnormal sites.
    • Peritoneal biopsies from inconspicuous regions.
    • Hysterectomy (removal of the uterus), extraperitoneal procedure if necessary.
    • Bilateral salpingo-ovarectomy (bilateral removal of fallopian tubes and ovaries).
    • Omentectomy (removal of the large mesh) at least infracolic.
    • Appendectomy appendectomy) for mucinous/unclear tumor type).
    • Lymphonodectomy (lymph node removal: bds. lymph nodes of the paraaortic, paracaval, interaortocaval, and vasa iliaca communis, externa, and interna).

Note: A laparoscopic operate should only be done in studies at this time! Further notes

  • In approximately 30 percent of patients with ovarian cancer, the disease is limited to the small pelvis at the time of diagnosis (stage FIGO I or II). In these early stages, there is a good chance of a permanent cure.
  • A benefit for primary chemotherapy (= neoadjuvant chemotherapy, NACT) followed by interval surgery does not exist, therefore chemotherapy should be performed after surgery. Standard is thus still the primary debulking surgery (reduction of tumor mass for curative or palliative reasons).
  • A second-look surgery should not be performed

Advanced ovarian cancer.

Crucial for the prognosis of advanced disease is macroscopically complete tumor resection (surgical removal (resection) of a tumor). The surgical procedure corresponds to that of early ovarian carcinoma. In the case of macroscopically (“visible to the naked eye”) inconspicuous lymph nodes, systematic lymphadenectomy (lymph node removal) is no longer performed based on data from the prospective, randomized LION study. Patients with recurrence (recurrence of the tumor).

  • Ovarian cancer recurrence represents a palliative treatment situation.
  • The goal of recurrence surgery is macroscopic complete resection of the recurrence

Further notes

  • Patients with advanced ovarian cancer who underwent complete macroscopic resection of the tumor and its metastases lived a median of 65.5 months after surgery, including 25.5 months without tumor progression (control group without lymphadenectomy: patients lived a median of 69.2 months, including 25.5 months without tumor progression; thus, no significant difference). Furthermore, for the lymphadenectomy group were equally no significant benefits demonstrable for the risk of death and the risk of tumor progression or death.
  • Secondary surgical cytoreduction (removal of a majority of tumor masses/lowering of tumor burden) versus no cytoreduction resulted in the following: median survival of operated patients was 50.6 months versus 64.7 months of unoperated patients (hazard ratio on death compared with the unoperated group was 1.29 with a 95% confidence interval of 0.97-1.72). CONCLUSION: In the case of recurrence of ovarian cancer, the sense of a second cytoreduction and must be questioned.

Borderline tumors [S3 guideline]

Primary goal is complete tumor removal: median laparotomy (longitudinal incision to the umbilicus (at least)) + adnexectomy (removal of ovary and fallopian tube) bilaterally + omentectomy ((removal of the large mesh/peritoneum; infracolic) + any tumors present + resection of all abnormal areas + staging:

  • Inspection (viewing) + palpation (palpation) of the entire abdomen.
  • Irrigation cytology (examination of cells sheared from a surface by irrigation).
  • Smear cytology
  • Peritoneal biopsies (collection of tissue samples from the peritoneum) of inconspicuous areas.

Further notes

  • If histology reveals a mucinous borderline tumor, an extraovarian (outside the ovary) tumor should be excluded. For this purpose, there is also an indication for appendectomy (appendectomy).
  • If only the ovarian cyst (ovarian cyst) is removed under fertility-preserving aspects (instead of an adnexectomy / removal of ovary and fallopian tube on both sides) there is an increased recurrence rate.

Germline stromal tumors [S3 Guideline.]

Surgery includes: median laparotomy (longitudinal incision to the umbilicus (at least)) + adnexectomy (removal of ovary and fallopian tube) of the affected side. No lymphonodectomy (lymph node removal) if lymph nodes are unremarkable + staging (stage determination):

  • Inspection + palpation of the entire abdomen.
  • Peritoneal cytology

For tumors with malignant potential (granulosa cell tumor, Sertoli-Leydig cell tumor G2/G3 or steroid cell tumor NOS):

  • Definitive surgical staging analogous to ovarian cancer.
  • The benefit of systematic lymphonodectomy (lymph node removal) for inconspicuous lymph nodes is not proven.
  • If the uterus (womb) is left in place, hysteroscopy (uterine endoscopy) and abrasion (scraping) recommended (to rule out endometrial hyperplasia (proliferation of the endometrium) or endometrial carcinoma).

Germ cell tumors [S3 guideline]

Surgery includes: median laparotomy (longitudinal incision to the umbilicus) + adnexectomy (removal of ovary and fallopian tube) of the affected side, complete tumor resection if possible preserving fertility in young patients. No lymphonodectomy (removal of lymph nodes) if lymph nodes are unremarkable + staging.

  • Inspection + palpation of the entire abdomen.
  • Peritoneal cytology
  • Smear cytology
  • If necessary, peritoneal biopsies