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Case History

Image not available. A 56-year-old woman presents with a 3-month history of anorexia and abdominal swelling. The medical history is unremarkable. A computed tomography (CT) scan of abdomen shows an ovarian mass, ascites, extensive omental cake and liver surface deposits. The ascites contains malignant cells consistent with adenocarcinoma of ovarian origin.

What evidence is there in favour of initial surgery rather than neoadjuvant chemotherapy?

What factors and/or further investigations will influence the decision to attempt surgery now?

What regimens are acceptable first-line treatments for ovarian carcinoma and on what evidence are they based?

Background

What evidence is there in favour of initial surgery rather than neoadjuvant chemotherapy?

Image not available. For women with early-stage epithelial ovarian cancer (International Federation of Gynecology and Obstetrics [FIGO] stages I and II) the primary treatment is surgery. However, most women present with advanced disease (FIGO III or IV) - like our patient, who has at least FIGO stage IIIB disease. Optimal surgery in combination with platinum-based chemotherapy confers a survival advantage in women with ovarian cancer, which is largely related to the amount of postoperative residual bulk disease. Women with minimal residual disease, following optimal cytoreduction, i.e. residual disease less than 1 cm in greatest diameter, have the best prognosis.1

There is no definitive evidence from randomized controlled trials to support the optimal timing of surgery and chemotherapy. However, there is consensus that a 'maximal surgical effort', whatever the timing, is necessary. Primary surgery is useful for definitive staging and there are many plausible biological reasons why chemotherapy might be more effective after maximal debulking (all reviewed and further referenced by Thigpen2). Therefore primary surgery followed by chemotherapy remains the standard of care outside a clinical trial for a patient such as ours. A definitive answer for patients with advanced disease is awaited from a large prospective study (EORTC 55971) which finished recruitment in December 2006. This trial has randomized patients with IIIC and IV epithelial ovarian cancer to either neoadjuvant chemotherapy followed by surgery or primary surgery and postoperative chemotherapy.

What factors and/or further investigations will influence the decision to attempt surgery now?

Cytoreductive surgery is beneficial for women in whom the planned surgical procedure is possible in the absence of excessive morbidity. There is substantial evidence that primary chemotherapy followed by interval debulking surgery is a valid alternative in a selected group of women with advanced ovarian cancer. Therefore women in whom optimal cytoreduction is not initially possible may be treated by primary administration of systemic chemotherapy, i.e. neoadjuvant treatment, followed by later cytoreductive surgery.

Uncountable peritoneal metastases (>100), large peritoneal metastatic plaques, large volume ascites and a performance status of 2 or 3 are all relative indications for neoadjuvant chemotherapy,3–5 as are poor nutritional status or comorbidities which increase anaesthetic risk. If our patient is significantly cachectic or if full ...

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