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Surgical Approaches Continue to Evolve in Ovarian Cancer

Gina Columbus @ginacolumbusonc
Published: Monday, Apr 10, 2017

Shana Wingo, MD

Shana Wingo, MD

For patients with advanced ovarian cancer, surgical resection continues to be an effective and essential tool in the armamentarium, according to Shana Wingo, MD.

Whether a treatment plan includes cytoreduction upfront or neoadjuvant chemotherapy, patients with advanced disease are likely to benefit from surgical approaches that reduce the volume of the tumor.

Wingo, who specializes in gynecologic oncology at Arizona Oncology, lectured on surgery during the 2017 OncLive® State of the Science Summit on Ovarian Cancer. In an interview during the meeting, she explained how surgical approaches have evolved in ovarian cancer.

OncLive: What did you discuss at this meeting in your overview of surgery in ovarian cancer?

Wingo: We covered what we do for ovarian cancer and how we manage patients, mainly focusing on advanced stage ovarian cancer and what we do for patients when they initially present. Generally, what happens is that for the majority of patients, we consider upfront cytoreduction, which is for bulky disease that has metastasized and we remove the bulk of the tumor. We also call it debulking surgery. 

Now, when we do upfront surgery, there is a possibility where we might consider chemotherapy, depending on how involved a patient’s cancer is. If a patient has stage IV disease that might not be resectable or they have other medical comorbidities, they might be a good candidate for neoadjuvant chemotherapy.

One of the things that is getting traction and is more adopted now is doing laparoscopy as an initial assessment to determine if a laparotomy to a much larger incision is appropriate. If patients aren’t felt to be appropriate surgical candidates at the time of laparoscopy for debulking, then we stop the procedure, give them chemotherapy, and then do an interval cytoreduction where you’re doing debulking after they have had some chemotherapy. That shrinks the size of the tumor, leading to better success with cytoreduction. 

What evolution have we seen with surgery in ovarian cancer, and what can we expect going forward?

We now have a real solid understanding that the less tumor that is left behind, the better patients do. Really, we are talking about the amount of time they survive. The surgeries that we do can be very labor intensive from a general perspective. Most of us are probably doing a lot more pelvic surgery—involving the uterus, cervix, fallopian tubes, and ovaries—but then there are bowel resections that might involve the colon and pancreas, as well as lymph node removal. The omentum is always involved in the surgery, which is the upper abdomen.

As time goes on, you find that the more aggressive you are with surgery, perhaps the better patients do based on survival data. So, some of the high-volume centers are doing resection of liver metastases, the gallbladder and pancreas, and splenectomies. The goal is the same: no residual disease. That is a huge difference. The Gynecologic Oncology Group, over time, used to define optimal as less than 2 cm, then became less than 1 cm, and now the goal for all of us is a complete resection of disease. 

Are there ongoing clinical trials focused on surgery in ovarian cancer?

There are none to my knowledge. Some single institutions might be doing that. The clinical trials are not necessarily involving the actually surgery itself, but whether patients get chemotherapy or surgery upfront and then looking at the data to see if there is a difference. 

The big thing with our surgeries, especially when you are doing large debulking surgeries, is that there tends to be a lot of morbidity, meaning patients can have complications that are pretty significant. The mortality rate is not high, but it is certainly higher if you do surgery upfront versus after initiating chemotherapy.

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