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    Maximal effort cytoreductive surgery for advanced ovarian cancer

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    2 The condition, current treatments and procedure

    The condition

    2.1 Early symptoms of ovarian cancer can be similar to those of other pelvic or abdominal conditions and include persistent bloating, pain in the pelvis and lower abdomen, urinary frequency and urinary urgency. Ovarian cancer is usually at stage 3 or 4 when it is diagnosed and the outcome is generally poor. The overall 5-year survival rate for ovarian cancer is about 43%, and is lower for people with more advanced disease. The stage of the disease at diagnosis is the most important factor affecting outcome and is defined by the International Federation of Gynecology and Obstetrics (FIGO) system:

    • Stage 1 (A to C) – the tumour is confined to the ovary.

    • Stage 2 (A, B) – the tumour involves 1 or both ovaries and has extended into the pelvis.

    • Stage 3 (A to C) – the tumour involves 1 or both ovaries with microscopically confirmed peritoneal metastasis outside the pelvis or regional lymph node metastasis (if cancer cells are found only in fluid taken from inside the abdomen the cancer is stage 2).

    • Stage 4 (A, B) – there is distant metastasis beyond the peritoneal cavity (if ovarian cancer is only found on the surface of the liver and not within the liver itself, then the cancer is stage 3).

    2.2 The FIGO stage does not take into account the distribution of disease within the abdomen or the volume of the disease. Therefore FIGO stage 3C can range from a single cancer deposit of more than 2 cm on the omentum to widespread intra-abdominal disease where cancer is present on the surface of the large bowel, small bowel, spleen, diaphragm, liver and across the peritoneum.

    Current treatments

    2.3 NICE's guideline on ovarian cancer describes the initial management options. The main treatments for advanced ovarian cancer are surgery to remove all macroscopic residual disease (also known as debulking) and chemotherapy. Standard surgery usually involves, as a minimum, bilateral salpingo-oophorectomy, total abdominal hysterectomy and omentectomy. Maximal effort cytoreductive surgery uses additional surgical procedures including upper abdominal surgery, with the aim of achieving no residual disease. The most important factors affecting outcomes after treatment are responsiveness to platinum-based chemotherapy and the amount of cancer left behind at the end of cytoreductive surgery (residual disease).

    2.4 Conventional imaging techniques cannot accurately predict the distribution or volume of disease before surgery. Therefore, the only definitive assessment of the distribution or volume of disease found in the abdomen and pelvis is done at the time of surgery. Currently, no objective tools exist to select people for surgery and a decision for surgery will depend on many factors including fitness, patient choice, availability of surgeons with appropriate expertise, and resource levels.

    The procedure

    2.5 The aim of maximal effort cytoreductive surgery for advanced ovarian cancer is to remove all identifiable disease, to improve survival compared with standard surgery. It is a development and extension of surgery for ovarian cancer.

    2.6 The precise differences between standard, radical and maximal effort cytoreduction procedures are not well defined. Surgical complexity scores, such as the Aletti system, have been developed to try to quantify the complexity of surgery. Each procedure that is done during the surgery is allocated a score:

    • Total hysterectomy and bilateral salpingo-oophorectomy=1

    • Omentectomy=1

    • Pelvic lymphadenectomy=1

    • Paraaortic lymphadenectomy=1

    • Pelvic peritoneum stripping=1

    • Abdominal peritoneum stripping=1

    • Rectosigmoidectomy anastomosis=3

    • Large bowel resection=2

    • Diaphragm stripping or resection=2

    • Splenectomy=2

    • Liver resection=2

    • Small bowel resection=1

    The total score can then be used to categorise the surgery into low complexity (1 to 3), intermediate complexity (4 to 7) or high complexity (8 and above).