Controversies in the management of advanced ovarian cancer.

Whether advanced ovarian cancer should be treated with neoadjuvant chemotherapy or primary debulking surgery is one of the most debated topics in gynecologic oncology. In their article "Cytoreductive Surgery for Advanced Ovarian Cancer: Quo Vadis?" Schorge and his coauthors provide an excellent review of issues surrounding the management of advanced ovarian cancer. Primary cytoreductive surgery has been the cornerstone of treatment of advanced ovarian cancer. Theoretically, cytoreductive surgery can mediate the adverse metabolic effects of a large tumor burden, decrease chemotherapy resistance, and thereby improve the chances of responding to adjuvant treatment. Survival is predicated on the amount of disease present after cytoreduction. The most important benefit is the inverse relationship between the amount of residual disease and subsequent survival outcome. Although optimal cytoreductive surgery is the most important prognostic factor, optimal cytoreduction cannot be achieved in all patients with advanced ovarian cancer. The achievable rate of optimal cytoreduction for advanced disease varies widely; in addition, there is considerable heterogeneity among definitions of what could be regarded as optimal surgical outcome. Numerous studies have shown that to increase rates of optimal cytoreduction often requires the incorporation of a variety of ablative techniques and extensive upper abdominal procedures.[1] These techniques cannot be applied to all patients irrespective of comorbidity and performance status.