Secondary surgical cytoreduction for advanced epithelial ovarian cancer. Patient selection and review of the literature.

BACKGROUND Standard therapy for advanced epithelial ovarian cancer now includes primary cytoreductive surgery followed by combination chemotherapy. Optimal primary debulking is associated with improved clinical response rates to primary chemotherapy as well as longer overall survival. The benefits of secondary cytoreductive surgery for persistent or recurrent ovarian cancer have not been as clearly established as those of primary surgery. METHODS The English language literature was searched, using a MEDLINE database, to identify all clinical investigations pertaining to secondary cytoreductive surgery for epithelial ovarian cancer. Additional sources were found in reference lists from original research and review articles. Particular emphasis was placed on those studies allowing secondary operations for ovarian cancer to be grouped into four clinical scenarios: (1) recurrent disease, (2) second-look laparotomy (SLL), (3) interval cytoreduction, and (4) progressive disease. RESULTS Patients with recurrent disease, particularly after a prolonged disease free interval, may derive a significant survival benefit from optimal debulking. The available data also indicate that patients whose disease is in complete clinical remission, with macroscopic disease detected at the time of SLL, benefit from cytoreduction to microscopic disease residual. Cytoreduction that leaves SLL patients with a small amount of macroscopic disease may provide some survival benefit, but the degree of that benefit is unclear. Patients who undergo suboptimal primary debulking and later demonstrate a favorable response to induction chemotherapy may derive a modest survival advantage from an optimal interval cytoreductive procedure. CONCLUSIONS Proper selection of patients with recurrent or initially suboptimally resected ovarian cancer is essential to maximize the potential therapeutic benefit of secondary cytoreductive surgery.