Epithelial Ovarian Cancer Surgical and Staging Considerations

The recommended surgical procedure for a patient of reproductive age with epithelial ovarian cancer who desires continued fertility, and who has clinically limited disease with no involvement of the contralateral ovary or uterus, includes conservative therapy with unilateral salpingo-oophorectomy and staging. In a review of 36 patients with stage IA disease who underwent conservative fertility-sparing surgery with complete staging, only 3 patients relapsed, 1 of whom had involvement of the residual ovary [49]. The incidence of microscopic disease in the residual ovary at the time of primary surgery is 5-7% [50], and bivalving or biopsy of the normal-appearing contralateral ovary in the patient with true stage I disease may be unwar ranted, as this may lead to adhesion formation and decreased fertility. It may be acceptable to preserve a normal-appearing uterus in early-stage disease even if both ovaries are removed, thus preserving the option of donor egg conception. Although these approaches are controversial, fertility-sparing surgery for true early-stage ovarian carcinoma appears to be a viable option if the patient is adequately counseled about fertility preservation and recurrence risk [21]. One exception to this may be for clear-cell histology, which may connote a significantly more aggressive tumor, contra-indicating conservative surgery [50]. In addition, consideration should be given to surgical removal of the contralateral ovary once childbearing is complete [21].

The majority of ovarian epithelial tumors diagnosed in young women are stage I. The rare patient with apparent advanced-stage epithelial disease should undergo cyto-reductive surgery with every attempt made to achieve an optimal tumor reduction (no implant greater than 1 cm) and, when possible, leave no visible tumor. Response to chemotherapy and survival are significantly improved in patients with optimal or complete cytoreduction [51]. Preservation of reproductive capacity in patients with advanced invasive epithelial ovarian cancer cannot be advised; in these patients, the uterus, cervix, tubes, and ovaries should be removed.

Treatment for patients with epithelial tumors who have had inadequate staging is a difficult issue. If the patient has documented large residual disease with a limited initial attempt at tumor reduction, repeat exploration with staging and tumor reductive surgery is indicated. If the patient has had an inadequate exploration, additional studies should be performed, including repeat laparoscopic or open exploration with full surgical staging or, in some circumstances, a post-operative CT, serum inhibin, and serum CA-125 levels.

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