Treatment Guideline Chart
Ovarian cancer is a type of cancer that begins in the ovaries.
It is the 7th most common cancer in women (excluding skin cancer) and the leading cause of death from gynecologic cancer in developed countries.
The 3 histologic types of ovarian cancer are epithelial (primarily seen in women >50 years of age), germ cell (most commonly seen in women <20 years of age) and sex cord stromal (rare and produces steroid hormones).
The median age at the time of diagnosis is 63 years old and >70% present with advanced disease.

    Surgical Intervention

    Surgery for Epithelial Ovarian Carcinoma

    • Primary treatment for presumed ovarian cancer consists of appropriate surgical staging and cytoreduction followed by systemic chemotherapy in most patients
    • Initial surgery should be a comprehensive staging laparotomy, including a total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO)
      • Recommended for patients with stage IA-IV ovarian cancer if optimal cytoreduction is feasible, fertility is not a concern and patient is a surgical candidate 
      • Laparotomy is the standard surgical option in treating and staging patients with apparent early-stage ovarian carcinoma
      • Minimally invasive techniques may be an option in early-stage disease to achieve surgical goals in selected patients if performed by an experienced gynecologic surgeon
    • Omentectomy, peritoneal washing, peritoneal biopsies, evaluation of the entire abdominal cavity and retroperitoneal assessment that involves both the pelvic and para-aortic areas should be performed
    • For patients who wish to maintain their fertility, unilateral salpingo-oophorectomy (USO) or BSO may be adequate for young patients with stage IA and IB tumors, respectively and/or low-risk tumors (ie early stage, low-grade invasive tumors, low malignant-potential lesions, malignant germ cell or sex cord-stromal tumors)

    Cytoreductive or Debulking Surgery

    • Initial treatment recommendation for patients with clinical stage II, III or IV disease
    • Recommended to all patients with stage II-IV diseases with potentially resectable residual disease
    • Optimal if the residual tumor nodules are <1 cm in maximum diameter or thickness
    • Extensive resection of upper abdominal ovarian metastases is recommended for patients who can tolerate this surgery
    • Procedures that may be considered for optimal surgical cytoreduction (in all stages) include bowel resection, diaphragm or other peritoneal surface stripping, splenectomy, partial hepatectomy, cholecystectomy, partial gastrectomy or cystectomy, ureteroneocystostomy, distal pancreatectomy, or appendectomy

    Secondary Cytoreduction

    • Considered in patients with recurrent ovarian cancer who recur >6-12 months since completion of primary chemotherapy, with good performance status, do not have ascites and have a limited foci of disease amenable to complete resection

    Interval Debulking Surgery (IDS)

    • Should include completion hysterectomy and BSO with comprehensive staging 
    • Should be performed in patients responsive to 3-4 cycles of neoadjuvant chemotherapy or in patients with stable disease
      • Evaluation for potential IDS should be done after 3-4 cycles of neoadjuvant chemotherapy
        • IDS with completion hysterectomy with BSO and cytoreduction should be performed in patients responsive to neoadjuvant therapy
        • Patients with stable disease after 3-4 cycles of neoadjuvant therapy may consider IDS with completion hysterectomy with BSO and cytoreduction, or switching to persistent or recurrent disease treatment or treatment with additional cycles of neoadjuvant chemotherapy to a total of ≥6 cycles followed by reassessment to determine if IDS can be performed or to switch to recurrent or persistent disease treatment
    • Should be followed with at least 3 additional cycles of the same chemotherapy regimen
    • May be done through minimally invasive procedures in select patients provided that optimal debulking can be achieved

    Ancillary Palliative Surgery

    • May be suitable in select patients and include thoracentesis, pleurodesis, video-assisted thoracoscopy or insertion of a pleural catheter, paracentesis or insertion of indwelling peritoneal catheter, nephrostomy or use of ureteral stents, gastrostomy tube, intestinal stents or surgical relief of intestinal obstruction

    Surgery for Malignant Germ Cell Tumors

    • Completion surgery with comprehensive staging is recommended as initial surgery for patients who do not desire fertility preservation
    • Fertility-sparing surgery should be considered for those desiring fertility preservation regardless of stage
      • Should be monitored with ultrasound examinations, if necessary
      • Completion surgery should be considered after finishing childbearing

    Surgery for Sex Cord-Stromal Ovarian Carcinoma

    • Patients with stage IA or IC sex cord-stromal tumors desiring to preserve their fertility should be treated with fertility-sparing surgery with complete staging
      • Should be monitored with ultrasound examinations, if necessary
      • Completion surgery should be considered after finishing childbearing
    • Complete staging is also recommended for all other patients but lymphadenectomy may be omitted for tumors grossly confined to the ovary
    • For metastatic or recurrent granulosa cell tumors, IDS is recommended if feasible
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