Ovarian Cancer: Optimal Cytoreduction or Debulking

Optimal Surgery and Stage III and Stage IV Ovarian Cancer

What is optimal cytoreduction and debulking in ovarian cancer surgery?. Credit: Istockphoto.com/Stock Photo©Dmitrii Kotin

What's meant by "optimal" cytoreduction or debulking surgery for ovarian cancer?

Cytoreduction or Debulking Surgery

If you have undergone surgery for advanced ovarian cancer, one of the most important questions to ask your doctor is whether or not the debulking or cytoreduction was optimal. In other words, has most of the tumor been removed surgically?

What is "Optimal" Cytoreduction or Debulking

It is not always technically possible to remove most or all of the visible cancer during ovarian cancer surgery.

However, we have known that combining aggressive surgery with chemotherapy has led to the best cure rates for over 20 years. Over the years, the type of chemotherapy has changed and so has the definition of how aggressive or “optimal” surgery can or should be.

As recently as 10 years ago, the definition of an “optimal” surgery was that tumors no larger than 2 centimeters were left behind (that is about ¾ of an inch). This might be one, or two or many tumors, none of which exceeded 2 centimeters in size.

With better tools and surgical techniques, we now know that it is technically very possible for an “optimal” surgery to leave behind less than 1 centimeter tumors, getting to “miliary” (tiny “sand” size cancer nodules) in the majority of patients and even microscopic disease (can’t see it or feel it after surgery) in many patients.

Your Overall Medical Condition Makes a Difference

Not all patients are created physiologically equal.

In some cases, a patient may be too old or sick to tolerate the 4-8 hours that it might take to achieve “optimal” results. Also, bleeding or other complications might force the surgeon to stop the surgery earlier than they would have liked. In most cases, it is not the age itself but rather the additional medical conditions a patient might have which dictates how long of a surgery can be tolerated.

Who Your Surgeon Is Makes A Difference

Not all surgeons are created equal. This is true in all professions and all medical specialties. Even among gynecologic oncologists - those best suited to operate on you for ovarian cancer - there is a difference in skills. All are trained in appropriate decision-making and most can perform a cytoreduction to achieve 1-2 cm residual “optimal” surgery in the majority of their patients. At the very least make sure that a gynecologic oncologist is, or was, involved in your surgery.

Do I Need More Radical Surgery?

Medical studies have shown that the more that is removed the better when it comes to ovarian cancer surgery. There is no point beyond which there is no added benefit. However, sometimes to get to miliary or microscopic disease requires very aggressive surgery, including removing parts of the liver, spleen, lung, multiple bowel areas, lymph nodes in difficult areas and beyond. Not all patients can tolerate this well and not all surgeons are comfortable performing these procedures.



Some have called this “ultra”-radical cytoreductive surgery, where the goal is to achieve a microscopic to miliary (“sand” size) “optimal” surgery at almost all costs. Before proceeding, this requires a very thorough risk/benefit discussion with your gynecologic oncologist. If you decide to agree to this degree of surgery, keep in mind that not all surgeons have been trained, or do enough surgical cases of this type, in order to safely achieve this extra measure of “optimal” surgery. Conversely, they may simply not believe that this extra level of surgery is in the best interests of their patients. Although divergent opinions abound, this is a gray area in the medical literature.

Is "Ultra-Radical" Cytoreduction Proven?

Some experts maintain that if “ultra”-radical surgery is required to get to “optimal” surgery, this means that in that patient's situation the cancer is biologically more aggressive. So, they feel that this extra surgery does nothing to improve chances of cure. The reality is that, while this may be true in some patients, we simply do not know which patients are which at the time of surgery, or even after surgery.

Published research suggests that some women benefit more than others from radical and ultra-radical surgery. Cancers have variable degrees of sensitivity to chemotherapy, which is not reliably predictable. Some patients are cured. Some are not.

It boils down to a surgeon making an expert decision during surgery about how far to go with surgery based on what is technically possible and if they think you can tolerate further surgery. This may also be partly based on an assumption regarding biological aggressiveness of your particular cancer.

Keep in mind that in some cases it is technically not possible to get to the best measure of “optimal” without, for example, removing all of the intestines, which is obviously not compatible with good quality of life. Likewise, as mentioned before, in some cases medical conditions or intraoperative complications may force stopping surgery earlier than planned or desired. But there is a difference, which I hope you are starting to understand, between technically “impossible” and judgement calls or lack of surgical skills.

If possible, it is very worthwhile to discuss your gynecologic oncologist’s philosophy about the issues above BEFORE surgery. Again, you may or may not decide that a second opinion is required. You simply MUST develop a great relationship with a gynecologic oncologist of your choice whom you trust implicitly. While I would strongly discourage you from indiscriminate doctor shopping, if this relationship is lacking, find a doctor that you can develop this type of relationship with.

What About Stage 4 Ovarian Cancer?

A few words regarding Stage IV (4) cancer is important. In the past it was thought that if an ovarian cancer appeared in the lung area or in the liver or spleen, the prognosis was so poor that surgery would not help very much. Recent studies suggest that, while each situation is different,this may not be true. The prognosis may be somewhat worse than Stage III, but in most cases, aggressive surgical cytoreduction should still be strongly considered if technically feasible, if the patient understands the risk vs. benefit and if they are able to medically tolerate it. If the surgery is “optimal”, the prognosis can significantly improve and come closer to results seen in Stage III.

Summary of Cytoreductive Surgery Benefits

In general, a MAJOR predictor of the possibility of cure in Stage II to IV cancer is the degree to which “optimal” cytoreduction is achieved. Over the years, the strong weight of medical evidence (many medical papers) supports removing as much cancer as possible before chemotherapy. There are biological theories, which I will not go into detail about, that support the benefits of aggressive cytoreduction in improving chemo-response.

Basically, the surgery makes it easier for the chemotherapy to work by reducing the number of cells that the chemotherapy has to kill (from billions/trillions to hundreds/tens of thousands……or possibly less if nothing visible is left). The surgery also forces all cells that are left to start dividing at the same time (division is how they grow), making it easier for the chemo to kill them at the same time in their lifecycle.

Given this information, if you have not had “optimal” cytoreduction performed, a risk/benefit discussion should be considered about a second operation to complete this task. Issues include the technical and medical reasons for “sub-optimal” cytoreduction, how far away from the very best microscopic “optimal” you already are, the type of chemotherapy you are planning, how much time has passed since the initial surgery and other considerations. 

In general, a discussion about another surgery may be a bigger consideration if the initial surgery was rather minimal due to lack of expertise, or the lack of a gynecologic oncologist. For example, if you had a surgery which amounted mainly to biopsies only, an additional surgery might be reasonable. However, you have to consider how the chemotherapy plan fits into the overall picture. 

Education, Support, and Empowerment

Write out a list of questions to ask your gynecologic oncologist. Bring a friend with you - it always seems that having another person helps you hear all that's said.  Take notes.  Search for ovarian cancer support and information online. And get a second opinion if you aren't 100% sure of the options you are choosing. Not only does being an advocate for yourself as a cancer patient put you in the driver's seat - but for some people with some cancers, it's even been shown to improve survival.

Sources:

Chern, J., and J. Curtin. Appropriate Recommendations for Surgical Debulking in Stage IV Ovarian Cancer. Current Treatment Options in Oncology. 2016. 17(1):1.

Chiva, L, Lapuente, F., Castellanos, T., Alonso, S., and A. Gonzalez-Martin. What Should We Expect After a Complete Cytoreduction at the Time of Interval or Primary Debulking Surgery in Advanced Ovarian Cancer? Annals of Surgical Oncology. 2015 Dec 29. (Epub ahead of print).

Liu, Z., Beach, J., Agdjanian, H. et al. Suboptimal cytoreduction in ovarian carcinoma is associated with molecular pathways characteristic of increased stromal activation, Gynecologic Oncology. 2015. 139(9):394-400.

Vidal, F., Al Thani, H., Haddad, P. et al. Which Surgical Attitude to Choose in the Context of Non-Resectability of Ovarian Carcinomatosis: Beyond Gross Residual Disease Considerations. Annals of Surgical Oncology. 2016. 23(2):434-42.

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