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Surgery of ovarian and fallopian tube cancer

The treatment goal is to achieve the correct stage determination and to remove all tumor tissue. Surgical treatment for this cancer is often technically demanding and should be carried out at a center with expertise in this type of surgery.  

Patients with unexpected malignant/borderline histology after operation for a presumed benign tumor, must be submitted to evaluation for reoperation at a gynecologic oncology department.

Epithelial ovarian and fallopian tube cancer

In stage I ovarian and fallopian tube cancer, a hysterectomy and removal of the ovaries is performed. BSO (bilateral salpingo-oophorectomy), omentectomy and extirpation of lymph nodes in the pelvis and paraaortally are standard operations. 

For stage II–IV, surgery is the standard initial treatment. The goal is to remove all tumor tissue. BSO, hysterectomy, omentectomy, resection of peritoneal implants and extirpation of suspicious lymph nodes in the pelvis and paraaortal region are usual procedures.

For a patient with a significantly reduced health condition or unresectable tumor, it may be recommended to give start treatment with chemotherapy and evaluate surgery after 3 courses of chemotherapy (neoadjuvant chemotherapy).

In cases where optimal debulking was not achieved by the primary operation, it may be recommended to perform interval debulking, which is optimally performed after three cycles, but not later than after 4 cycles. This is most appropriate when the primary surgery was performed by a non-specialized gynecological oncologist, while an effect on survival was not found after the primary surgery was carried out by a specialized gynecological oncologist.

Secondary debulking after completing six cycles of chemotherapy has not been shown to improve survival.

Borderline ovarian cancer occurs usually in younger women still wishing to become pregnant. Since these tumors seldom are bilateral, a unilateral extirpation of the adnexa may be adequate. It is recommended to perform an omentectomy for full stage determination. If the contralateral ovary appears normal, it is recommended to avoid taking a biopsy from this ovary. Lymph node staging is not recommended. In case of peritoneal implants, it is recommended to perform as complete a surgical resection as possible. With aneuploid tumors, there is a significant increase in risk for recurrence. Bilateral salpingo-oophorectomy and omentectomy should be considered. A hysterectomy is not necessary unless there are implants on the uterus. 

Non-epithelial ovarian cancer

Women wishing to preserve fertility:

  • For younger women wishing to preserve their fertility, it is recommended to refer primary surgery to a regional center with a gynecological oncology department. A unilateral oophorectomy is performed. With tumor involvement of the contralateral ovary, a tumor resection is recommended with preservation of the ovary. Remaining tumor in an ovary is allowed if necessary to preserve fertility because these tumors are extremely sensitive to chemotherapy.
  • For intraabdominal spread, a maximal tumor reduction is performed. 
  • Pelvic and paraaortal lymph node staging is recommended. For a unilateral tumor, it is recommended to perform lymph node staging on the same side. At minimum, palpation with biopsy is done on the enlarged lymph nodes. 

Women not wishing to preserve fertility:

  • Hysterectomy, BSO and omentectomy is recommended.
  • Pelvic and para-aortal lymph node staging is recommended.
  • For advanced disease, debulking surgery is performed including removal of both ovaries.

Women with Y-chromosome:

  • With granulosa cell tumors where the uterus is not removed, curettage is performed to exclude uterine cancer. 
  • Second-look laparotomy is not recommended.

Treatment of recurrence

Data from recent studies on recurrence indicates that surgery can extend survival in cases where all tumor tissue can be removed by operation. A long interval (>12 months), after primary surgery, is a good prognostic sign. 

Surgery may be beneficial for late-occurring localized recurrences, but should be performed at a regional center. Most studies recommend secondary cytoreduction only if single site of disease (vs. carcinomatosis) and long disease-free interval.

The most common form of recurrence in borderline tumors is in the remaining ovary. Surgical treatment with resection or extirpation of the ovary can be performed. For other forms of intraperitoneal recurrence, a resection is performed where possible.

For recurrence of non-epithelial ovarian cancer, removal of all tumor tissue is recommended if possible.

Palliative surgery

Many patients are bothered by subileus/ileus. Intestinal surgery to relieve symptoms should be considered if expected survival is > 1 month and the patient's general health condition allows. Ascites and pleural taps are performed as needed.

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