Epithelial ovarian carcinoma: principles of primary surgery.

Surgery remains the most important facet in the initial management of epithelial ovarian cancer. Initial surgical therapy involves the establishment of the diagnosis, appropriate surgical staging, and primary cytoreductive surgery. For patients with advanced disease, surgical staging of ovarian cancer is obvious, but for apparently early disease (Stage I or II), appropriate surgical staging is extremely important and will result in the upstaging of about one-third of patients (usually to Stage III). The theoretical benefit of initial cytoreductive surgery is the removal of large necrotic tumors with a poor blood supply and the removal of large tumors that are in a slower growth phase, leaving behind tumors that are more sensitive to the effects of chemotherapy. There are multiple clinical studies indicating that "optimal" cytoreduction (removal of all tumor larger than 2 cm) results in improved complete response rates to chemotherapy, improved progression-free and overall survival, and a significant increase in the number of patients who will have a negative second-look surgical reassessment. Recent studies by the Gynecologic Oncology Group have further clarified the role of initial surgery, showing that the "biology" of the tumor is also important and that survival is directly related to residual disease within the following categories: (i) microscopic disease, (ii) optimal disease (2 cm or less in residual diameter), and (iii) suboptimal disease (greater than 2 cm diameter of residual disease). In the latter group (suboptimal disease), there may be a benefit to second attempts at surgical cytoreduction (interval cytoreductive surgery).