Management

The initial approach to ovarian cancer is to confirm the diagnosis by an exploratory laparotomy.

• once confirmed, standard procedure is to perform a total abdominal hysterectomy, bilateral salpingo-oophorectomy, and infracolic omentectomy
• a thorough surgical staging is made. All serosal surfaces are examined, biopsies are obtained of grossly involved areas, and any free ascitic fluid or peritoneal washings taken for cytologic studies. Retroperitoneal lymph nodes should be examined if the disease appears confined to the ovary as this will alter management.
• patients with stage IA tumours which are well or moderately differentiated, and who wish to remain fertile, may receive a unilateral salpingo-oophorectomy without compromising survival. However, the patient must be made to understand that there is a 10% risk of developing a contralateral lesion (1).
• all gross disease should be debulked. If all macroscopic disease cannot be removed, aim to reduce individual tumour nodules to less than 1.5 cm diameter as nodules larger than this are considered to have a deleterious impact on outcome. This "cytoreductive surgery" may necessitate bowel resection in some cases.

NICE suggest (2):

• management of suspected early (stage I) ovarian cancer
  • role of systematic retroperitoneal lymphadenectomy
    • perform retroperitoneal lymph node assessment as part of optimal surgical staging in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease)
    • do not include systematic retroperitoneal lymphadenectomy (block dissection of lymph nodes from the pelvic side walls to the level of the renal veins) as part of standard surgical treatment in women with suspected ovarian cancer whose disease appears to be confined to the ovaries (that is, who appear to have stage I disease)
      
      
  • adjuvant systemic chemotherapy for stage I disease
    • do not offer adjuvant chemotherapy to women who have had optimal surgical staging13 and have low-risk stage I disease (grade 1 or 2, stage Ia or Ib)
    • offer women with high-risk stage I disease (grade 3 or stage Ic) adjuvant chemotherapy consisting of six cycles of carboplatin
      
      
• management of advanced (stage II-IV) ovarian cancer
  • primary surgery
    • If performing surgery for women with ovarian cancer, whether before chemotherapy or after neoadjuvant chemotherapy, the objective should be complete resection of all macroscopic disease
      
      
  • intraperitoneal chemotherapy
    • do not offer intraperitoneal chemotherapy to women with ovarian cancer, except as part of a clinical trial

Combination chemotherapy is then indicated for patients with advanced disease - stage III or IV - and is also recommended for stage IC or poorly differentiated stage I, and any stage II disease. It is unnecessary for well or moderately differentiated stage IA or B tumours.

With respect to advanced ovarian cancer (stages III or IV) (2)

• platinum based chemotherapy
  • there appears to be no difference in overall or progression free survival from regimens based on carboplatin or cisplatin
    • carboplatin based regimens are associated with less gastrointestinal toxicity but more haematological adverse effects compared with cisplatin based regimens
    • carboplatin is now used routinely in women with advanced ovarian cancer, reflecting the similar efficacy but different toxicity compared with cisplatin
• there is evidence that the addition of paclitaxel to platinum did not significantly improve outcomes compared with platinum based chemotherapy alone. This has led to the suggestion that consensus that taxane/platinum combination treatment should not be exclusively recommended as first line therapy (2)

Subsequent management depends on the response to chemotherapy where indicated.

Reference:

1. GP (22/6/2001); 42.
2. NICE (March 2011). Ovarian cancer The recognition and initial management of ovarian cancer
3. BMJ (October 2006). Clinical Evidence - advanced ovarian cancer.