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Stage III and IV Ovarian Epithelial Cancer

Note: Some citations in the text of this section are followed by a level of evidence. The PDQ editorial boards use a formal ranking system to help the reader judge the strength of evidence linked to the reported results of a therapeutic strategy. (Refer to the PDQ summary on Levels of Evidence for more information.)

The same observations concerning surgery and chemotherapy pertain to patients with stage III or stage IV disease; however, the outcome of patients with stage IV disease is somewhat less favorable. The role of surgery for patients with stage IV disease is unclear, but in most instances, the bulk of the disease is intra-abdominal and similar surgical procedures are applied as in the management of stage III patients. Also, the options for intraperitoneal (IP) regimens are less likely to apply both practically (as far as inserting an IP catheter at the outset) and theoretically (aimed towards destroying microscopic disease in the peritoneal cavity).

Clinical trials have traditionally explored regimens leading to improvements in eradicating minimal (=1 cm) or gross (>1 cm) residual disease with postoperative systemic therapy. More recently, larger trials have stratified for the extent of residuum but have included all patients regardless of residuum within the same trial, and these are appropriate to consider as the first option for patients with stage III and stage IV disease.



Surgery has been used as a therapeutic modality and also to adequately stage the disease. Surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as can safely be performed. While primary cytoreductive surgery may not correct for biologic characteristics of the tumor, considerable evidence indicates that the volume of disease left at the completion of the primary surgical procedure is related to patient survival.[1] A literature review showed that patients with optimal cytoreduction had median survival of 39 months compared with survival of only 17 months in patients with suboptimal residual disease.[1] Results of a retrospective analysis of 349 patients with postoperative residual masses =1 cm, however, suggested that patients who present at the outset with large-volume disease and achieve small-volume disease by surgical debulking have poorer outcomes than similar patients who present with small-volume disease.[2] Gradual improvement in survival with decreasing residual tumor volume is likely. Although the association may not be causal, retrospective analyses, including a meta-analysis of patients receiving platinum-based chemotherapy, have found cytoreduction to be an independent prognostic variable for survival.[3,4]

The value of interval cytoreductive surgery has also been the subject of phase III trials. In the first study, performed by the European Organisation for Research and Treatment of Cancer, patients subjected to debulking after 4 cycles of cyclophosphamide and cisplatin (with additional cycles given later) had an improved survival over patients who completed 6 cycles of this chemotherapy without surgery.[5][Level of evidence: 1iiB] A similar trial by the Gynecologic Oncology Group (GOG-162 [6]), but using paclitaxel plus cisplatin as the chemotherapy, did not demonstrate any advantage from interval cytoreductive surgery. Wider use of maximal surgical effort at the time of diagnosis by US gynecologic oncologists may be a factor accounting for these divergent results. Although many patients with stage IV disease undergo cytoreductive surgery, whether this improves survival has not been established.[7]


WebMD Public Information from the National Cancer Institute

Last Updated: May 04, 2006
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.

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