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Cytoreductive Surgery for Ovarian Cancer

Medically Reviewed by Sabrina Felson, MD on July 25, 2022

Almost every woman with ovarian cancer will have surgery. The kind of surgery depends on your cancer type and stage, and your overall health.

Because ovarian cancer has few or no symptoms, about three-quarters of people are diagnosed when it’s at the advanced stage. Standard treatment for advanced ovarian cancer – meaning it has spread beyond where the tumor first started – is cytoreductive surgery (CRS), a complicated procedure.

What Is Cytoreductive Surgery?

Your ovaries and other reproductive organs are located in your abdomen. The peritoneum lines the organs in your abdomen. It bends and folds around the organs. Some of the folds come together to make the omentum. This holds your organs in place and protects them.

About 90% of ovarian cancers are epithelial, meaning the cancer started in the outer layer of the ovary. The closeness of this area to the omentum and peritoneum gives cancer cells a clear path to spread into the abdominal cavity.

Cancer surgeons usually operate to stage and remove ovarian cancer at the same time. In this type of exploratory surgery – also called “upfront cytoreductive surgery” – doctors look for signs of cancer in the abdominal cavity. Before the operation, your surgeon may use a drug to help show – or “light up” where cancer might be hidden. To do that, they’ll use a special imaging machine during surgery.

Doctors test (biopsy) tissue samples from several areas in your abdomen to find out where the cancer may have spread. They rinse the peritoneum with saline (salt water) and look at the fluid for signs of cancer.

Then, the surgeon works to remove as much visible cancer around the ovaries and throughout the abdomen as possible, especially tumors larger than 1 centimeter (about one-third of an inch). The more cancer that’s removed during CRS, the better the outcome.

CRS is complex and may include removing:

  • The uterus (a total hysterectomy)
  • Both ovaries and the fallopian tubes (a bilateral salpingo-oophorectomy)
  • The omentum
  • Any visible tumors or cancerous tissue in the organs or elsewhere in the abdomen
  • Any affected lymph nodes in the abdomen

If the cancer spreads outside the reproductive system, the surgeon may have to remove parts of other organs including the colon, small intestine, spleen, bladder, and gallbladder.

You may see cytoreductive surgery referred to as “debulking” or debulking cytoreductive surgery. Debulking simply means removing as much cancer as possible through surgery. An effort is going on to only use the term “cytoreductive” for this type of surgery, especially when talking about ovarian cancer.

Cytoreductive Surgery and Chemotherapy

CRS is usually done in combination with chemotherapy. If your cancer has not spread outside of the abdominal cavity, chemotherapy drugs may be delivered directly into your abdomen through a small tube. This is called intraperitoneal (IP) chemotherapy. It can be done during or after your surgery. The medical team usually only delivers IP chemotherapy when all visible cancer has been successfully removed. Chemotherapy doesn’t work as well when too much cancer remains. As an alternative to, or along with IP, you might also be given intravenous chemotherapy after surgery.

One advantage of IP chemotherapy is that it targets cancer cells directly, but can also travel outside of your abdomen to target cancer cells elsewhere in the body. This type of chemotherapy has been shown to improve survival rates. But it tends to have harsher side effects. That can make some people stop their treatment. If you can tolerate its side effects, a large study showed that combination IP and intravenous chemotherapy improved survival for ovarian cancer by more than a year.

If you are unable to have upfront cytoreductive surgery because of other health issues, you may be given chemotherapy first. Doctors might also use chemotherapy first in an effort to shrink tumors before cytoreductive surgery.

Doctors are researching another procedure called CRS/HIPEC (cytoreductive surgery/hyperthermic intraperitoneal chemotherapy). In it, warm chemotherapy is pumped into the abdominal cavity after cytoreductive surgery. The heat is believed to help the chemotherapy penetrate the surface of the peritoneum better and help kill more cancer cells. Patients seem to tolerate this method of direct chemotherapy delivery better than standard IP. An added benefit: there’s only one treatment after surgery.

Early studies of CRS/HIPEC showed poor outcomes. Later studies showed better results. But the procedure is not all that common in the U.S. because of continued concerns about its benefits and safety.

Researchers in China did a 7-year study that found CRS/HIPEC produced better outcomes for patients with stage III ovarian cancer than cytoreductive surgery alone. The median survival was almost 16 months longer for patients who had the combined procedure. And 3-year survival rates were almost 11% better.

What to Know if You’re Having CRS

Cytoreductive surgery followed by combination chemotherapy is the standard treatment for ovarian cancer. “Optimal” cytoreduction (successfully removing all visible tumors or only leaving tumors less than 1 cm in size), improved survival.

Also, people with ovarian cancer have better outcomes if cytoreductive surgery (alone or in combination with IP or HIPEC chemotherapy) is performed at a medical center with a team of doctors experienced doing the procedure.

During cytoreductive surgery, you are under general anesthesia – asleep. Depending on the spread of the cancer, the operation can take anywhere from 8 to 14 hours. Estimates vary, but most people stay in the hospital about a week after surgery. Complete recovery at home usually takes another 4-6 weeks. You should expect pain afterward. But, you’ll be given medicine at the hospital and at home to manage it.

During this time you might notice some vaginal bleeding or discharge for several days or several weeks. Tell your doctor if the bleeding:

  • Stops, then restarts
  • Gets heavier
  • Changes color from red or brown to green or yellow
  • Has an unpleasant smell

Other complications may include:

  • A rare infection of your chemotherapy port (a disc placed under your skin that’s used to give you chemo), if you have one
  • An infection where your incision was
  • Blood clots
  • Swelling
  • Trouble using the bathroom

There is some concern about such complicated surgery as CRS and whether it truly benefits patients and makes their quality of life better. So far, there is no sure evidence that cytoreductive surgery improves survival in patients with ovarian cancer. And, cytoreductive surgery carries similar risks of complications and death as other types of radical (complicated) surgery. Some doctors say, in ovarian cancer, the biology of the tumor is more important to surgical outcomes than aggressive operations.

Another challenge is that doctors in the U.S. feel unsure about CRS/HIPEC and don’t use it often. Fewer than 15 hospital centers in the country perform the HIPEC treatment. Elsewhere in the world, it is seen as a promising therapy, and said to be the only one to achieve notable 5-year survival rates in abdominal cancers, including ovarian cancer.

Currently, not all patients are able to have cytoreductive surgery because of their tumor type, the extent of their disease, or the likelihood that they might not survive the procedure. A team of doctors – including your surgeon and those specializing in cancer, anesthesiology, pathology, and radiology – will help figure out whether you are a good candidate. And as always, you should get a second opinion.

Show Sources

SOURCES:

American Cancer Society: “Can Ovarian Cancer Be Found Early?” “Chemotherapy for Ovarian Cancer,” “If You Have Ovarian Cancer,” “Surgery for Ovarian Cancer,” “Treatment of Invasive Epithelial Ovarian Cancers, by Stage.”

Annals of Surgical Oncology: “Time to Evolve Terminology from ‘Debulking’ to Cytoreductive Surgery (CRS) in Ovarian Cancer.”

Cancer Research UK: “Epithelial Ovarian Cancer,” “Problems after Ovarian Cancer Surgery,” “Types of Surgery for Ovarian Cancer.”

Cleveland Clinic: “Peritoneum.”

Indian Journal of Surgical Oncology: “Cytoreductive Surgery and Peritonectomy Procedures.”

JAMA Network: “Are We Ready for Hyperthermic Intraperitoneal Chemotherapy in the Upfront Treatment of Ovarian Cancer?” “Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Safety Is Only Half of the Story,” “Morbidity and Mortality Rates Following Cytoreductive Surgery Combined With Hyperthermic Intraperitoneal Chemotherapy Compared With Other High-Risk Surgical Oncology Procedures.”

Journal of Gynecologic Oncology: “Role of Aggressive Surgical Cytoreduction in Advanced Ovarian Cancer.”

Moffitt Cancer Center: “Cytoreductive Surgery,” “Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC),” “Debulking Cytoreductive Surgery for Ovarian Cancer,” “Ovarian Cancer Surgery.”

National Cancer Institute: “Intraperitoneal Chemotherapy in Advanced Ovarian Cancer Improves Survival, But Is Underused,” “Debulking,” “Ovarian Epithelial, Fallopian Tube, and Primary Peritoneal Cancer Treatment (PDQ)–Patient Version.”

University of Maryland Medical Center: “Cytoreductive Surgery and HIPEC—FAQs.”

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