Why does it matter so much who performs the first operation?

The completeness of cytoreduction — how fully all visible tumor was removed — is the factor within the doctors’ control that most strongly affects the outcome. This sometimes requires removing segments of bowel, peritoneum or other organs, so the operation should be done by a surgeon prepared for that extent.

I was given chemotherapy before surgery. Is that worse?

No, if the whole tumor cannot be removed at the outset or your condition does not allow major surgery. After 3 cycles the response is assessed: often the tumor shrinks, and interval cytoreduction is more often complete. What matters is that the operation is actually performed after chemotherapy.

It helps predict how effective PARP inhibitors will be as maintenance therapy and whether female relatives need screening. The test is recommended for patients with non-mucinous epithelial ovarian cancer, especially high-grade.

Can fertility be preserved?

In young patients with low-risk early cancer, the uterus and the other ovary can be preserved after complete surgical staging. Fertility-sparing surgery is not appropriate for advanced cancer.

What happens if the cancer comes back?

It depends on the time since platinum treatment and on the extent of spread. For a late recurrence in patients in good condition whose first operation was complete, repeat cytoreduction is possible. Otherwise treatment is with drugs.

Ovarian cancer: cytoreductive surgery, HIPEC, chemotherapy

Ovarian cancer is most often diagnosed after the tumor has already spread across the peritoneum: the symptoms are nonspecific, and there is no reliable screening. Yet even at advanced stages curative treatment is possible for many patients, and its core is surgery that leaves no visible tumor in the abdomen. The completeness of cytoreduction has the strongest influence on outcome, so the first operation should be performed by a surgeon prepared to remove affected segments of bowel, peritoneum and other organs if needed. Chemotherapy and maintenance therapy complement surgery; drug treatment becomes the mainstay only when surgery is impossible or too risky.

Kateryna Valikhnovska, MD, surgical oncologist, during a laparoscopic operation — The laparoscopic stage of an operation: the lights in the operating room are dimmed because the surgeon works from the camera image on the monitor.

Why ovarian cancer develops

The most common type is high-grade serous carcinoma; many of these tumors start not in the ovary itself but in the fallopian tubes. Endometrioid, clear cell and mucinous carcinomas and low-grade serous carcinoma are less common; borderline tumors are considered separately, as they behave much less aggressively.

The strongest risk factor is an inherited mutation in the BRCA1 or BRCA2 gene, less often Lynch syndrome. Risk also rises with age, with ovarian or breast cancer in the family, and with endometriosis. That is why BRCA genetic testing is recommended for patients with non-mucinous epithelial ovarian cancer, especially high-grade: the result affects both treatment and screening of female relatives. Carriers are advised to have their fallopian tubes and ovaries removed preventively once they have completed childbearing.

Are there symptoms

Early symptoms are vague: bloating, a feeling of fullness, early satiety, lower abdominal pain, frequent urination. They are easy to blame on the bowel or on age. An enlarging abdomen due to fluid (ascites), shortness of breath and weight loss usually indicate advanced disease.

If such complaints persist for several weeks and are new to you, it is worth having a pelvic ultrasound and a CA-125 test rather than waiting for them to pass.

Examinations needed

Transvaginal ultrasound by an experienced specialist — the nature of the ovarian mass, ascites, signs of spread.
CA-125 tumor marker, HE4 when indicated, and CEA and CA 19-9 to rule out a digestive tract tumor.
Contrast-enhanced CT of the chest, abdomen and pelvis — peritoneal spread, lymph nodes, liver, pleural cavity; pelvic MRI when the nature of the mass is unclear.
Biopsy — for advanced tumors if treatment will start with chemotherapy: guided by ultrasound or CT, or during laparoscopy.
Diagnostic laparoscopy — to assess whether the whole tumor can be removed when CT leaves this unclear.
BRCA genetic testing and tumor testing for homologous recombination deficiency (HRD) — to choose maintenance therapy.
Upper endoscopy and colonoscopy — when indicated, to rule out a stomach or bowel tumor with ovarian metastases.

When surgery is possible

For early cancer confined to the ovaries, surgical staging is performed: removal of the uterus, tubes and ovaries and the omentum, peritoneal washings and biopsies and, when indicated, removal of pelvic and para-aortic lymph nodes. It is important to remove the tumor without rupturing its capsule. Carefully selected young patients with low-risk early cancer may keep the uterus and the other ovary after complete staging.

For advanced cancer, if all visible tumor can be removed and the patient’s condition allows, treatment starts with primary cytoreductive surgery. If complete cytoreduction is not possible at the outset or the patient is not fit for major surgery, 3 cycles of chemotherapy are given first, the response is assessed and, if there is no progression, interval cytoreduction follows. The MDT chooses between these paths based on CT, laparoscopy and general condition.

If surgery is not possible now

Treatment is based on platinum and taxane chemotherapy; afterward the response is assessed and surgery is discussed again. If ascites or pleural effusion interferes with breathing and eating, the fluid is drained.

For a first recurrence that appears long after platinum treatment, some patients may have repeat cytoreduction — when general condition is good, the first operation was complete, and there is a chance to remove everything again. Other recurrences are treated with drugs.

How the operation is performed

Cytoreduction is done through a midline incision: the uterus with tubes and ovaries, the omentum and all visible tumor deposits are removed — if necessary together with areas of peritoneum (peritonectomy), bowel, the spleen, or the surface of the diaphragm. The goal is to leave no visible tumor. In advanced disease, lymph nodes that are not enlarged on CT or during surgery are not removed systematically.

In some patients, HIPEC is considered during interval cytoreduction — washing the abdomen with a heated chemotherapy solution immediately after the tumor is removed. The MDT decides on the indications. In selected cases, early staging, when the tumor is confined to the ovary, can be performed laparoscopically, avoiding tumor rupture.

In ovarian cancer, the first operation matters most. What is not removed then is harder to remove later.

Kateryna Valikhnovska, MD, surgical oncologist

Recovery after surgery

Care follows the enhanced recovery after surgery (ERAS) protocol: early mobilization, early feeding, controlled pain relief. After extensive cytoreduction the hospital stay is longer, the first days may be spent in intensive care, and sometimes a temporary stoma is created while the bowel heals.

Once the patient has recovered, usually within the first 6 weeks after surgery, chemotherapy starts or continues. After a response, taking into account BRCA/HRD testing and stage, maintenance therapy is discussed — PARP inhibitors, bevacizumab or a combination. Premenopausal patients enter surgical menopause after removal of the ovaries; it is worth discussing its symptoms with your doctor.

Follow-up

For the first 2–3 years, examination, usually with CA-125, every 3–4 months, then less often; CT is done for symptoms, a rising CA-125 or on the doctor’s schedule. Bloating, pain or an enlarging abdomen should be reported right away, without waiting for the scheduled visit.

What to bring to the consultation

pelvic ultrasound reports, CT or MRI discs with reports;
CA-125, HE4, CEA, CA 19-9 results;
the pathology report and tissue blocks with slides, if a biopsy or surgery has already been done;
the previous operative report and discharge summary;
the BRCA test result and information about ovarian and breast cancer in the family;
chemotherapy records, if treatment has already started.

If some materials are missing, that is no reason to postpone the consultation: some examinations can be done on site.

The consultation is free of charge. How it goes and how long it takes is described on the page “Oncologist Consultation”.