SURGICAL MANAGEMENT OF OVARIAN AND FALLOPIAN TUBE CANCERS
Primary surgical therapy is indicated in most of the ovarian malignancies, using the principle of cytoreduc-tive surgery, or “tumor debulking.” The rationalefor cytoreductive surgery is that adjunctive radiation therapy and chemotherapy are more effective when all tumor masses are reduced to less than 1 cm in size. Because direct peritoneal seeding is the primary method of intraperitoneal spread, multiple adjacent structures commonly contain tumor, resulting in cytoreductive proce-dures that are often extensive. Each procedure includes the following:
· Peritoneal cytology is obtained on entering the abdomen to assess microscopic spread of tumor. Gross ascites is aspirated and submitted for cytologic analysis or, if no ascites are found, saline irrigation is used to “wash” the peritoneal cavity in an attempt to find microscopic disease.
· Inspection and palpation of the entire peritoneal cavity is done to determine the extent of disease. This includes the pelvis, pericolic gutters, omentum, and upper abdo-men, including the liver, spleen, and undersurface of the diaphragm.
· Partial omentectomy is usually performed, whether or not tumor involvement is evident.
· Sampling of the pelvic and periaortic lymph nodes is performed. Without gross disease, biopsies are obtained from the anterior and posterior cul-de-sac, right and left pelvic sidewalls, right and left pericolic gutters, and diaphragm.
Because most ovarian cancer presents at an advanced stage, adjunctive treatment using chemotherapy is usually neces-sary. First-line chemotherapy is with paclitaxel (Taxol) combined with carboplatin.
With recurrence of disease, other chemotherapeutic agents may be used, including ifosfamide, hexamethylmel-amine, doxorubicin, topotecan, gemcitabine, etoposide, vinorelbine, and tamoxifen. Radiation therapy has only a limited role in the management of ovarian cancer.
Follow-up consists of clinical history and examina-tion, various imaging studies (ultrasound and/or CT), and in epithelial cell tumors, the use of serum tumor markers such as CA-125.