Ovarian cancer is one of the most common gynecologic malignancies with the highest mortality and recurrence rates. For patients with ovarian cancer, we can prolong their survival time by some means, and the position of surgery is irreplaceable in the treatment of ovarian cancer. Tumor cytoreductive surgery is a common surgical procedure for the treatment of ovarian tumors. This section will introduce the knowledge of ovarian cancer tumor cytoreductive surgery.
I. Preface
Ovarian cancer is one of the most common gynecologic malignancies. In our country, probably cervical cancer is still the most common, but ovarian cancer is the most painful because of the highest mortality rate and the highest recurrence rate. In fact, recurrence of cervical cancer is much more difficult to treat than recurrence of ovarian cancer. We can at least prolong her survival time for recurrence of ovarian cancer, while it is difficult for us to treat recurrence of cervical cancer.
The surgical treatment of ovarian cancer is the most challenging among the surgical treatment of gynecologic tumors. We often say that surgery for cervical cancer has a definite style, while surgery for ovarian cancer is very difficult for one person after another. The status of surgery is irreplaceable in the treatment of ovarian cancer. Without a good surgery, it is impossible to have a relatively good result.
Initial tumor cell reduction surgery
(I) Purpose of primary tumor cytoreductive surgery
The purpose of initial tumor cytoreductive surgery is to clarify the diagnosis of ovarian cancer; surgical staging; and maximum removal of tumor, which is mainly for those patients with advanced ovarian cancer.
(B) Definition and meaning of tumor cytoreduction or bulky resection
Cytoreductive surgery or debulking surgery actually refers to those surgical measures that aim to maximize the removal of tumor in patients with advanced ovarian cancer.
The real meaning of debulking surgery is: (1) to remove as much of the tumor as possible to achieve a clean cut; (2) if a clean cut is not possible, to do everything possible to reduce the maximum diameter of the remaining tumor to less than 1 cm. In order to achieve this goal, one can actually do whatever it takes. Many surgical methods are now available.
(C) Relevant provisions of the new version of NCCN practice guidelines
The latest edition of NCCN practice guidelines gives us a lot of information: full staging surgery is the standard procedure for patients with clinical stage I; for patients with stage Ia and Ic who wish to preserve their reproductive function, full staging surgery with preservation of reproductive function can be performed; tumor cytoreduction is the standard procedure for patients with clinical stage II, III or IV; for patients with advanced stage who are not suitable for surgery, they can be treated with chemotherapy first and then intermediate tumor cytoreduction. For patients with advanced disease who are not suitable for surgery, they can be treated with chemotherapy followed by intermediate tumor cytoreductive surgery, but pathological confirmation must be available before chemotherapy.
The NCCN describes a number of initial surgical irregularities: unresected uterus; unresected adnexa; unresected greater omentum; incomplete staging; and residual tumor with the possibility of resection.
The NCCN also makes provisions for the treatment of suspicious patients: for patients with suspicious IA, IB, and G1, surgical staging. Suspicious IA, IB, G2: ① If no chemotherapy, surgery must be staged; ② Suspicious residual, surgery must be staged; ③ Possible no residual, chemotherapy for 6 courses or staged surgery. Suspicious IA, IB, G3 or IC: ①suspicious residual, surgical staging; ②possibly no residual, 6 courses of chemotherapy or staged surgery. stage II, III, IV: ①with resectable tumor residual, tumor cytoreduction; ②with unresectable tumor residual, 6 to 8 courses of chemotherapy or 3 to 6 courses of chemotherapy with subsequent tumor cytoreduction.
For junctional ovarian epithelial carcinoma, the NCCN has relevant regulations: at any stage, full staging surgery or tumor cytoreductive surgery should be performed; preservation of reproductive function is not limited by stage; if there is no invasive implantation after surgery, no further treatment is required; if there is invasive implantation after surgery, observation or chemotherapy is an option; if the previous surgery is not formal but there is residual, full staging surgery should be performed; if the previous surgery is not formal, but no residual, the patient may choose to undergo observation, full staging surgery or chemotherapy.
(iv) Basic principles of initial surgery
1. When the tumor is confined to the ovary or pelvis
When the tumor is confined to the ovary or pelvis, full staging surgery is the standard procedure. Generally, a median longitudinal incision in the abdomen is used. Ascites or washout fluid should be retained for cytological examination. The peritoneal surface should be visible and any suspicious areas or adhesions should be excised or biopsied, and biopsies should be taken randomly in patients without suspicious findings. If no definite suspicious lesions are found, biopsies should be taken with emphasis on the following sites for biopsy: bilateral lateral colonic sulci, transverse septal surface (Pap slices are also acceptable) and pelvic peritoneum. Excision of uterus and bilateral adnexa should be performed to ensure complete removal of tumor as much as possible. For patients who wish to preserve fertility, excision of the affected adnexa can be performed. The greater omentum should be completely removed. The pelvic lymph nodes should be resected. Abdominal aortic lymph node dissection should remove the entire lymphatic fatty tissue on both sides of the inferior vena cava and abdominal aorta.
The NCCN guidelines state that there are two criteria for doing parietal aortic lymph node dissection: a minimum standard, which means that it should reach the level of the inferior mesenteric artery; and a maximum standard, which is to cut to the level of the renal vessels. Because the right ovarian vein is returning to the inferior vena cava, and the left ovarian vein is returning to the renal vessels and renal veins, both of which are very high. And our recent study found that there are more lymph node metastases in this segment above the inferior mesenteric artery than in the lower lymph nodes. This shows that it is not a progressive metastasis, but a jump, it actually jumps directly above the inferior mesenteric artery through the blood vessels of the ovary. So it must be done at the level of the renal vasculature. We have recently found that many patients have completely negative pelvic lymph nodes, but the lymph nodes above the inferior mesenteric artery can have more than a dozen positive ones.
2.When the tumor involves the upper abdominal cavity
When the tumor involves the epigastric cavity, in order to obtain the maximum tumor cell reduction, the maximum diameter of residual tumor