Ovarian Cancer Surgery

Guidelines

Advanced stage

(provisional document)

OVARIAN CANCER SURGERY - GUIDELINES 2

Specialized multidisciplinary decision making

Treatment must be planned preoperatively at a multidisciplinary team meeting, after workup aiming at rulingout 1 unresectable metastases, 2 secondary ovarian and peritoneal metastasis from other primarymalignancies.

Surgery must be carried out by experienced and trained operators. Surgery in low-volume and low-qualitycenters is discouraged. The existence of an intermediate care facility, and access to an intensive care unitmanagement, are required. Participation to clinical trials is a quality indicator.

Surgical managementComplete resection of all visible disease is the goal of surgical management.

Primary surgery is recommended in patients who can be debulked upfront to no residual tumor with areasonable complication rate.

Minimum required elements in operative reportsAdequate information must be available in the operative report.

The operative report must be structured. Location and size of the disease at the beginning of the operation mustbe described.

All the areas of the abdominal and pelvic cavity must be evaluated and described.

All the completed surgical procedures must be mentioned.

If any, the size and location of residual disease at the end of the operation must be described. Reasons for notachieving complete cytoreduction must be reported.

Minimal information contained in the ESGO operative report1 must be present.

Minimum required elements in pathology reportsAdequate information must be available in the pathology report.

Reporting of postoperative complicationsComplications must be recorded, and selected cases must be discussed at morbidity and mortality conferences.

Selection rules for primary debulkingRisk-benefit ratio in favor of primary surgery when:

There is no unresectable tumor extent

Complete debulking to no residual tumour seems feasible with reasonable morbidity, taking into account thepatient’s status. Decisions are individualized and based on multiple parameters performance status,comorbidities, imaging and/or exploratory laparoscopy or laparotomy, pathologic type and grade.

Patient accepts potential supportive measures as blood transfusions or stoma.

1 The ESGO operative report is available in Appendix 1.

guidelines.esgo.org | esgo-guidelines@esgomail.orgPublished October 2016 by European Society of Gynaecological Oncology Copyrights: © European Society of Gynaecological OncologyESGO Ovarian Cancer Surgery Guidelines (advanced stage)_v1

OVARIAN CANCER SURGERY - GUIDELINES 3

Criteria against abdominal debulking Diffuse deep infiltration of the root of small bowel mesentery

Diffuse carcinomatosis of the small bowel involving such large parts that resection would lead to a shortbowel syndrome remaining bowel < 1.5 m

Diffuse involvement/deep infiltration of

o Stomach/duodenum limited excision is possible

o Head or middle part of pancreas tail of the pancreas can be resected

Involvement of truncus coeliacus, hepatic arteries, left gastric artery celiac nodes can be resected.

Non-resectable metastatic disease stage IVB 2

Central or multisegmental parenchymal liver metastases

Multiple parenchymal lung metastases preferably histologically proven

Nonresectable lymph node metastases

Brain metastases

Examples of potentially resectable extra-abdominal disease

o Inguinal lymph nodes

o Retrocrural or paracardiac nodes

o Focal parietal pleural involvement

o Isolated parenchymal lung metastases

Examples of resectable intra-abdominal parenchymal metastases

o Splenic metastases

o Capsular liver metastases

o Single deep liver metastasis, depending on the location

2 In stage IVA pleural cavity must be surgically assessed by thoracoscopy or intraoperatively.

guidelines.esgo.org | esgo-guidelines@esgomail.orgPublished October 2016 by European Society of Gynaecological Oncology Copyrights: © European Society of Gynaecological OncologyESGO Ovarian Cancer Surgery Guidelines (advanced stage)_v1

ESGO Ovarian Cancer Surgery Guidelines (advanced stage)_v1

Appendix 1: ESGOOvarianCancerOPERATIVEREPORTTheGuidelines, RecommendationandAssuranceQualityCommittee

1

1. SurgeryData 1st SurgeonDr: 2nd Surgeon Dr: TypeofTumor:

Ca-125UI/mlatSurgery: SuspectedstageIV? Extraabdominallymphnodes

2.Surgical Approach and Findings

VolumenofAscites: FrozenSection: FrozenSectionDiagnosis:

Tumorinvolvement

Rightovary Uterus Rightgutter Smallbowelmesentery Liverparenchymal Celiac nodes

Leftovary Bladder/ureter Leftgutter Largebowelmesentery Lesseromentum Abdominalwall

Righttube Sigmoid-Rectum Smallbowel Paraaorticnodes Stomach Skin

Lefttube Recto-vaginalseptum Omentum Right diaphragm Pancreas Pericardiophrenicnodes

Douglas Pelvicwall Largebowel Leftdiaphragm Spleen Inguinalnodes

Vagina Pelvicnodes Appendix Liversurface Hepatichilumnodes Specifyother:

Hospital-Institution: City: Country:Identificationcode (for internal use only): Dateofbirth: DateofSurgery:

0Central1Rightupper2Epigastrium3Leftupper4Leftflank5Leftlower6Pelvis7Rightlower8Rightflank9Upperjejunum10Lowerjejunum11Upperileum12Lowerileum

PCI

0 Interaortocava/preaort.1 PortaHepatis2CeliacAxis3Suprarenal/Splenic4Left aortic5 Left common iliac6 Leftext iliac7 Left inguinal

9 Rightext iliac10Rightcommon iliac11Pre-Paracava12Right cardio phrenic13Left cardio phrenic

AimofSurgery:

IfYes,pleaseselect: SkinLungPleura

Abdominal wall Liver Parenchyma Spleen Parenchyma Other sites:

Approach: Type of procedure:

PRE POST

PERITONEAL CANCER INDEX

8 Right inguinal

+ R+ R0

+: Suspicious or Positive R+: Residual disease R0: No residual disease

RETROPERITONEAL DISEASE

Pf Status-ECOG

ESGOOvarianCancerOPERATIVEREPORT.TheGuidelinesandAssuranceQualityCommittee

2

3. SurgicalProcedures.

Hysterectomy Pelvicnodes

Smallbowelresection

Livercapsuleresection

Unilateralsalpingooophorectomy

Paraaorticnodes

Largebowelresection

AtypicalLiverresection

Bilateralsalpingooophorectomy

InguinalnodesAppendicectomy

Parcialhepatectomy

Smallbowelmesentery

Pericardiophrenicnodes

Peritonectomy gutters

Cholecistectomy

Ureteralresection

Hepatichilumnodes

Diaphragmaticstripping Peritonectomy Morrison

Colorectalresection

Celiacaxis

Diaphragmaticresection

Resectionlesseromentum

Partialcystectomy Infracolicomentectomy Splenectomy

Partialgastrectomy

Pelvicperitonectomy Radicalomentectomy Partialpancreatectomy Other:

Nº anastomoses: Residualsmallbowel(cm): StomaFormation: Type:

Otherprocedures: IP-Port-a-cath IV-Port-a-cath Abdominalwallresection Meshplacement VATS HIPEC

Residualdisease(Intra-abdominal): No macroscopic 0.1-0.5cm 0.6-1cm >1cm

Anycommentthathasnotbeen specified:

Location/size of residual disease:

Durationoftheprocedure(minutes): EstimatedBloodLoss(cc): NºRBCunitstransfused:Severecomplicationsduringtheoperation:PatientwasbroughttoICUwith: NGtube FoleyCath EpiduralCath Endotrachealtube Chesttube Drain/s:(n)

Dateofcompletionofthisoperativereport: OperativeReportfilledbyDr:

Definitive Temporary

Residualdisease(Extra-abdominal): No macroscopic 0.1-0.5cm 0.6-1cm >1cm

Pelvic procedures Medium abdomen procedures Upper abdomen procedures

5ƛŦdzǎŜ {ŜNJƻǎŀƭ [ƛǾŜr tŀƴŎNJŜŀs {dzLJNJŀŘƛŀLJƘNJŀƎ. /ŜƭƛŀŎ !ȄƛǎReason of Residual : Other Hepatic hilum