Zusammenfassung
Durch das zunächst asymptomatische und später unspezifische Beschwerdebild wird das Ovarialkarzinom im Großteil der Fälle im fortgeschrittenen Stadium diagnostiziert. Ein wichtiger prognostischer Faktor ist das Erreichen der makroskopischen Tumorfreiheit im Rahmen der Primäroperation. Dies geht mit einem medianen Überlebensvorteil von > 5 Jahren einher. Die systematische LNE (Lymphonodektomie) hat beim fortgeschrittenen Ovarialkarzinom mit unauffälligen Lymphknoten nach aktueller Datenlage keinen Einfluss auf das Gesamtüberleben und sollte daher ab dem Stadium IIB bei in der Bildgebung und palpatorisch unauffälligen Lymphknoten auch nicht mehr durchgeführt werden. Im frühen Krankheitsstadium ist die Operation im Sinne eines Stagings primär von diagnostischer Bedeutung. In diesen Fällen bleibt die systematische LNE ein wichtiger Bestandteil der Operation, um den Nodalstatus und damit das FIGO(Fédération Internationale de Gynécologie et dʼObstétrique)-Stadium korrekt festlegen zu können. Auch das perioperative Management hat Auswirkungen auf das Gesamtüberleben und führte zuletzt zu einer Reduktion von frühen Ereignissen im QS(Qualitätssicherung)-Programm der AGO(Arbeitsgemeinschaft Gynäkologische Onkologie)-Ovar. Internationale Studien zum ERAS(Enhanced Recovery After Surgery)-Protokoll konnten zeigen, dass über einen multimodalen Ansatz mit schnellerer postoperativer Erholung verbunden mit einer kürzeren Liegedauer letztlich auch Kosten für das Gesundheitssystem reduziert werden können. Der international kontrovers diskutierten Frage zum optimalen Operationszeitpunkt widmet sich die TRUST-Studie erneut und auf höchstem operativem Niveau. Ergebnisse werden für 2024 erwartet.
Abstract
As ovarian cancer is initially asymptomatic and does not typically present with specific symptoms, it often remains undiscovered until advanced stages of disease. Achieving macroscopic complete resection in primary debulking surgery is one of the most important prognostic factors and is associated with a median survival benefit of >5 years. According to current data, systematic lymphadenectomy (LNE) in advanced ovarian cancer with inconspicuous lymph nodes has no influence on overall survival. It should therefore no longer be carried out above stage IIB in cases of inconspicuous lymph nodes by imaging and palpation. In early stages of disease surgery is primarily of diagnostic importance in the sense of a staging. In these cases, systematic LNE remains an important component of the surgical procedure in order to be able to correctly determine the nodal status and therefore the Fédération Internationale de Gynécologie et dʼObstétrique (FIGO) stage. The perioperative management also has consequences for the overall survival and ultimately led to a reduction of early events in a recent analysis of the quality assurance (QA) program of the working group on gynecology and oncology (AGO-Ovar). International studies on the enhanced recovery after surgery (ERAS) protocol could show that using a multimodal approach with faster postoperative recovery associated with a shorter hospital stay, the costs for the healthcare system could also ultimately be reduced. The optimal timing of surgery in advanced ovarian cancer has internationally been the subject of debate for many years and has recently been readdressed by the TRUST trial at the highest surgical level. The results are expected for 2024.
Literatur
Harter P, Hilpert F, Pfisterer J, Sehouli J, Lamparter C, Kerkmann M, du Bois A (2020) Die Therapiequalität des fortgeschrittenen Ovarialkarzinoms in Deutschland. Daten der QS Ovar der AGO Studiengruppe. Frauenarzt 61(3):182–188
Du Bois A, Reuss A, Pujade-Lauraine E, Harter P, Ray-Coquard I, Pfisterer J (2009) Role of surgical outcome as prognostic factor in advanced epithelial ovarian cancer: a combined exploratory analysis of 3 prospectively randomized phase 3 multicenter trials: by the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR) and the Groupe d’Investigateurs Nationaux Pour les Etudes des Cancers de l’Ovaire (GINECO). Cancer 115(6):1234–1244
Modesitt SC, Sarosiek BM, Trowbridge ER, Redick DL, Shah PM, Thiele RH, Hedrick TL (2016) Enhanced recovery implementation in major gynecologic surgeries: effect of care standardization. Obstet Gynecol 128(3):457–466
Nelson G, Altman AD, Nick A, Meyer LA, Ramirez PT, Achtari C, Acheson N (2016) Guidelines for postoperative care in gynecologic/oncology surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations—Part II. Gynecol Oncol 140(2):323
Kalogera E, Bakkum-Gamez JN, Jankowski CJ, Trabuco E, Lovely JK, Dhanorker S, Bursiek AA (2013) Enhanced recovery in gynecologic surgery. Obstet Gynecol 122(2 Pt 1):319
Nelson G, Kalogera E, Dowdy SC (2014) Enhanced recovery pathways in gynecologic oncology. Gynecol Oncol 135(3):586–594
Pache B, Joliat GR, Hübner M, Grass F, Demartines N, Mathevet P, Achtari C (2019) Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery. Gynecol Oncol 154(2):388–393
SEER (2020) Cancer of the ovary-cancer stat facts. https://seer.cancer.gov/statfacts/html/ovary.html. Zugegriffen: 13.12.2021
Thrall MM, Goff BA, Symons RG, Flum DR, Gray HJ (2011) Thirty-day mortality after primary cytoreductive surgery for advanced ovarian cancer in the elderly. Obstet Gynecol Clin North Am 118(3):537
Aletti GD, Santillan A, Eisenhauer EL, Hu J, Aletti G, Podratz KC, Bristow RE, Chi DS, Cliby WA (2007) A new frontier for quality of care in gynecologic oncology surgery: multi-institutional assessment of short-term outcomes for ovarian cancer using a risk-adjusted model. Gynecol Oncol 107(1):99–106
Axtell AE, Lee MH, Bristow RE, Dowdy SC, Cliby WA, Raman S, Weaver JP, Gabbay M, Ngo M, Lentz S, Cass I, Li AJ, Karlan BY, Holschneider CH (2007) Multi-institutional reciprocal validation study of computed tomography predictors of suboptimal primary cytoreduction in patients with advanced ovarian cancer. J Clin Oncol 25(4):384–389
van de Vrie R, Rutten MJ, Asseler JD, Leeflang MMG, Kenter GG, Mol BWJ, Buist M (2019) Laparoscopy for diagnosing resectability of disease in women with advanced ovarian cancer. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD009786.pub3
S3-Leitlinie Diagnostik, Therapie und Nachsorge maligner Ovarialtumoren Version 5.0 – September 2021 AWMF-Registernummer: 032/035O.
Bolze PA, Collinet P, Golfier F, Bourgin C (2019) Surgery in early-stage ovarian cancer: Article drafted from the French Guidelines in oncology entitled „Initial management of patients with epithelial ovarian cancer“ developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa. Gynecol Obstet Fertil Senol 47(2):168–179
Crafton SM, Cohn DE, Llamocca EN, Louden E, Rhoades J, Felix AS (2020) Fertility-sparing surgery and survival among reproductive-age women with epithelial ovarian cancer in 2 cancer registries. Cancer 126(6):1217–1224
Powless CA, Aletti GD, Bakkum-Gamez JN, Cliby WA (2011) Risk factors for lymph node metastasis in apparent early-stage epithelial ovarian cancer: implications for surgical staging. Gynecol Oncol 122(3):536–540
Maggioni A, Benedetti Panici P, Dell’Anna T, Landoni F, Lissoni A, Pellegrino A, Rossi RS, Chiari S, Campagnutta E, Si G, Angioli R, Manci N, Calcagno M, Scambia G, Fossati R, Floriani I, Torri V, Grassi R, Mangioni C (2006) Randomised study of systematic lymphadenectomy in patients with epithelial ovarian cancer macroscopically confined to the pelvis. Br J Cancer 95(6):699–704
Minig L, Heitz F, Cibula D, Bakkum-Gamez JN, Germanova A, Dowdy SC, Kalogera E, Zapardiel I, Lindemann K, Harter P, Scambia G, Petrillo M, Zorrero C, Zanagnolo V, Rebollo JMC, du Bois A, Fotopoulou C (2017) Patterns of lymph node metastases in apparent stage I low-grade epithelial ovarian cancer: a multicenter study. Ann Surg Oncol 24(9):2720–2726
Trimbos B, Timmers P, Pecorelli S, Coens C, Ven K, Van der Burg M, Casado A (2010) Surgical staging and treatment of early ovarian cancer: long-term analysis from a randomized trial. JNCI J Natl Cancer Inst 102(13):982–987
Falcetta FS, Lawrie TA, Medeiros LRF, da Rosa MI, Edelweiss MI, Stein AT, Zelmanowicz A, Moraes AB, Zanini RR, Rosa DD (2016) Laparoscopy versus laparotomy for FIGO stage I ovarian cancer. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD005344.pub4
Harter P, Sehouli J, Lorusso D, Reuss A, Vergote I, Marth C, du Bois A (2019) LION: Lymphadenectomy in ovarian neoplasms—A prospective randomized AGO study group led gynecologic cancer intergroup trial. N Engl J Med 380:822–832
Tozzi R, Valenti G, Vinti D, Garruto Campanile R, Cristaldi M, Ferrari F (2021) Rectosigmoid resection during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC–IV ovarian cancer: morbidity of gynecologic oncology vs. colorectal team. Gynecol Oncol 32(3):e42
Kalogera E, Dowdy SC, Mariani A, Weaverb AL, Aletti G, Bakkum-Gamez JN, Cliby WA (2013) Multiple large bowel resections: potential risk factor for anastomotic leak. Gynecol Oncol 130(1):213–218
Zivanovic O, Sima CS, Iasonos A, Hoskins VJ, Pingle PR, Leitao MMM Jr., Sonoda Y, Abu-Rustum NR, Barakat RR, Chi DS (2010) The effect of primary cytoreduction on outcomes of pationts with FIGO stage IIIC ovarian cancer stratified by the initial tumor burden in the upper abdomen cephalad to the greater omentum. Gynecol Oncol 116:351–357
Dowdy SC, Loewen RT, Aletti G, Feitoza SS, Cliby W (2008) Assessment of outcomes and morbidity following diaphragmatic peritonectomy for women with ovarian carcinoma. Gynecol Oncol 109(2):303–307
Di Donato V, Bardhi E, Tramontano L, Capomacchia FM, Palaia I, Perniola G, Plotti F, Angioli R, Giancotti A, Muzii L, Benedetti Panici P (2020) Management of morbidity associated with pancreatic resection during cytoreductive surgery for epithelial ovarian cancer: a systematic review. Eur J Surg Oncol 46(4, Part A):694–702
Chang S‑J, Bristow RE, Chi DS, Cliby WA (2015) Role of aggressive surgical cytoreduction in advanced ovarian cancer. J Gynecol Oncol 26(4):336–342
Heitz F, Harter P, Alesina PF, Walz MK, Lorenz D, Groeben H, Heikaus S, Fisseler-Eckhoff A, Schneider S, Ataseven B, Kurzeder C, Prader S, Beutel B, Traut A, du Bois A (2016) Pattern of and reason for postoperative residual disease in patients with advanced ovarian cancer following upfront radical debulking surgery. Gynecol Oncol 141(2):264–270
Du Bois A, Reuss A, Harter P, Pujade-Lauraine E, Ray-Coquard I, Pfisterer J (2010) Potential role of lymphadenectomy in advanced ovarian cancer: a combined exploratory analysis of three prospectively randomized phase III multicenter trials. J Clin Oncol 28(10):1733–1739
Aletti GD, Dowdy S, Podratz KC, Cliby WA (2006) Role of lymphadenectomy in the management of grossly apparent advanced stage epithelial ovarian cancer. Am J Obstet Gynecol 195(6):1862–1868
Vergote I, Tropé CG, Amant F, Kritenesen GB, Ehlen T, Johnson N et al (2010) Neoadjuvant chemotherapy or primary surgery in stage IIIC or IV ovarian cancer. N Engl J Med 363:943–953
Kehoe S, Hook J, Nankivell M, Jayson GC, Kitchener H, Lopes T et al (2015) Primary chemotherapy versus primary surgery for newly diagnosed advanced ovarian cancer (CHORUS): an open-label, randomised, controlled, non-inferiority trial. Lancet 386:249–257
Fagotti A, Vizzielli G, Ferrandina G, Fanfani F, Gallotta V, Chiantera V, Costantini B, Margariti P, Alletti SG, Cosentino F, Tortorella L, Scambia G (2020) Survival analyses from a randomized trial of primary debulking surgery versus neoadjuvant chemotherapy for advanced epithelial ovarian cancer with high tumor load (SCORPION trial). Int J Gynecol Cancer 30:1657–1664
Onda T, Satoh T, Saito T et al (2018) Comparison of survival between upfront primary debulking surgery versus neoadjuvant chemotherapy for stage III/IV ovarian, tubal and peritoneal cancers in phase III randomized trial: JCOG0602. J Clin Oncol 36(15_suppl):5500
Mahner S, du Bois A, Pfisterer J, Hilpert F, Sehouli J, Lamparter C, Harter P (2019) Behandlungsqualität des Ovarialkarzinoms in Deutschland: Aktuelle Ergebnisse des Qualitätssicherungsprogramms QS OVAR. Geburtshilfe Frauenheilkd 79(08):PD45
Machida H, Tokunag H, Matsuoc K, Matsumurad N, Kobayashie Y, Tabataf T, Kaneuchi M, Nagase S, Mikami M (2020) Survival outcome and perioperative complication related to neoadjuvant chemotherapy with carboplatin and paclitaxel for advanced ovarian cancer: a systematic review and meta-analysis. Eur J Surg Oncol 46(5):868–875
Liu YL, Filippova OT, Zhou Q, Iasonos A, Chi DS, Zivanovic O et al (2020) Characteristics and survival of ovarian cancer patients treated with neoadjuvant chemotherapy but not undergoing interval debulking surgery. J Gynecol Oncol 31:e17
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Interessenkonflikt
C. v. Bülow, K. Prieske, A. Jäger und B. Schmalfeldt geben an, dass kein Interessenkonflikt besteht.
Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.
Additional information
Redaktion
Barbara Schmalfeldt, Hamburg
Tanja Fehm, Düsseldorf
QR-Code scannen & Beitrag online lesen
Rights and permissions
About this article
Cite this article
v. Bülow, C., Prieske, K., Jäger, A. et al. Aktuelle Aspekte zur operativen Therapie des primären Ovarialkarzinoms. Gynäkologe 55, 155–163 (2022). https://doi.org/10.1007/s00129-022-04905-w
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00129-022-04905-w