Relapse: Surgical Considerations and Secondary Cytoreduction

  • Sara M. Jordan
  • Robert E. BristowEmail author


This chapter focuses on the survival benefit, selection criteria, and morbidity and mortality associated with secondary cytoreduction for recurrent ovarian cancer in the general population and the elderly. The goal of secondary cytoreduction is to improve overall survival by maximizing surgical tumor eradication in patients who demonstrate a complete clinical response to initial platinum-based chemotherapy. Retrospective studies consistently demonstrate a survival benefit associated with maximal secondary cytoreduction. Patient selection criteria should be individualized based on the patient’s life goals, comorbidities and performance status, and availability of adjuvant therapy. Morbidity and mortality rates are comparable to those associated with primary cytoreduction. The role of secondary cytoreduction in the geriatric population is still evolving. In general, elderly are less likely to receive standard treatment for ovarian cancer, but research suggests that secondary cytoreduction can be both safe and feasible and advanced age alone should not be a contraindication to surgery.


Secondary cytoreductive surgery Secondary cytoreduction Recurrent epithelial ovarian cancer Relapse Elderly 


  1. 1.
    Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011;61(4):212–36.PubMedCrossRefGoogle Scholar
  2. 2.
    Rubin SC, Hoskins WJ, Benjamin I, Lewis JL. Palliative surgery for intestinal obstruction in advanced ovarian cancer. Gynecol Oncol. 1989;34(1):16–9.PubMedCrossRefGoogle Scholar
  3. 3.
    Hoskins WJ, Bundy BN, Thigpen JT, Omura GA. The influence of cytoreductive surgery on recurrence-free interval and survival in small-volume stage III epithelial ovarian cancer: a Gynecologic Oncology Group study. Gynecol Oncol. 1992;47(2):159–66.PubMedCrossRefGoogle Scholar
  4. 4.
    Berek JS, Hacker NF, Lagasse LD, Nieberg RK, Elashoff RM. Survival of patients following secondary cytoreductive surgery in ovarian cancer. Obstet Gynecol. 1983;61(2):189–93.PubMedGoogle Scholar
  5. 5.
    Bristow RE, Puri I, Chi DS. Cytoreductive surgery for recurrent ovarian cancer: a meta-analysis. Gynecol Oncol. 2009;112(1):265–74.PubMedCrossRefGoogle Scholar
  6. 6.
    Eisenkop SM, Friedman RL, Spirtos NM. The role of secondary cytoreductive surgery in the treatment of patients with recurrent epithelial ovarian carcinoma. Cancer. 2000;88(1):144–53.PubMedCrossRefGoogle Scholar
  7. 7.
    Scarabelli C, Gallo A, Carbone A. Secondary cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma. Gynecol Oncol. 2001;83(3):504–12.PubMedCrossRefGoogle Scholar
  8. 8.
    Chi DS, McCaughty K, Diaz JP, Huh J, Schwabenbauer S, Hummer AJ, et al. Guidelines and selection criteria for secondary cytoreductive surgery in patients with recurrent, platinum-sensitive epithelial ovarian carcinoma. Cancer. 2006;106(9):1933–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Harter P, du Bois A, Hahmann M, Hasenburg A, Burges A, Loibl S, et al. Surgery in recurrent ovarian cancer: the Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) DESKTOP OVAR trial. Ann Surg Oncol. 2006;13(12):1702–10.PubMedCrossRefGoogle Scholar
  10. 10.
    Sehouli J, Richter R, Braicu EI, Bühling KJ, Bahra M, Neuhaus P, et al. Role of secondary cytoreductive surgery in ovarian cancer relapse: who will benefit? A systematic analysis of 240 consecutive patients. J Surg Oncol. 2010;102(6):656–62.PubMedCrossRefGoogle Scholar
  11. 11.
    Tebes SJ, Sayer RA, Palmer JM, Tebes CC, Martino MA, Hoffman MS. Cytoreductive surgery for patients with recurrent epithelial ovarian carcinoma. Gynecol Oncol. 2007;106(3):482–7.PubMedCrossRefGoogle Scholar
  12. 12.
    Tian WJ, Jiang R, Cheng X, Tang J, Xing Y, Zang RY. Surgery in recurrent epithelial ovarian cancer: benefits on survival for patients with residual disease of 0.1-1 cm after secondary cytoreduction. J Surg Oncol. 2010;101(3):244–50.PubMedGoogle Scholar
  13. 13.
    Benedetti Panici P, De Vivo A, Bellati F, Manci N, Perniola G, Basile S, et al. Secondary cytoreductive surgery in patients with platinum-sensitive recurrent ovarian cancer. Ann Surg Oncol. 2007;14(3):1136–42.PubMedCrossRefGoogle Scholar
  14. 14.
    Frederick PJ, Ramirez PT, McQuinn L, Milam MR, Weber DM, Coleman RL, et al. Preoperative factors predicting survival after secondary cytoreduction for recurrent ovarian cancer. Int J Gynecol Cancer. 2011;21(5):831–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Meier W, Baumgartner L, Stieber P, Hasholzner U, Fateh-Moghadam A. CA125 based diagnosis and therapy in recurrent ovarian cancer. Anticancer Res. 1997;17(4B):3019–20.PubMedGoogle Scholar
  16. 16.
    Santillan A, Garg R, Zahurak ML, Gardner GJ, Giuntoli RL, Armstrong DK, et al. Risk of epithelial ovarian cancer recurrence in patients with rising serum CA-125 levels within the normal range. J Clin Oncol. 2005;23(36):9338–43.PubMedCrossRefGoogle Scholar
  17. 17.
    Rustin GJ, van der Burg ME, Griffin CL, Guthrie D, Lamont A, Jayson GC, et al. Early versus delayed treatment of relapsed ovarian cancer (MRC OV05/EORTC 55955): a randomised trial. Lancet. 2010;376(9747):1155–63.PubMedCrossRefGoogle Scholar
  18. 18.
    Prayer L, Kainz C, Kramer J, Stiglbauer R, Schurawitzki H, Baldt M, et al. CT and MR accuracy in the detection of tumor recurrence in patients treated for ovarian cancer. J Comput Assist Tomogr. 1993;17(4):626–32.PubMedCrossRefGoogle Scholar
  19. 19.
    Reuter KL, Griffin T, Hunter RE. Comparison of abdominopelvic computed tomography results and findings at second-look laparotomy in ovarian carcinoma patients. Cancer. 1989;63(6):1123–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Megibow AJ, Bosniak MA, Ho AG, Beller U, Hulnick DH, Beckman EM. Accuracy of CT in detection of persistent or recurrent ovarian carcinoma: correlation with second-look laparotomy. Radiology. 1988;166(2):341–5.PubMedGoogle Scholar
  21. 21.
    Bristow RE, del Carmen MG, Pannu HK, Cohade C, Zahurak ML, Fishman EK, et al. Clinically occult recurrent ovarian cancer: patient selection for secondary cytoreductive surgery using combined PET/CT. Gynecol Oncol. 2003;90(3):519–28.PubMedCrossRefGoogle Scholar
  22. 22.
    Mansueto M, Grimaldi A, Mangili G, Picchio M, Giovacchini G, Viganò R, et al. Positron emission tomography/computed tomography introduction in the clinical management of patients with suspected recurrence of ovarian cancer: a cost-effectiveness analysis. Eur J Cancer Care (Engl). 2009;18(6):612–9.CrossRefGoogle Scholar
  23. 23.
    Buist MR, Golding RP, Burger CW, Vermorken JB, Kenemans P, Schutter EM, et al. Comparative evaluation of diagnostic methods in ovarian carcinoma with emphasis on CT and MRI. Gynecol Oncol. 1994;52(2):191–8.PubMedCrossRefGoogle Scholar
  24. 24.
    Ricke J, Sehouli J, Hach C, Hänninen EL, Lichtenegger W, Felix R. Prospective evaluation of contrast-enhanced MRI in the depiction of peritoneal spread in primary or recurrent ovarian cancer. Eur Radiol. 2003;13(5):943–9.PubMedGoogle Scholar
  25. 25.
    Morris M, Gershenson DM, Wharton JT. Secondary cytoreductive surgery in epithelial ovarian cancer: nonresponders to first-line therapy. Gynecol Oncol. 1989;33(1):1–5.PubMedCrossRefGoogle Scholar
  26. 26.
    Jänicke F, Hölscher M, Kuhn W, von Hugo R, Pache L, Siewert JR, et al. Radical surgical procedure improves survival time in patients with recurrent ovarian cancer. Cancer. 1992;70(8):2129–36.PubMedCrossRefGoogle Scholar
  27. 27.
    Segna RA, Dottino PR, Mandeli JP, Konsker K, Cohen CJ. Secondary cytoreduction for ovarian cancer following cisplatin therapy. J Clin Oncol. 1993;11(3):434–9.PubMedGoogle Scholar
  28. 28.
    Gadducci A, Iacconi P, Cosio S, Fanucchi A, Cristofani R, Riccardo Genazzani A. Complete salvage surgical cytoreduction improves further survival of patients with late recurrent ovarian cancer. Gynecol Oncol. 2000;79(3):344–9.PubMedCrossRefGoogle Scholar
  29. 29.
    Oksefjell H, Sandstad B, Tropé C. The role of secondary cytoreduction in the management of the first relapse in epithelial ovarian cancer. Ann Oncol. 2009;20(2):286–93.PubMedCrossRefGoogle Scholar
  30. 30.
    Eisenkop SM, Friedman RL, Wang HJ. Secondary cytoreductive surgery for recurrent ovarian cancer. A prospective study. Cancer. 1995;76(9):1606–14.PubMedCrossRefGoogle Scholar
  31. 31.
    Zang RY, Li ZT, Tang J, Cheng X, Cai SM, Zhang ZY, et al. Secondary cytoreductive surgery for patients with relapsed epithelial ovarian carcinoma: who benefits? Cancer. 2004;100(6):1152–61.PubMedCrossRefGoogle Scholar
  32. 32.
    Tay EH, Grant PT, Gebski V, Hacker NF. Secondary cytoreductive surgery for recurrent ­epithelial ovarian cancer. Obstet Gynecol. 2002;99(6):1008–13.PubMedCrossRefGoogle Scholar
  33. 33.
    Salani R, Santillan A, Zahurak ML, Giuntoli RL, Gardner GJ, Armstrong DK, et al. Secondary cytoreductive surgery for localized, recurrent epithelial ovarian cancer: analysis of prognostic factors and survival outcome. Cancer. 2007;109(4):685–91.PubMedCrossRefGoogle Scholar
  34. 34.
    Bae J, Lim MC, Choi JH, Song YJ, Lee KS, Kang S, et al. Prognostic factors of secondary cytoreductive surgery for patients with recurrent epithelial ovarian cancer. J Gynecol Oncol. 2009;20(2):101–6.PubMedCrossRefGoogle Scholar
  35. 35.
    Berek JS, Bertelsen K, du Bois A, Brady MF, Carmichael J, Eisenhauer EA, et al. Advanced epithelial ovarian cancer: 1998 consensus statements. Ann Oncol. 1999;10 Suppl 1:87–92.PubMedCrossRefGoogle Scholar
  36. 36.
    Harter P, Hahmann M, Lueck HJ, Poelcher M, Wimberger P, Ortmann O, et al. Surgery for recurrent ovarian cancer: role of peritoneal carcinomatosis: exploratory analysis of the DESKTOP I Trial about risk factors, surgical implications, and prognostic value of peritoneal carcinomatosis. Ann Surg Oncol. 2009;16(5):1324–30.PubMedCrossRefGoogle Scholar
  37. 37.
    Harter P, Sehouli J, Reuss A, Hasenburg A, Scambia G, Cibula D, et al. Prospective validation study of a predictive score for operability of recurrent ovarian cancer: the Multicenter Intergroup Study DESKTOP II. A project of the AGO Kommission OVAR, AGO Study Group, NOGGO, AGO-Austria, and MITO. Int J Gynecol Cancer. 2011;21(2):289–95.PubMedCrossRefGoogle Scholar
  38. 38.
    Tian WJ, Chi DS, Sehouli J, Tropé CG, Jiang R, Ayhan A, et al. A risk model for secondary cytoreductive surgery in recurrent ovarian cancer: an evidence-based proposal for patient selection. Ann Surg Oncol. 2012;19(2):597–604.PubMedCrossRefGoogle Scholar
  39. 39.
    Bristow RE, Peiretti M, Gerardi M, Zanagnolo V, Ueda S, Diaz-Montes T, et al. Secondary cytoreductive surgery including rectosigmoid colectomy for recurrent ovarian cancer: operative technique and clinical outcome. Gynecol Oncol. 2009;114(2):173–7.PubMedCrossRefGoogle Scholar
  40. 40.
    Cliby W, Dowdy S, Feitoza SS, Gostout BS, Podratz KC. Diaphragm resection for ovarian cancer: technique and short-term complications. Gynecol Oncol. 2004;94(3):655–60.PubMedCrossRefGoogle Scholar
  41. 41.
    Woelber L, Jung S, Eulenburg C, Mueller V, Schwarz J, Jaenicke F, et al. Perioperative morbidity and outcome of secondary cytoreduction for recurrent epithelial ovarian cancer. Eur J Surg Oncol. 2010;36(6):583–8.PubMedCrossRefGoogle Scholar
  42. 42.
    United States Census Bureau. Accessed on 20 Oct 2011.
  43. 43.
    Alphs HH, Zahurak ML, Bristow RE, Díaz-Montes TP. Predictors of surgical outcome and survival among elderly women diagnosed with ovarian and primary peritoneal cancer. Gynecol Oncol. 2006;103(3):1048–53.PubMedCrossRefGoogle Scholar
  44. 44.
    Cloven NG, Manetta A, Berman ML, Kohler MF, DiSaia PJ. Management of ovarian cancer in patients older than 80 years of age. Gynecol Oncol. 1999;73(1):137–9.PubMedCrossRefGoogle Scholar
  45. 45.
    Díaz-Montes TP, Zahurak ML, Giuntoli RL, Gardner GJ, Gordon TA, Armstrong DK, et al. Surgical care of elderly women with ovarian cancer: a population-based perspective. Gynecol Oncol. 2005;99(2):352–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Moore KN, Reid MS, Fong DN, Myers TK, Landrum LM, Moxley KM, et al. Ovarian cancer in the octogenarian: does the paradigm of aggressive cytoreductive surgery and chemotherapy still apply? Gynecol Oncol. 2008;110(2):133–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Uyar D, Frasure HE, Markman M, von Gruenigen VE. Treatment patterns by decade of life in elderly women (> or =70 years of age) with ovarian cancer. Gynecol Oncol. 2005;98(3):403–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Chéreau E, Ballester M, Selle F, Rouzier R, Daraï E. Ovarian cancer in the elderly: impact of surgery on morbidity and survival. Eur J Surg Oncol. 2011;37(6):537–42.PubMedCrossRefGoogle Scholar
  49. 49.
    Aletti GD, Dowdy SC, Podratz KC, Cliby WA. Relationship among surgical complexity, short-term morbidity, and overall survival in primary surgery for advanced ovarian cancer. Am J Obstet Gynecol. 2007;197(6):676.e1–7.CrossRefGoogle Scholar
  50. 50.
    Thigpen T, Brady MF, Omura GA, Creasman WT, McGuire WP, Hoskins WJ, et al. Age as a prognostic factor in ovarian carcinoma. The Gynecologic Oncology Group experience. Cancer. 1993;71(2 Suppl):606–14.PubMedGoogle Scholar
  51. 51.
    Wright JD, Herzog TJ, Powell MA. Morbidity of cytoreductive surgery in the elderly. Am J Obstet Gynecol. 2004;190(5):1398–400.PubMedCrossRefGoogle Scholar
  52. 52.
    Leitao MM, Kardos S, Barakat RR, Chi DS. Tertiary cytoreduction in patients with recurrent ovarian carcinoma. Gynecol Oncol. 2004;95(1):181–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Shih KK, Chi DS, Barakat RR, Leitao MM. Tertiary cytoreduction in patients with recurrent epithelial ovarian, fallopian tube, or primary peritoneal cancer: an updated series. Gynecol Oncol. 2010;117(2):330–5.PubMedCrossRefGoogle Scholar
  54. 54.
    Burton E, Chase D, Yamamoto M, de Guzman J, Imagawa D, Berman ML. Surgical management of recurrent ovarian cancer: the advantage of collaborative surgical management and a multidisciplinary approach. Gynecol Oncol. 2011;120(1):29–32.PubMedCrossRefGoogle Scholar
  55. 55.
    DESKTOP III. Accessed on 21 Oct 2011.

Copyright information

© Springer-Verlag London 2013

Authors and Affiliations

  1. 1.Division of Gynecologic Oncology, Department of Obstetrics and GynecologyUniversity of California Irvine, Medical CenterOrangeUSA

Personalised recommendations