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 | [email protected] 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 | [email protected] 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