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Ovarian Cancer: Optimal Cytoreduction or Debulking

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Updated February 18, 2008

Cytoreduction or Debulking Surgery

If you have undergone surgery for advanced ovarian cancer, one of the most important questions to ask your doctor is whether or not the debulking or cytoreduction was optimal. In other words, has most of the tumor been removed surgically?

What is "optimal"?

It is not always technically possible to remove most or all of the visible cancer during surgery. However, we have known that combining aggressive surgery with chemotherapy has led to the best cure rates for over 20 years. Over the years, the type of chemotherapy has changed and so has the definition of how aggressive or “optimal” surgery can or should be.

As recently as 10 years ago, the definition of an “optimal” surgery was that tumors no larger than 2 centimeters were left behind (that is about ¾ of an inch). This might be one, or two or many tumors, none of which exceeded 2 centimeters in size.

With better tools and surgical techniques, we now know that it is technically very possible for an “optimal” surgery to leave behind less than 1 centimeter tumors, getting to “miliary” (tiny “sand” size cancer nodules) in the majority of patients and even microscopic disease (can’t see it or feel it after surgery) in many patients.

Your Overall Medical Condition Makes a Difference

Not all patients are created physiologically equal. In some cases, a patient may be too old or sick to tolerate the 4-8 hours that it might take to achieve “optimal” results. Also, bleeding or other complications might force the surgeon to stop the surgery earlier than they would have liked. In most cases, it is not the age itself but rather the additional medical conditions a patient might have which dictates how long of a surgery can be tolerated.

Who Your Surgeon Is Make A Difference

Not all surgeons are created equal. This is true in all professions and all medical specialties. Even among gynecologic oncologists, those best suited to operate on you for ovarian cancer, there is a difference in skills. All are trained in appropriate decision-making and most can perform a cytoreduction to achieve 1-2 cm residual “optimal” surgery in the majority of their patients. At the very least make sure that a gynecologic oncologist is, or was, involved in your surgery.

Do I Need More Radical Surgery?

Medical studies have shown that the more that is removed the better. There is no point beyond which there is no added benefit. However, sometimes to get to miliary or microscopic disease requires very aggressive surgery, including removing parts of the liver, spleen, lung, multiple bowel areas, lymph nodes in difficult areas and beyond. Not all patients can tolerate this well and not all surgeons are comfortable performing these procedures.

Some have called this “ultra”-radical cytoreductive surgery, where the goal is to achieve a microscopic to miliary (“sand” size) “optimal” surgery at almost all costs. Before proceeding, this requires a very thorough risk/benefit discussion with your gynecologic oncologist. If you decide to agree to this degree of surgery, keep in mind that not all surgeons have been trained, or do enough surgical cases of this type, in order to safely achieve this extra measure of “optimal” surgery. Conversely, they may simply not believe that this extra level of surgery is in the best interests of their patients. Although divergent opinions abound, this is a gray area in the medical literature.

Is "Ultra-Radical" Cytoreduction Proven?

Some experts maintain that if “ultra”-radical surgery is required to get to “optimal” surgery, this means that in that patient's situation the cancer is biologically more aggressive. So, they feel that this extra surgery does nothing to improve chances of cure. The reality is that, while this may be true in some patients, we simply do not know which patients are which at the time of surgery, or even after surgery.

Published research suggests that some women benefit more than others from radical and ultra-radical surgery. Cancers have variable degrees of sensitivity to chemotherapy, which is not reliably predictable. Some patients are cured. Some are not.

It boils down to a surgeon making an expert decision during surgery about how far to go with surgery based on what is technically possible and if they think you can tolerate further surgery. This may also be partly based on an assumption regarding biological aggressiveness of the cancer in you.

Keep in mind that in some cases it is technically not possible to get to the best measure of “optimal” without, for example, removing all of the intestines, which is obviously not compatible with good quality of life. Likewise, as mentioned before, in some cases medical conditions or intraoperative complications may force stopping surgery earlier than planned or desired. But there is a difference, which I hope you are starting to understand, between technically “impossible” and judgement calls or lack of surgical skills.

If possible, it is very worthwhile to discuss your gynecologic oncologist’s philosophy about the issues above BEFORE surgery. Again, you may or may not decide that a second opinion is required. You simply MUST develop a great relationship with a gynecologic oncologist of your choice whom you trust implicitly. While I would strongly discourage you from indiscriminate doctor shopping, if this relationship is lacking, find a doctor that you can develop this type of relationship with.

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