Neoadjuvant chemotherapy and ovarian cancer

Primary surgical cytoreduction followed by chemotherapy usually is the preferred management of advanced (stage III or IV) ovarian cancer. The presence of residual disease after surgery is one of the most important adverse prognostic factors for survival. Neoadjuvant chemotherapy has been proposed as an alternative approach to conventional surgery as initial management of bulky ovarian cancer, with the goal of improving surgical quality. Retrospective analyses suggest that a subgroup of patients with Stage III and IV ovarian carcinoma can be treated with neoadjuvant chemotherapy followed by interval debulking surgery. The absolute indications for neoadjuvant chemotherapy appear to be Stage IV disease (excluding pleural fluid) or metastases of more than 1 g at sites where resection is impossible. Interval debulking surgery in patients with suboptimal primary debulking surgery has been proven effective in increasing overall survival and progression-free survival in a large prospective, randomized trial of the European Organization for Research and Treatment of Cancer (EORTC). GOG evaluated the effect of adding secondary cytoreductive surgery to postoperative chemotherapy. Unfortunately in this study, for patients with advanced ovarian carcinoma in whom primary cytoreductive surgery was considered to be maximal, the addition of secondary cytoreductive surgery to postoperative chemotherapy with paclitaxel plus cisplatin does not improve progression-free survival or overall survival. The strategy of neoadjuvant chemotherapy, followed by interval debulking surgery, should be confirmed in a prospective randomized trial. The EORTC55971 trial is currently addressing this issue.     

Cytoreductive surgery in the management of ovarian cancer

The standard management for previously untreated advanced-stage epithelial ovarian cancer is optimum cytoreductive surgery followed by aggressive cytotoxic chemotherapy. This approach is based on a retrospective review of a single-institution experience published more than 30 years ago and has yet to be confirmed in a prospective randomized trial. Many subsequent studies have supported the observation that advanced ovarian cancer patients who have the longest survival invariably have no macroscopic disease left at the completion of the initial surgery. The combination of a platinum- and taxane-based chemotherapy regimen is now well established as the most active one for treating women with advanced ovarian cancer. However, the overwhelming majority of patients with advanced ovarian cancer will eventually experience disease recurrence and develop resistance to cytotoxic chemotherapy. Selected patients with recurrent ovarian cancer--ie, those with an isolated recurrence identified more than 6 months following completion of initial chemotherapy and who have an excellent performance status--are managed with cytoreductive surgery followed by a platinum-based regimen. As in previously untreated patients, patients who have no macroscopic residual tumor left after secondary debulking for recurrent ovarian cancer have a significantly better survival than those left with any gross tumor. This article will review the role of surgery in the initial management of advanced-stage and recurrent ovarian cancer, focusing on the definition of optimum surgical cytoreduction.     

Primary surgery or neoadjuvant chemotherapy followed by interval debulking surgery in advanced ovarian cancer

Advanced ovarian cancer has a poor prognosis. De-bulking surgery and platinum-based chemotherapy are the cornerstones of the treatment. Primary debulking surgery has been the standard of care in advanced ovarian cancer. Recently a new strategy with neoadjuvant chemotherapy followed by interval debulking surgery has been developed. In a recently published randomised trial of the EORTC-NCIC (European Organisation for Research and Treatment of Cancer - National Cancer Institute Canada) in patients with extensive stage IIIc and IV ovarian cancer it was shown that the survival was similar for patients randomised to neoadjuvant chemotherapy followed by interval debulking compared to primary debulking surgery, followed by chemotherapy. The post-operative complications and mortality rates were lower after interval debulking than after primary debulking surgery. The most important independent prognostic factor for overall survival was no residual tumour after primary or interval debulking surgery. In some patients obtaining the goal of no residual tumour at interval debulking is difficult due to chemotherapy-induced fibrosis. On the other hand the patients randomised had very extensive stage IIIc and IV disease and in patients with metastases smaller than 5 cm the survival tended to be better after primary debulking surgery. Hence, selection of the correct patients with stage IIIc or IV ovarian cancer for primary debulking or neoadjuvant chemotherapy followed by interval debulking surgery is important. Besides imaging with CT, diffusion MRI and/or PET-CT, also laparoscopy can play an important role in the selection of patients. It should be emphasised that the group of patients included in this study had extensive stage IIIc or IV disease. Surgical skills, especially in the upper abdomen, remain pivotal in the treatment of advanced ovarian cancer. However, very aggressive surgery should be tailored according to the general condition and extent of the disease of the patients. Otherwise, this type of aggressive surgery will result in unnecessary postoperative morbidity and mortality without improving survival. Hence, neoadjuvant chemotherapy should not be an easy way out, but is in some patients with stage IIIc or IV ovarian cancer a better alternative treatment option than primary debulking. According to the current treatment algorithm at the University Hospitals Leuven about 50% of the patients with stage IIIc or IV ovarian cancer are selected for neoadjuvant chemotherapy.     

Role of Neoadjuvant Chemotherapy in the Management of Advanced Ovarian Cancer

Objective: To analyze efficacy of neoadjuvant chemotherapy for advanced ovarian cancer. Materials andMethods: A total of 107 patients with advanced ovarian cancer undergoing cytoreductive surgery were dividedinto a neoadjuvant chemotherapy group (n=61) and a primary debulking group (n=46) and retrospectivelyanalyzed. Platinum-based adjuvant chemotherapy was applied to both groups after cytoreductive surgery andeoverall and progression-free survival times were calculated. Results: No significant difference was observed induration of hospitalization (20.8±6.1 vs. 20.2±5.4 days, p>0.05). The operation time of neoadjuvant chemotherapygroup was shorter than the initial surgery group (3.1±0.7 vs. 3.4±0.8 h, p<0.05). There were no significantdifferences in median overall survival time between neoadjuvant chemotherapy group and surgery group (42 vs.55 months, p>0.05). Similarly, there was no difference in median progression-free survival between neoadjuvantchemotherapy group and surgery group (16 vs. 17 months, p>0.05). The surgical residual tumor size demonstratedno significant difference between initial surgery and neoadjuvant chemotherapy groups (p>0.05). Multivariateanalysis showed that more than 3 cycles of regimen with neoadjuvant chemotherapy was associated with moreresistance to chemotherapy compared with patients without receiving neoadjuvant chemotherapy (OR: 5.962,95%CI: 1.184-30.030, p<0.05). Conclusions:Neoadjuvant chemotherapy can shorten the operation time. However,it does not improve survival rates of advanced ovarian cancer patients.     

新辅助化疗联合肿瘤细胞减灭术及术后腹腔热灌注化疗治疗晚期卵巢癌的疗效观察

  目的   探讨新辅助化疗联合肿瘤细胞减灭术及术后腹腔热灌注治疗晚期卵巢癌的临床疗效。   方法   分析郑州人民医院从2009年4月至2012年7月收治的60例晚期卵巢癌的患者,分为两组,研究组患者术前采取新辅助化疗联合肿瘤细胞减灭术及术后腹腔热灌注辅助化疗2次（顺铂80 mg）,术后给予TC/TP方案化疗,对照组采取常规肿瘤细胞减灭术+术后TC/TP方案化疗,比较两组患者在手术时间、出血量、腹水量、术后化疗疗程、疗效、复发与死亡、生存率等数据的差异。   结果   研究组患者在术中的各项疗效指标优于对照组,且有统计学显著性差异（P < 0.05）,临床治疗有效率高于对照组。   结论   在临床上对于晚期卵巢癌患者采取术前新辅助化疗联合肿瘤细胞减灭术术后腹腔热灌注辅助化疗,对于患者的疗效较常规的方法有较大的提高,值得在临床上进行推广。      

Neoadjuvant chemotherapy for advanced epithelial ovarian cancer]

Primary surgical cytoreduction followed by paclitaxel/carboplatin combination chemotherapy currently is the treatment of choice for advanced epithelial ovarian cancer. Aggressive surgery is widely accepted as a valid approach to initial cytoreduction of stage III disease, but suboptimal residual disease following primary surgical resection is one of the most important adverse prognostic factors in these patients. Neoadjuvant chemotherapy has been proposed as an alternative approach to conventional surgery for initial management of bulky ovarian cancer, with the goal of improving surgical quality. General acceptance of neoadjuvant chemotherapy as an alternative to primary surgery for patients who are not ideal surgical candidates remains limited, because equivalent or superior survival has not yet been demonstrated in a prospective randomized study. A large-scale, prospective, randomized study is being conducted by the European Organization for Research and Treatment of Cancer (EORTC) Gynecologic Cancer Cooperative Group and Gynecologic Oncology Group (GOG) to compare outcomes (overall and progression-free survival, quality of life, treatment complications) of neoadjuvant chemotherapy/interval debulking surgery versus primary cytoreductive surgery/adjuvant chemotherapy in patients with advanced epithelial ovarian carcinoma.     

The neoadjuvant approach in the treatment of patients with advanced epithelial ovarian carcinoma

AimsOvarian cancer has a very poor prognosis, with 5-year survival rates of 5–20% for advanced-stage disease. This work was designed to verify whether the neoadjuvant approach had an effect on survival in patients with advanced-stage ovarian cancer.Materials and methodsPatients with stage III or IV disease who received neoadjuvant platinum-based chemotherapy (group 1) were compared with a group of conventionally treated patients (group 2).ResultsMost of the patients in group 1 (76%) had partial tumoral responses after chemotherapy. Patients from group 1 (n = 42) had a median survival that was not different from that in patients from group 2 (n = 348). Patients who received platinum-based chemotherapy with taxanes had the same survival of patients who received no taxanes.ConclusionsOur results showed similar responses and survival rates for patients with stage III or IV ovarian cancer treated with neoadjuvant platinum-based chemotherapy, when compared with patients who underwent primary suboptimal cytoreductive surgery. Our data therefore support the ongoing trials to determine the optimum timing of surgery for ovarian cancer.     

Clinical Trials of Neoadjuvant Chemotherapy for Ovarian Cancer: What Do We Gain After an EORTC Trial and After Two Additional Ongoing Trials Are Completed?

The aim of neoadjuvant chemotherapy is to reduce the tumor volume or spread of the disease before the main treatment, and it could possibly make the main procedures easier or less invasive. Although the standard therapeutic strategy for advanced ovarian cancer is a maximum primary debulking surgery followed by chemotherapy, a European Organisation for Research and Treatment of Cancer (EORTC) prospective randomized trial demonstrated that neoadjuvant chemotherapy followed by interval debulking surgery was not inferior to the standard procedure. This study raised a number of controversies, particularly regarding the quality of debulking surgery. To solve the questions, we need to wait for the results of two additional ongoing randomized trials. However, the results of those two trials must be carefully assessed, because the quality of debulking surgery would significantly affect survival, and may make the interpretation of the trial results more confusing and difficult.     

晚期上皮性卵巢癌术前新辅助化疗的临床总结

探讨晚期卵巢癌能否行手术治疗的预测因素及新辅助化疗在晚期卵巢癌中的临床价值。方法:回顾性分析了大连医科大学附属第一医院1996年1月至2008年12月收治的Ⅲ～Ⅳ期晚期卵巢癌病例92例,其中18例接受新辅助化疗（NAC组）,74例接受初次手术（PCS组）。结果:使初次肿瘤细胞减灭术满意率降低的因素:伴有合并症（P=0.022）;初次治疗时存在胸腔积液（P=0.011）;CA125>1 000 U/L（P=0.030）;有肝、肺转移的Ⅳ期患者（P=0.031）。新辅助化疗的总有效率为66.7%。新辅助化疗可以提高肿瘤细胞减灭术的满意率（P=0.022）,缩短引流管置留天数（P=0.011）,减少腹水量（P=0.005）、术中出血量（P=0.048）,但在手术时间、输血量、平均住院天数、患者生存时间方面,NAC组与PCS组的差异无统计学意义（P>0.05）。结论:伴有合并症、胸腔积液、CA125>1 000 U/L、临床分期为Ⅳ期、表现为肝、肺转移的患者适合新辅助化疗。新辅助化疗可以提高肿瘤细胞减灭术的满意率,减少术中、术后并发症,可能会改善患者预后。      

Role of aggressive surgical cytoreduction in advanced ovarian cancer

Ovarian cancer is the eighth most frequent cancer in women and is the most lethal gynecologic malignancy worldwide. The majority of ovarian cancer patients are newly diagnosed presenting with advanced-stage disease. Primary cytoreductive surgery and adjuvant taxane- and platinum-based combination chemotherapy are the standard treatment for advanced ovarian cancer. A number of studies have consistently shown that successful cytoreductive surgery and the resultant minimal residual disease are significantly associated with survival in patients with this disease. Much has been written and even more debated regarding the competing perspectives of biology of ovarian cancer versus the value of aggressive surgical resection. This review will focus on the current evidences and outcomes supporting the positive impact of aggressive surgical effort on survival in the primary management of ovarian cancer.     

The role of neoadjuvant chemotherapy in the treatment of advanced ovarian cancer

Primary cytoreductive surgery followed by chemotherapy represents the current standard treatment for patients with advanced ovarian cancer. Neoadjuvant chemotherapy followed by interval debulking surgery has been proposed as an alternative approach for the initial management of bulky ovarian cancer, aiming at the improvement of surgical efficiency and patients' quality of life. According to the hitherto published studies, consisting mainly of retrospective observations, neoadjuvant chemotherapy followed by interval cytoreduction appears to improve the prognosis and quality of life in selected groups of patients. The survival outcome in these patients is similar to that of the conventional approach, or even better in some of the cases. Moreover, patients undergoing debulking surgery after having received neoadjuvant chemotherapy had a reduced perioperative morbidity compared to patients undergoing primary cytoreduction. Concurrently, neoadjuvant chemotherapy provides preoperative knowledge of tumor chemosensitivity, hence allowing the surgeon to choose appropriately aggressive treatment. However, until the results of prospective randomized trials become available, neoadjuvant chemotherapy followed by interval surgery should be applied only to individual cases and primarily in the context of clinical trials.     

新辅助化疗联合中间性肿瘤细胞减灭术治疗晚期上皮性卵巢癌的疗效及对HE4、VEGF、CA125水平的影响

目的 探讨新辅助化疗联合中间性肿瘤细胞减灭术治疗晚期上皮性卵巢癌的疗效及其对血清人附睾蛋白4(HE4)、血管内皮细胞生长因子(VEGF)、糖类抗原125(CA125)水平的影响.方法 回顾性分析68例晚期上皮性卵巢癌患者的病历资料,根据治疗方法不同将患者分为联合组与对照组,每组34例.联合组患者采用新辅助化疗联合中间性肿瘤细胞减灭术治疗,对照组患者仅接受卵巢肿瘤细胞减灭术治疗.观察并比较两组患者的近期疗效,手术相关指标,血清HE4、VEGF、CA125水平及预后情况.结果 联合组患者的治疗总有效率为79.4%,高于对照组的52.9%(P﹤0.05);联合组患者的手术时间明显短于对照组(P﹤0.01);联合组患者的术中失血量、腹腔积液量均明显低于对照组(P﹤0.01);治疗后,联合组患者的血清HE4、VEGF、CA125水平均明显低于对照组(P﹤0.01);治疗后,两组患者的1年、2年、3年生存率比较,差异均无统计学意义(P﹥0.05).联合组和对照组患者的中位生存时间分别为32.0个月(95%CI:25.3~35.6)和28.0个月(95%CI:22.1~33.9),两组患者的生存情况比较,差异无统计学意义(χ2=1.96,P﹥0.05).结论 新辅助化疗联合中间性肿瘤细胞减灭术治疗晚期上皮性卵巢癌可以缩短手术时间,减少术中出血量,降低血清肿瘤相关标志物水平,但该方法对改善患者的远期生存意义不大.     

新辅助化疗在晚期卵巢癌治疗中的作用

目的：探讨新辅助化疗在晚期卵巢癌治疗中的临床意义。方法：分析我院63例曾行肿瘤细胞减灭术的晚期卵巢癌患者，其中24例行术前化疗，采用以铂类药物为主的化疗1～3个疗程：39例未行术前化疗，比较两组患者的疗效及5年生存率。结果：术前化疗组，手术基本切净率83.3％，术后并发症12．5％：术前未化疗组，手术基本切净率59．0％，术后并发症35．9％，两组比较差异具有显著意义（P〈0．05）。两组5年生存率分别为41．7％、43．6％．两组比较差异无显著意义（P〉0．05）。结论：新辅助化疗可提高晚期卵巢癌的基本切净率，减少术后并发症的发生率．但并未延长患者的生存期。     

Patterns of First-Line Systemic Therapy Delivery and Outcomes in Advanced Epithelial Ovarian Cancer in Ontario

Background: First-line treatment of epithelial ovarian cancer (EOC) consists of a combination of cytoreductive surgery and platinum-based chemotherapy. Recently, targeted therapies such as bevacizumab have been shown to improve oncologic outcomes in a subset of a high-risk population. The objective of this study is to evaluate the patterns of practice and outcomes of first-line systemic treatment of advanced EOC, focusing on the adoption of bevacizumab. Methods: A population cohort study was conducted using administrative data in Ontario, Canada. Patients diagnosed with advanced stage non-mucinous EOC between 2014 and 2018 were identified. Datasets were linked to obtaining information on first-line treatment including surgery, systemic therapy, providers of care, systemic therapy facilities, and acute care utilization (emergency department (ED) visits and hospitalizations) during systemic treatment. Multivariate logistic regression was used to determine factors associated with systemic therapy utilization. Results: Among 3726 patients with advanced EOC, 2838 (76%) received chemotherapy: 1316 (47%) received neoadjuvant chemotherapy, 1060 (37%) underwent primary cytoreductive surgery followed by chemotherapy, and 462 (16%) received chemotherapy only. The median age was 67 (range: 20–100). Most chemotherapies were prescribed by gynecologic oncologists (60%) and in level 1 academic cancer centres (58%). Only 54 patients (3.1%) received bevacizumab in the first-line setting after its approval in Ontario in 2016. Bevacizumab was more likely to be administered by medical oncologists compared to gynecologic oncologists (OR 3.95, 95% CI 2.11–7.14). In total, 1561 (55%) and 1594 (56%) patients had at least one ED visit and/or hospitalization during systemic treatment, respectively. The most common reasons for ED visits were fever and bowel obstruction. Conclusion: Patterns of care for EOC in Ontario differed between care providers. The uptake of bevacizumab for first-line treatment of EOC was low. Acute care utilization related to EOC was high.     

Clinical Outcome of Iranian Patients with Advanced Ovarian Cancer with Neoadjuvant Chemotherapy versus Primary Debulking Surgery

Objective: The aim of this study is to evaluate the results of neoadjuvant chemotherapy (NACT) and theimpact of interval debulking surgery (IDS) on clinical outcomes of patients with advanced-stage ovarian cancer.Methods: We performed a retrospective analysis on 92 patients with advanced ovarian cancer admitted to Vali-Asr Gynecologic oncology departments during 1996–2002. Comparison was made with results of neoadjuvantchemotherapy of 24 patients with unresectable advanced epithelial ovarian cancer treated with platinum- basedNACT followed by IDS and clinical outcomes of 68 consecutive stage III and IV ovarian cancer patients treatedwith primary cytoreduction followed by platinum-based adjuvant chemotherapy. Results: Primary cytoreductivesurgery caused longer survival compared to neoadjuvant chemotherapy. Patients who underwent optimal intervaldebulking surgery (IDS) had a better progression free survival (PFS) (p=0.002) and overall survival (p=0.03)than those who did not. There were not significant differences between the two groups in complications ofsurgery. Conclusion: NACT followed by successful IDS can lead to high survival percentage in patients withchemoresponsive advanced ovarian cancer; although the result is more effective in those with optimal primarycytoreduction, we still got the same results with those with suboptimal primary cytoreduction.     

卵巢上皮癌淋巴结转移化疗的临床疗效分析

背景与目的：卵巢上皮癌属化疗中度敏感肿瘤,随着肿瘤细胞减灭术及铂类联合化疗的应用,其疗效有明显改善,但其淋巴结转移病灶对化疗的敏感性尚存异议。本研究通过回顾性分析临床资料,以评价卵巢上皮癌患者淋巴结转移对化疗的敏感性及其预后,方法：对1986年6月－2001年2月收治的50例卵巢上皮癌淋巴结转移患者进行回顾性分析,其中Ⅲ-Ⅳ期32例,治疗后复发18例,50例均有可评价疗交的淋巴结转移灶,其中38例有可评价的盆腔,腹腔肿瘤。46例接受术前化疗1－3疗程,肿瘤细胞减灭术、术后化疗。化疗疗效评价按实体瘤疗效评价标准。化疗包括术前、术后或复发患者的化疗,其中45例接受含铂类联合化疗,包括CP（环磷酰胺＋顺铂）,CAP（环磷酰胺＋顺铂＋阿霉素或表阿霉素）,TC（紫杉醇＋卡铂）,TP（紫杉醇＋顺铂）,吉西他滨＋卡铂及IEP（顺铂＋异环磷酰胺＋足叶乙甙）方案,1例用美法仑,1例用CF（环磷酰胺和5－氟尿嘧啶）方案,3例用IFO＋VP－16（异环磷酰胺＋足叶乙甙）,结果：全组淋巴结转移灶和肿瘤的有效率分别为68．0％、71．1％,Ⅲ-Ⅳ期初治患者淋巴结转移和盆腹腔肿瘤有效率分别为78．1％,76．6％,而复发组两者有效率均为50．0％,结论：卵巢上皮癌的淋巴结转移,无论Ⅲ-Ⅳ期还是复发患者,其对化疗敏感性与盆腹腔肿瘤相近,Ⅲ-Ⅳ期患者预后与减瘤术是否彻底,以及化疗的疗程数多少有明显的相关性。     

Phase II study evaluating consolidation whole abdominal intensity-modulated radiotherapy (IMRT) in patients with advanced ovarian cancer stage FIGO III - The OVAR-IMRT-02 Study

Background  

The prognosis for patients with advanced FIGO stage III epithelial ovarian cancer remains poor despite the aggressive standard treatment, consisting of maximal cytoreductive surgery and platinum-based chemotherapy. The median time to recurrence is less than 2 years, with a 5-years survival rate of -20-25%. Recurrences of the disease occur mostly intraperitoneally.     

Primary surgery for ovarian cancer.

AIM: Review studies on survival outcomes for all survival treatment methods of primary ovarian cancer. METHODS: This presentation is based on systematic literature search in Pubmed, Medline, Cochrane and Internet addresses for treatment protocols. RESULTS: Major controversies still exist on what constitutes optimal surgical staging in a patient with early-stage ovarian cancer and what is optimal surgical management for high-risk patients. Several large retrospective studies consistently identify the size of the largest residual disease after primary cytoreductive surgery as an independent determinant of prognosis, but the size limit of residual disease that needs to be fulfilled for cytoreduction to have effect on survival is not identified. The effect of neoadjuvant chemotherapy in advanced ovarian cancer is uncertain. A large prospective randomized study is initiated for assessing the role of neoadjuvant chemotherapy. The survival rate is better for patients treated at teaching hospitals compared with non-teaching hospitals. CONCLUSION: This systematic review demonstrates the need for more studies on survival outcomes for all surgical treatment methods of primary ovarian cancer assessed in this report.     

Outcome of Interval Debulking in Advanced Ovarian Cancer Patients

Interval debulking and neoadjuvant chemotherapy have been used in management of advanced epithelialovarian cancer for many years in order to achieve optimal residual disease and reduce surgical morbidity. Thepresent study was conducted to evaluate the outcomes of advanced ovarian cancer patients treated with thesetwo approaches prior to cytoreductive surgery in Chiang Mai University Hospital between January 2001 andDecember 2006. The medical records of 29 patients who met the criteria were retrospectively reviewed. Mosthad stage IIIC serous cystadenocarcinomas. We found that the 5 year progression free survival and overallsurvival were 10% and 22% while the median values were 13 months and 34 months, respectively. Multivariateanalysis showed that a suboptimal residual tumor volume was a statistically significant adverse prognosticfactor for overall survival. In conclusion, interval debulking surgery and neoadjuvant chemotherapy beforecytoreductive surgery lead to a more favorable outcome with advanced epithelial ovarian cancers.     

Aggressive surgical strategies in advanced ovarian cancer: a monocentric study of 203 stage IIIC and IV patients

AIMS: The standard treatment for advanced ovarian cancer consists of cytoreductive surgery associated with a platinum/paclitaxel-based chemotherapy. Nevertheless, there is still the question as to the extent and timing of the surgical debulking. The aim of this study was to evaluate the place of surgery in the therapeutic sequence. PATIENTS AND METHODS: We reviewed data from all consecutive patients with stage IIIC and IV epithelial ovarian cancer, operated on at our institution between 1990 and 2005. Patients were divided into 2 groups, according to the position of surgery in the therapeutic sequence. Patients in group 1 received initial debulking surgery. Group 2 consisted of patients having received their first debulking after initial chemotherapy. RESULTS: Two hundred and three patients were identified and frequently underwent aggressive surgery, in particular, digestive surgery with bowel resections. Perioperative mortality and morbidity rates were low (2% and 14%, respectively) and there was no difference between the groups. Overall survival in group 1 for patients with complete cytoreduction (residual disease (RD)=0), optimal surgery (RD<1cm) or sub-optimal surgery (RD>1cm) was 50%, 30% and 14%, respectively. In group 2, overall survival following complete surgery was 30%, and no long-term survival was observed when surgery was not complete at the time of interval surgery. Survival was worse for patients who had received more than 4 cycles of neoadjuvant chemotherapy. CONCLUSION: This study confirms the importance of surgery in the prognosis of advanced ovarian cancer. Only the patient subgroup that underwent complete initial or interval surgery was associated with a prolonged remission. Optimal surgery with a controlled morbidity can be achieved in many cases, even if bowel resection is needed, at the time of primary debulking. In the interval cytoreductive surgery subgroup, the response to initial chemotherapy and surgery was found to be essential for prognosis.