Operative techniques

a. The incision used should provide maximum exposure of the pelvis and allow thorough evaluation of the upper abdomen. If present, ascites should be aspirated and sent for cytopathologic evaluation. A small amount of heparin should be added to prevent clotting of bloody or mucoid specimens. If ascites is not present, abdominal washings with saline should be obtained from the pericolic gutters, the suprahepatic space, and the pelvis. A Pap test of the diaphragm should be taken.

b. The abdominal cavity should be explored systematically. The lower surface of the diaphragm, the upper abdominal recesses, the liver, and retroperitoneal nodes should be carefully noted for tumor involvement. In addition, the intestines, mesentery, and omentum should be examined. The presence or absence of metastases in the pelvis and abdomen should be noted, and the exact location and size of tumor nodules should be described.

c. In cases in which disease is grossly confined to the pelvis, efforts should be made to detect occult metastasis with peritoneal cytologies, biopsies of peritoneum from the pelvis and pericolic gutters, and resection of the greater omentum. In addition, selective pelvic and paraaortic lymphadenectomy also should be carried out.

Definitions of the Stages in Primary Carcinoma of the Ovary

Stage

Definition

I

Growth is limited to the ovaries

IA

Growth is limited to one ovary; no ascites present containing malignant cells; no tumor on the external surface; capsule is intact

IB

Growth is limited to both ovaries; no ascites present containing malignant cells; no tumor on the external surfaces; capsules are intact

IC

Tumor is classified as either stage IA or IB but with tumor on the surface of one or both ovaries; or with ruptured capsule(s); or with ascites containing malignant cells present or with positive peritoneal washings

II

Growth involves one or both ovaries with pelvic extension

IIA

Extension and/or metastases to the uterus and/or tubes

IIB

Extension to other pelvic tissues

IIC

Tumor is either stage IIA or lib but with tumor on the surface of one or both ovaries; or with capsule(s) ruptured; or with ascites containing malignant cells present or with positive peritoneal washings

III

Tumor involves one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver metastasis equals stage III; tumor is limited to the true pelvis but with histologically proven malignant extension to small bowel or omentum

IIIA

Tumor is grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces

IIIB

Tumor involves one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are negative

IIIC

Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes

IV

Growth involves one or both ovaries with distant metastases; if pleural effusion is present, there must be positive cytololgy findings to assign a case to stage IV; parenchymal liver metastasis equals stage IV

C. Cytoreductive surgery improves response to chemotherapy and survival of women with advanced ovarian cancer. Operative management is designed to remove as much tumor as possible. When a malignant tumor is present, a thorough abdominal exploration, total abdominal hysterectomy, bilateral salpingo-oophorectomy, lymphadenectomy, omentectomy, and removal of all gross cancer are standard therapy.

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