Handling Ovarian Cancer FIGO III-IV : Evolution over the last 30 years

The treatment of ovarian cancer FIGO III-IV has undergone substantial changes in the last 30 years. As I was involved as an oncological surgeon in the treatment of these patients since 1979 and made my PhD thesis on this subject, I consider myself a privileged witness of this evolution. In the late 1970's two major changes took place : the introduction of combination chemotherapy containing cisplatin and the concept of debulking surgery. In 1980 we embarked on an ambitious treatment plan combining maximal cytoreductive surgery, 6 cycles of chemotherapy, second look laparotomy and panabdominal irradiation. The results were analyzed in 1991 and gave rise to the following changes. Surgical cytoreduction could only be considered optimal if no residual tumor was left and residual tumor correlated with median survival. Upfront surgery was abandoned in FIGO IV and FIGO III with a very high tumor load. Panabdominal irradiation was too toxic. A recent randomized study has established equivalency of survival in FIGO IIIc between interval debulking after 3 cycles and upfront surgery. Initial tumor load remains a determinant of long term cure and optimal upfront surgery is critical in patients with a metastatic tumor load of less than 100 gram. Retroperitoneal node dissection becomes important when complete resection of peritoneal metastases can be obtained. In experienced hands selection for primary debulking or for interval debulking seems possible at laparoscopic exploration.