title: Primary surgery or interval debulking for advanced epithelial ovarian cancer: does it matter?
abstract: OBJECTIVE
  The aim of the present study was to investigate the surgical complexity, the postoperative morbidity, and the survival of the women after primary debulking surgery (PDS) and neoadjuvant chemotherapy followed by interval debulking surgery (NACT-IDS) for advanced epithelial ovarian cancer.
  
  
  METHODS
  We consecutively included all patients who underwent debulking surgery at our institution between January 2007 and December 2012 for stages IIIc and IV of epithelial ovarian cancer.
  
  
  RESULTS
  Of the 332 patients included, 165 (49.7%) underwent PDS, and 167 (50.3%) had NACT-IDS. Complete intraperitoneal cytoreduction was achieved in 70.9% after PDS and in 59.9 % after NACT-IDS. Residual disease of greater than 1 cm was left in 18.5% and 27.5% after PDS and NACT-IDS, respectively. Compared with NACT-IDS, PDS was associated with higher surgical complexity (P < 0.001), longer operating time (P < 0.001), greater blood loss (P < 0.001), longer hospitalization (P = 0.001), and a higher rate of major postoperative complications (26.7% vs 16.8%). No statistical difference in the median overall survival (OS) was found between the patients having complete cytoreduction and residual disease of 1 cm or less after NACT-IDS. Furthermore, no statistical difference in the median OS was found between the patients with macroscopic residual disease (≤1 vs >1 cm) after NACT-IDS. Patients with residual disease of greater than 1 cm after PDS had a median OS of 15 months.
  
  
  CONCLUSIONS
  We suggest that NACT-IDS may be a better treatment alternative for the group of highly selected women not suitable for PDS, where expected suboptimal cytoreduction does not have any appreciable survival benefit and exposes them for unnecessary risks. A substantial number of women who receive either PDS or NACT-IDS have greater than 1 cm of tumor tissue left after the operation. These women probably have no survival benefit from the operation, and future studies should focus on how to select these women preoperatively.
authors.affiliation: *Department of Gynaecology & Obstetrics, Odense University Hospital; and †Research Unit of General Practice, University of Southern Denmark, Odense, Denmark.
authors.forename: Algirdas
authors.initials: A
authors.lastname: Markauskas
authors.forename: Ole
authors.initials: O
authors.lastname: Mogensen
authors.forename: René
authors.initials: R
authors.lastname: dePont Christensen
authors.forename: Pernille Tine
authors.initials: PT
authors.lastname: Jensen
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D000077216:Carcinoma, Ovarian Epithelial; D065426:Cytoreduction Surgical Procedures / Q000379:methods*; D018450:Disease Progression; D005260:Female; D006801:Humans; D008875:Middle Aged; D009017:Morbidity; D020360:Neoadjuvant Therapy; D009375:Neoplasms, Glandular and Epithelial / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D010051:Ovarian Neoplasms / Q000188:drug therapy* / Q000453:epidemiology / Q000473:pathology / Q000601:surgery*; D010052:Ovariectomy / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology; D016896:Treatment Outcome; D055815:Young Adult