Conservative treatment of high risk epithelial ovarian cancer

Enrica Bentivegna (FR)

[Bentivegna] Gustave Roussy

CONTEXT Fertility-sparing surgery (FSS) of epithelial ovarian cancer (EOC) is based on unilateral (salpingo-)oophorectomy and complete surgical staging. This empirical treatment option had initially been proposed to young women presenting with an early-stage invasive tumour and a low risk of recurrence. Many questions about oncological outcomes and fertility issues continue to fuel debate and remain unclear concerning this management: the impact of the tumour grade on the risk of recurrence; the oncological results in the most controversial subgroup of stage IC disease in the light of the new FIGO staging system; the oncological results in stage I and the oncological results in ‘high risk’ histologic subtypes, particularly clear-cell ovarian tumours. METHODS A systematic review of the literature was done in accordance with the PRISMA guidelines. Data were identified from searches of Medline, Current Contents, PubMed and from references in relevant articles published in English from 1988 to April 2016. RESULTS 32 papers written by 21 teams and 7 multicentre studies were retained (39 articles) and analysed summarising 1150 patients who had undergone FSS. 139 (12%) recurrences had occurred: 124 in stage I disease and 14 or 15 in stage II or III disease. CONCLUSIONS The management of patients with early EOC eligible for FSS should be multidisciplinary. The histological review of the ovarian tumour and surgical staging should be done by experienced teams. This conservative treatment can be safely carried out in stage IA and IC grade 1 and 2 disease and stage IC1 according to the 2014 FIGO staging system. Nevertheless, the number of patients reported with grade 2 disease is too small to definitively confirm whether FSS is safe in this subgroup. For patients with ‘less favourable’ prognostic factors (grade 3 or stage IC3 disease), the safety of FSS could not be confirmed. However, patients should be informed that radical surgery may not necessarily improve their oncological outcome, because the poorest survival observed is related to the natural history of the disease and not specifically to the use of a conservative treatment. FSS could probably be considered for stage I clear-cell tumours but should remain contraindicated in stage II/III disease.