The ovary is a small organ that is normally located in the pelvic cavity. Because the pelvic cavity is large and the ovaries are small, the space around the ovaries is extremely large. Therefore, when the ovaries suffer from malignant tumors, most people do not seek medical treatment until later. Therefore, late-stage ovarian cancer accounts for the vast majority of ovarian cancers. A small number of patients with early-stage ovarian cancer are discovered basically by luck, such as physical examination or other surgeries.
In early-stage ovarian cancer, the tumor cells are only limited to the ovary, and it belongs to stage I, but it is relatively rare. Once the tumor cells have metastasized to the pelvic organs, it is considered stage II. Stage II tumors are certainly more common than stage I tumors. Stage I tumors and stage IIa tumors are customarily called early-stage tumors. If ovarian cancer cells metastasize to intra-abdominal organs, such as the greater omentum, appendix, abdominal wall, especially subdiaphragm, or metastasis to retroperitoneal lymph nodes, it is classified as stage III. Metastasis beyond the abdominal cavity is classified as distant metastasis, that is, stage IV, such as metastasis to the liver, lungs, etc. Distant metastasis has little therapeutic value. Clinically, it is customary to refer to tumors above IIb as advanced tumors, which mainly refers to tumors above IIb and stage III. Stage IV tumors are now subdivided into stage IVa and IVb tumors. Stage IVb tumors are very late and have little therapeutic value. However, stage IVa tumors refer to cancer cells in the pleural effusion. The surgical method is similar to that of stage IIIc. The effect after thorough surgery is It\’s still good, but of course, this is only limited to a few high-level hospitals.
Once ovarian cancer is diagnosed, surgical treatment should in principle be chosen except for stage IVb tumors. Unlike other tumors, ovarian cancer is still worthy of surgery even if it reaches stage IVa. Other tumors, such as liver cancer, lung cancer and other malignant tumors, have no value in surgical treatment when they reach stage III, but ovarian cancer in stage IVa still has therapeutic value. The most different biological behavior of ovarian cancer from other tumors is that ovarian cancer generally metastasizes within the abdominal cavity and pelvic cavity, and this is also true for stage III. The process from stage III to stage IV seems to be quite long.
Different from the principle of surgery for other malignant tumors, the principle of treatment for ovarian cancer is \”cytoreduction\”, which uses mechanical methods to remove most of the tumor. The first thing that needs to be removed is the pelvic internal organs, such as the contralateral ovary, uterus and fallopian tube. Secondly, the omentum and appendix in the patient\’s body, which are prone to cancer cell metastasis, should be removed. If no tumor is visible to the naked eye, surgery for early-stage ovarian cancer ends here. ifThe tumor has metastasized to organs such as the peritoneum, mesentery, and intestines, and ovarian cancer cell debulking surgery is recommended. The so-called cytoreduction surgery uses mechanical methods to mechanically remove tumor cells from metastases, and the remaining cancer cells are killed using chemotherapy and other methods to achieve the purpose of treatment. For early-stage ovarian cancer, during surgical treatment, the pelvic and retroperitoneal lymph nodes must be removed to understand the actual stage of ovarian cancer. Therefore, surgery for ovarian cancer is also called staging surgery.
Ovarian cancer surgery is the most courageous surgery among gynecological tumors. There are almost no rules to follow in the operation, and it all depends on the doctor\’s freedom. Different from cervical cancer surgery, during ovarian cancer surgery, a large number of cancer cells are attached to other organs, such as peritoneum, intestines, mesentery, etc. Should these organs be cut or not? It depends not only on the gynecologist who performs the surgery, but also on the surgeon who works with the gynecological surgeon. Generally speaking, for large, invaded intestines, most doctors advocate doing nothing, while for small, macroscopically visible but not deeply invaded metastatic tumors, they try to preserve these organs. For example, if there are small tumors visible to the naked eye on the entire intestine, or there are some small metastases on the entire mesentery, organ removal is not a good option. It is better to save the organs and burn out the tumors. The so-called \”burning\” means using electrosurgery to destroy tumor cells. How to burn tumor cells that are visible to the naked eye but not large in size on the intestines, and how to use the power and time of the electrosurgical knife? It all depends on the doctor\’s experience. Severe fever will damage the intestines and should be avoided; mild fever will not destroy tumor cells and is not possible.
In ovarian cancer, the most important surgical skill test is how to remove peritoneal metastasis? In the past, mechanical methods, that is, traditional scalpels, were used to remove the peritoneum, but clinically it was found that even if the removal was clean, the effect was not good. The main reason is that it is difficult to completely remove the peritoneum of all metastases using mechanical methods. It is now found that it is best to use an electrosurgical knife to remove all the peritoneum as cleanly and thoroughly as a rolled carpet. This method looks scary, but is actually very simple. Because there is a gap between the peritoneum and the tissue below it, it is not difficult to use this gap to remove all peritoneal and peritoneal metastases. The difficulty is that there will be a lot of leakage in the area where the peritoneum is removed. A large amount of exudate leaks into the abdominal cavity, making it difficult for patients to maintain their water and electrolyte balance within 24 hours after surgery. Therefore, for any patient who has a large amount of peritoneal resection, the anesthesiologist must insert a central venous pressure catheter into the patient\’s neck during the operation to monitor the patient\’s central venous pressure and provide guidance on water and electrolytes within 24 hours after the operation. supplement, otherwise, hypovolemic shock may easily occur, endangering the patient\’s life.
The above difficulties are actually relatively easy to master. The most difficult one is how to remove the right subphrenic metastasis. The vast majority of gynecological oncologists in China have not received training in upper abdominal surgery. Most subdiaphragmatic metastases are located on the diaphragm, with the rightThe main part is separated by the liver in the middle and the inferior vena cava behind it. This part has long been considered a restricted area for surgery. When performing surgery on this area, it is easy to rupture the diaphragm, leading to \”artificial pneumothorax\” and damage to the inferior vena cava. Once the inferior vena cava is damaged, it is basically equal to death. Furthermore, it is difficult to completely remove all metastases at this site. Only some doctors abroad perform this surgery. However, literature reports have found that most gynecological oncologists who are skilled in the field of gynecological oncology are unable to completely remove the metastases in this area. In most cases, the resection is done in collaboration with a liver surgery specialist. Of course, for experts who have mastered this technology, it is actually very simple.
The prognosis of ovarian cancer depends on whether tumor cells, especially those in metastases, are removed during surgery. If the residual tumor diameter is greater than 2cm, the prognosis is similar to that without surgery. Of course, there is still some controversy on this issue in academic circles. Some people suggest that if the residual lesion is larger than 2cm, chemotherapy should be performed first, and then the residual lesion can be resected after the residual lesion shrinks, and then chemotherapy can be performed. However, the effect of patients treated with this method is not as good as that of patients treated with chemotherapy after complete resection for the first time. It would be the best thing if surgery could remove all the metastases and make sure there are no tumors visible to the naked eye. If this is not possible, it is also good to achieve residual disease diameter less than 5 mm. If it can only be below 2cm but above 5mm, the prognosis is much better than without surgery, but it is definitely not as good as the first two situations.
Many doctors claim that the surgery was successful and achieved \”optimal debulking\”. However, about 50% of ovarian cancers have elevated preoperative tumor markers. Therefore, whether the surgery is done well or not depends on comparing the changes in tumor markers before and after surgery. Generally speaking, if the plasma tumor marker level drops quickly or even returns to normal soon after surgery, it means that the surgery was indeed done well; if the plasma tumor marker level does not drop much, or even has no change, it means that the residual tumor during the surgery It was so big that the surgery was not considered a success.
Unlike other tumors, except for patients with stage Ia ovarian cancer who do not need chemotherapy, patients with all other stages should receive standard chemotherapy after surgery. If the patient is very young, has not yet given birth, and the tumor is in stage Ia, when choosing surgery, preservation of the patient\’s fertility function can also be considered under close monitoring. That is, only the organs on the affected side are removed, and the ovaries, fallopian tubes and uterus on the opposite side of the patient are not removed. Some people also undergo radical surgery after the patient has given birth. While preserving fertility, it is best to remove the omentum and appendix to prevent cancer cells from metastasizing to these areas. These sites are most susceptible to cancer cell metastasis.
Surgery or no surgery for ovarian cancer? The biggest misunderstanding before surgery is that many doctors think that there is no need to operate if there is ascites. In fact, almost all advanced ovarian cancers have ascites before surgery, and there are very few advanced ovarian cancers without ascites. Ascites is not scary, it’s scaryThe problem is that the treatment method is incorrect. Another misunderstanding is that when combined with pleural effusion, many people think that it is a manifestation of tumor metastasis into the thoracic cavity. In fact, this is also a misunderstanding. Many patients with pleural effusion can also undergo surgery. Pleural effusion can be managed both intraoperatively and postoperatively. As long as the tumors in the abdominal cavity are well treated, the mere presence of cancer cells in the pleural effusion will have little impact on the prognosis.
Since the removal of tumors on the diaphragm involves surgery or thoracic surgery, the removal of paraspleen metastases is also more difficult and involves general surgery, so hospitals that are too specialized, especially those without Hospitals with these departments are not suitable for surgery for advanced ovarian cancer.