Surgery

Johns Hopkins surgeons have a particular interest and expertise in performing the full range of ovarian cancer operations safely and effectively.  Minimally invasive surgical techniques are used whenever possible for diagnosis and treatment of ovarian neoplasms.  Our team of surgeons takes a proactive approach to cytoreductive ("debulking") surgery at the time of initial diagnosis and for selected patients with recurrent ovarian cancer.  Read more on a recent study characterizing ovarian cancer surgery rates in Maryland.

Initial Diagnosis
Members of the Johns Hopkins Ovarian Cancer Center surgical team have special interests and expertise in minimally invasive surgical approaches for the evaluation and diagnosis of the ovarian (or adnexal) mass.  Minimally invasive surgery (MIS) involves laparoscopic approaches for evaluation of suspicious masses.  Advantages of using these techniques for removal of a benign mass include faster recovery and, in most cases, no overnight hospital stay.  Evaluation and diagnosis of the mass by expert gynecologic pathologists takes place immediately during surgery.  Duration of the pathology evaluation is 20-30 minutes and results are relayed directly to the surgical team.  If an ovarian cancer is diagnosed, the team can proceed with additional surgery as indicated.

Primary Surgery
Following diagnosis of ovarian cancer, primary surgery consists of an incision in the abdomen (a laparotomy), hysterectomy (removal of the uterus), removal of the fallopian tubes and ovaries, a complete staging procedure, lymph node biopsies, removal of the appendix and omentum (the fat pad which hangs like an apron off the colon), and random biopsies throughout the abdominal cavity to look for microscopic cancer spread or metastasis. 

Importance of staging: In the staging portion of the operation, surgeons perform biopsies from the appropriate number of sites throughout the pelvis and abdominal cavity so that the cancer can be treated with chemotherapeutic agents right away if necessary.  Otherwise, small cancers that can be found through staging may not be discovered until the disease recurs and perhaps may not have recurred if the patient had received the appropriate chemotherapy regimen.  Approximately 60 to 70 percent of ovarian cancer patients will be found to have advanced stage disease after undergoing a comprehensive staging evaluation.  Staging is not only important for prognostic information (or to understand what a patient’s survival may be) but it also is critically important for determining the appropriate therapy after surgery.  Select patients with some categories of Stage I disease do not require any additional therapy, whereas most patients with Stage II-IV disease will require chemotherapy. 

Fertility preservation: For a select group of younger women of childbearing age with Stage I ovarian cancer and no evidence of disease outside of the ovary, who want to maintain their reproductive capacity, a more conservative surgical approach is reasonable.  The surgical team can preserve the uterus and disease-free ovary and fallopian tube to maintain childbearing potential.

Metastatic Disease -- Ovarian Cancer Spread:
The four principle routes of ovarian cancer spread are through:
1) direct extension to contiguous organs such as the peritoneum of the bladder, the sigmoid colon or uterus;
2) intraperitoneal exfoliation -- the majority of ovarian tumors grow outward  and project into the abdominal cavity, similar to stalks on a plant.  The metastatic or spreading cells are exfoliated (similar to exfoliating skin cells) and get caught in the abdominal cavity and float in the abdominal fluid.  The process of ovarian cancer spread is analogous to scattering sand across a table – each of the sand particles gets exposed to every part of the surface of the table. Similarly, each metastatic ovarian cancer cell spreads and sticks to each abdominal organ and grows into small tumors.  Ovarian cancer normally presents at an advanced stage because intraperitoneal exfoliation tends to occur simultaneously with direct extension;
3) lymphatic system – this route of spread is very common – approximately 70 percent of patients with advanced ovarian cancer will have disease that has spread to their lymph nodes; and
4) hematogenous – this type of metastasis is less common and involves spread to the liver or lung parenchyma cells, which are the cells in the organ itself, as opposed to connective tissue or blood vessels.  Lung involvement most often occurs as a pleural effusion, which is a build-up of fluid between two layers of a lining covering the lungs called pleura.  As opposed to traveling through the blood system to the lungs, it is believed that these tumor cells spread first by intraperitoneal exfoliation up toward the diaphragm, then they implant on the diaphragm and migrate through the diaphragm to the lymphatics and migrate to the underside of the pleural surface of the lung and create the effusion. 

Debulking Surgery or Cytoreduction
This type of surgery is performed when there is widespread evidence of advanced stage of ovarian cancer with obvious spread to other organs outside of the ovary typically in the upper abdomen, intestines, the omentum (the fat pad that, like an apron, hangs off the colon) or the diaphragm or liver.

Over the last 25 years, one of the most powerful determinants of a patient’s subsequent survival is the amount of residual disease remaining after initial surgery.  There is an inverse relationship between the amount of residual disease and survival – the smaller amount of residual disease, the longer a patient is likely to live.  So, it is critically important to exhaust all of our efforts at the initial surgery to remove as much of the cancer as possible.  Read more on NEJM study that evaluates survival after secondary debulking and chemotherapy after secondary surgery. The goal is to remove everything visible, as well as metastatic sites that are determined through microscopic evaluation of multiple biopsies.  Sometimes this involves removing other organs where the ovarian cancer has spread – for example, 30 – 40 percent of the time it is necessary to remove a portion of the intestine, though it is important to note that advanced surgical techniques have eliminated the need for a colostomy bag in almost all cases.

Optimal Debulking
Optimal debulking indicates that all of the cancer has been removed except for residual nodules that measure no more than 1 cm in maximum diameter.  These nodules may remain if they are too numerous or located at critical structures where it may be too risky to attempt removal.

Sophisticated Surgical Tools and Techniques
The Ovarian Cancer Center surgical team uses conventional surgical techniques in addition to more advanced surgical methods and tools.  Gynecologic oncology faculty train the next generation of specialized surgeons with these tools and techniques.

Argon Beam Coagulator (ABC): Survival of patients with advanced stages of ovarian cancer depends on complete removal of tumors. A surgical tool, called the argon beam coagulator (ABC), removes more tumor than traditional surgery. The ABC uses a “laser beam” to cut with more precision than a surgical knife and reduces blood loss during surgery. 

Cavitron Ultrasonic Surgical Aspirator (CUSA): This tool uses sound waves to break up tissue into tiny pieces. 

Peritonectomy:  This technique is also called peritoneal stripping.  It is based on the fact that everything in the abdominal cavity is lined with peritoneum – a one cell layer thick coating, akin to covering everything in the abdomen with cellophane.  Ovarian cancer tends not to penetrate the peritoneum, but spreads along the surface.  In a peritonectomy, surgeons peel the “cellophane” or peritoneum off the underlying structure.  This does not generally compromise the integrity or immunity of the organs since the peritoneum regenerates itself. 

Radical Oopherectomy for Frozen Pelvis: A select group of patients will present with massive local extension of the disease.  The tumor will involve the uterus, peritoneum, bladder, sigmoid colon, and rectum and basically obliterates all the normal anatomy for the pelvis.  It looks like a bucket of cancer sand was poured into the pelvis.  Incisions are made in the peritoneum at cancer sites, and the cancer is peeled away along with all of the attached structures towards the center of the pelvis leaving the blood vessels, ureters, and bladder intact.  Because the colon projects into the cavity, it is usually involved in the cancer, and so a portion of the colon may be resected as well and hooked back up to the rectum.  The procedure leaves a disease-free pelvic area.

Secondary Debulking/Cytoreduction: A select group of patients with recurrent disease who have had a complete response to initial therapy (those who have achieved a remission for at least 12 months without demonstrating a recurrence) may be candidates for secondary debulking or cytoreductive surgery.  The initial remission implies that the cancer cells, even though they have come back, are responsive to chemotherapy.  Patients undergoing secondary debulking must have a good performance status, meaning that they can tolerate a second surgical effort.  Ideally, patients should have relatively localized disease, for example, recurrence at a lymph node or lesion in the spleen or liver.  In most of these cases, there is an 80 percent chance that surgeons will be able to remove the lesion.  In order to detect these lesions early enough so that secondary debulking will be effective, patients should undergo aggressive surveillance through the use of advanced imaging techniques.  During secondary debulking surgery, surgeons can harvest tissue to be used in drug resistance assays which can predict chemotherapy drugs that will not be useful to a particular patient, allowing medical oncologists to target chemotherapeutic efforts with other, potentially more effective drugs.

Placement of Intraperitoneal Port: With the advent of intraperitoneal chemotherapy becoming part of initial therapy to treat advanced ovarian cancer, it is important to understand the concept of how the port is placed and how it works.

In order for your surgeon to deliver chemotherapy directly into your abdomen, you will need to have an intraperitoneal (IP port) placed. This is done either at the time of your initial surgery or within a few weeks after you recover from the initial debulking procedure through a laparoscopic approach. The port is placed in the operating room and the procedure takes approximately 60 minutes. The port is the size of a half dollar and will be placed under the skin, just directly over the bottom of your rib cage, in the left upper quadrant of the abdominal wall. The tubing of the port will be tunneled under the skin of your abdominal wall and placed into the peritoneal cavity through a small hole. The tip of the catheter is placed directly into the pelvis. There are multiple small holes along the catheter tubing that facilitate the delivery of chemotherapy.

You will note that the incision is approximately 1 inch wide and the incision is closed with sutures that dissolve under your skin. The port is sutured into placed under the skin level so that you can perform daily activities. You will also note that there will be two smaller incisions where the surgeon introduces trocars and instruments which help with the placement and tunneling of the catheter during the laparoscopic procedure. Those incisions heal quite quickly.

Below you will see an example of what intraperitoneal ports look like.

Once the recommended course of chemotherapy has been completed, the surgeon will remove the port in the operating room. This is a minor procedure that takes approximately 30 minutes.