DOI: 10.1111/1471-0528.

15328 Review article

www.bjog.org

Surgery in ovarian cancer – Brazilian Society of

Surgical Oncology consensus
AT Tsunoda,a,b,c R Ribeiro,a RJ Reis,d,e CEM da Cunha Andrade,f,g R Moretti Marques,h G Baiocchi,i
F Fin,j,k PH Zanvettor,l,m D Falcao,l TP Batista,n BRB Azevedo,o,p G Guitmann,q,r SA Pessini,s
JS Nunes,t,u LM Campbell,v JC Linhares,a,u V Carneiro,w FJF Coimbrax,y
a
Gynaecological Oncology Department, Hospital Erasto Gaertner, Curitiba, Brazil b Albert Einstein Hospital, S~ao Paulo, Brazil c Positivo
University, Curitiba, Brazil d Hospital Erasto Dorneles e Hospital M~ae de Deus, Porto Alegre, Brazil e Brazilian Lutheran University, Porto
Alegre, Brazil f Gynaecological Oncology Department, Barretos Cancer Hospital, Barretos, Brazil g Paulo Prata Medical University, Barretos,
Brazil h Oncology Department, Albert Einstein Hospital, S~ao Paulo, Brazil i Gynaecological Oncology Department, AC Camargo Cancer
Centre, Sao Paulo, Brazil j Gynaecological Oncology Department, Hospital S~ao Vicente, Curitiba, Brazil k Faculdade Evangelica de Curitiba,
Curitiba, Brazil l Gynaecological Oncology Department, Aristides Maltez Hospital, Salvador, Brazil m AMO Clinic, Salvador, Brazil n Surgery
Department, Instituto de Medicina Integral Professor Fernando Figueira, Recife, Brazil o Hospital São Vicente, Curitiba, Brazil p Instituto de
Hemato Oncologia do Paraná, Curitiba, Brazil q Brazilian National Cancer Institute, Rio de Janeiro, Brazil r Americas Hospital, Rio de
Janeiro, Brazil s Gynaecological Oncology Department, Fundação Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre,
Brazil t Hospital Erasto Gaertner, Curitiba, Brazil u Instituto de Oncologia do Paraná, Curitiba, Brazil v Santa Lucia Cancer Centre, Brasilia,
Brazil w Hospital de Câncer de Pernambuco, Recife, Brazil Instituto de Medicina Integral Professor Fernando Figueira NeoH – Núcleo
Especializado em Oncologia e Hematologia D’OR, Recife, Brazil x AC Camargo Cancer Centre, Sao Paulo, Brazil y Brazilian Society of Surgical
Oncology 2016/2017, Sao Paulo, Brazil
Correspondence: AT Tsunoda, Rua Cel Amazonas Marcondes, 448, ap 1501 ZIP 80035-230 Curitiba, PR, Brazil. Email: atsunoda@gmail.com

Accepted 29 May 2018. Published Online 18 July 2018.

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights15328

Surgical management in epithelial ovarian cancer (EOC) has a states the final recommendations from BSSO for management of
significant impact in overall survival and progression-free survival. EOC.
The Brazilian Society of Surgical Oncology (BSSO) supported a
Keywords Brazilian Society of Surgical Oncology, consensus,
taskforce of experts to reach a consensus: experienced and
epithelial ovarian cancer, surgery.
specialised trained surgeons, in cancer centres, provide the best
EOC surgery. Laparoscopic and/or radiological staging Tweetable abstract Brazilian Society of Surgical Oncology
prognosticates the possibility of complete cytoreduction (CC0) consensus for surgery in epithelial ovarian cancer patients.
and helps to reduce unnecessary laparotomies. Surgical techniques
Linked article This article is commented on by LR Duska, p. 1253
were reviewed. Multidisciplinary input is essential for treatment
in this issue. To view this mini commentary visit https://doi.org/
planning. Quality assurance criteria are proposed and require
10.1111/1471-0528.15329.
national consensus. Genetic testing is mandatory. This consensus

Please cite this paper as: Tsunoda AT, Ribeiro R, Reis RJ, da Cunha Andrade CEM, Moretti Marques R, Baiocchi G, Fin F, Zanvettor PH, Falcao D, Batista
TP, Azevedo BRB, Guitmann G, Pessini SA, Nunes JS, Campbell LM, Linhares JC, Carneiro V, Coimbra FJF. Surgery in ovarian cancer – Brazilian Society
of Surgical Oncology consensus. BJOG 2018;125:1243–1252.

multidisciplinary team of experienced surgeons in cancer

Introduction
Ovarian cancer is associated with 40–50% mortality, as it is
frequently diagnosed in advanced stages of the disease.
Optimal surgical management is a predictor of overall
survival (OS) and progression-free survival (PFS) in EOC.
Complete cytoreduction (R0 or CC0) may involve complex
surgical procedures such as peritonectomy and diaphrag-
matic resections. This is best achieved by a
care centres. Centralisation of treatment, where evidence-
based approaches are offered, has become important over
the years.1,2 New technology and human resources should
be distributed according to levels of complexity of surgery.3
In the absence of a formal surgical specialty focused on
gynaecological cancer treatment, scientific task forces may
play an important educational role. More than 200 Brazil-
ian medical professionals have been collaborating to

ª 2018 Royal College of Obstetricians and Gynaecologists 1243

 Tsunoda et al.
Table 1. Levels of evidence (modified from NCCN categories of
evidence and consensus)4
Category Evidence Consensus
1 High-level evidence Uniform consensus that the
intervention is appropriate
2 Lower-level evidence Uniform consensus that the
intervention is appropriate
3 Any level of evidence Major disagreement that the
intervention is appropriate
develop a digital network for better cancer care. The Brazil-
ian Society of Surgical Oncology created a taskforce on
EOC with the aim of establishing minimum standards for
treatment.
Method
This initiative united experts representing major surgical
and oncological Brazilian societies from different regions
and institutions. Over a 10-month period, 17 leading
experts (16 surgeons included) from 12 cancer centres
attended meetings, web meetings, held digital discussions,
and wrote electronic positional papers. A comprehensive
literature review of studies published between January 2005
and June 2017 was carried out. This open and collaborative
approach allowed all members to participate and express
criticism, in addition to a scientific review adjusted to
Brazilian current standards. Key questions were answered
as consensus statements. Levels of evidence were designated
according to a conventional classification, modified from
NCCN guidelines (Table 1).4
What is the current situation of EOC?
In 2012, according to GLOBOCAN, 238 719 new EOC cases
were detected and 151 917 women died from the disease.5 It
is the seventh most common cancer and the eighth cause of
death from cancer in women.6 EOC constitutes around 90%
of malignant ovarian neoplasms.7 It was estimated in Brazil
in 2016 that there would be 6150 new cases of EOC and 3283
deaths due to the disease. It is the seventh most common
cancer in Southern Brazilian women.8 There is incomplete
reporting in Brazil regarding stages at diagnosis, modalities
of treatment, access to medication and surgical standards.
Oncological data from S~ao Paulo State showed that EOC
cases correspond to 3.2% of total nonskin cancer diagnosis
in women. The mean time for diagnosis is 14 days and for
primary treatment from 12 days (at cancer centres) to
70 days (outside cancer centres).9
Since 2012, all Brazilian citizens have had the right to
start treatment for first-stage cancer within 60 days of the
1244
diagnosis. Advanced-stage EOC patients cannot cope with
such a long waiting time. Centralisation of EOC cases in
cancer centres provides better time intervals and is sup-
ported by this panel.
What institutions and surgeons should provide
surgical management for EOC patients?
Consensus: Patients with high risk or with an established
diagnosis of EOC should be evaluated by a specialised gynae-
cological oncologist or a surgical oncologist focused on gynae-
cological cancer treatment. First-stage surgery should be
performed by a high-volume specialist (more than ten proce-
dures per year), preferably in a high-volume hospital (20 or
more cases per year) (Category 2).
EOC mortality depends on a multidisciplinary surgi-
cal team operating in a tertiary hospital or a cancer
centre. Patients with EOC treated by gynaecological
oncologists have superior outcomes when compared
with those treated by general gynaecologists and general
surgeons.10
Guideline-adherent cancer care is associated with high-
volume hospitals (20 or more cases per year; 50.8 versus
34.1%; P < 0.001) and high-volume physicians (ten or
more cases per year; 47.6 versus 34.5%; P < 0.001).2
Adherence to NCCN guidelines for treatment of EOC is
correlated with improved survival and may be a useful pro-
cess to measure the quality of cancer care.2,11
What are the best imaging tools prior to surgical
management?
Consensus: All patients should have a chest CT scan and a
complete abdominal imaging acquisition, CT or MRI (Cate-
gory 2). Relative contraindications to surgery should be dis-
cussed in a multidisciplinary tumour board meeting and
preoperative surgical planning (Category 2).
Imaging methods are useful for diagnosis and to assess
the extent of disease. Diffusion magnetic resonance
(MRI) is the best preoperative alternative to evaluate
peritoneal disease compared with ultrasound (USG),
tomography (CT) or PET-CT. Diffusion MRI is more
accurate in detecting peritoneal disseminated disease,
hepatic and splenic metastasis, and in predicting
resectability.12
Radiological contraindications to primary debulking sur-
gery include the following:
 massive mesenteric infiltration and retraction with seg-
mental small bowel subocclusions
 massive porta hepatis or hepatic round ligament infiltra-
tion
 liver or lung parenchymal multiple metastases
 omental cake with clear infiltration of the lesser gastric
curvature (demanding total gastrectomy with en bloc trans-
verse colectomy).13
ª 2018 Royal College of Obstetricians and Gynaecologists
 Surgery in ovarian cancer – Brazilian consensus

with a score of 8, only 8.3% will achieve complete cytore-

What are the best tools for selection of patients
duction.21
for surgery?
The decision to perform extensive surgical procedures
Consensus: A combination of performance status, age, and
must consider:
tumour burden should be considered for patient selection for
 extensive preoperative planning
primary surgery compared with neoadjuvant chemotherapy
 multidisciplinary meeting
followed by interval debulking surgery strategies (Category 2).
 PS and clinical/anaesthetical contraindications for pri-
Laparoscopic evaluation of tumour spread and resectability is
mary debulking surgery (PDS)
recommended as a feasible tool that may prevent unnecessary
 carcinomatosis extension that does not allow a complete
laparotomies (Category 2).
PDS, assessed by a trained surgical team
Adequate patient selection for EOC surgical treatment
requires individualised planning that takes into account the
What are the main surgical objectives?
individual functional evaluation and disease extension. Pre-
Consensus: Complete R0 resection is the main goal, with bal-
operative performance status (PS),14,15 rather than age,
anced morbidity (Category 1). Primary debulking surgery is
prognosticates perioperative morbidity and mortality, the
the mainstay approach (Category 1). Patients without good
ability to complete primary therapy, overall survival (OS),
surgical conditions or excessive tumour burden should be con-
and progression-free survival (PFS).16
sidered for neoadjuvant chemotherapy and interval debulking
In addition, nutritional, psychological, anaesthetical risk,
surgery (Category 2).
and comorbidities should be addressed and may impact
Surgical cytoreduction in the treatment of EOC has been
surgical results. A multidisciplinary evaluation is para-
the object of study since Griffiths in 1975,22 who related
mount, especially when a multivisceral resection is planned
greater survival with smaller residual lesion size. In 1982,
for a complete resection (R0).17
Blythe et al.23 demonstrated greater survival in a group of
Evaluation of adequate abdominal peritoneal spread may
patients with residual lesions of up to 2 cm. In 1986,
predict resectability and surgical complexity. In 2005,
Piver24 described the possibility of achieving this pattern of
Sugarbaker et al.18 standardised a peritoneal cancer index
cytoreduction in 75% of stage III and IV patients. The
(PCI) in 13 different abdominal regions, each classified as
GOG study published by Hoskins et al. in 199425 con-
0 (no tumour), 1 (tumours up to 0.5 cm), 2 (tumours up
cluded that residual disease of up to 2 cm was correlated
to 5 cm), or 3 (tumour of more than 5 cm at the largest
with a better patient survival overall. In 2007, the German
diameter).18 This index was created for an exploratory
Group AGO-OVAR26 published a prospective randomised
laparotomy in carcinomatosis independently of the primary
trial demonstrating that residual disease is an independent
tumour. A PCI greater than 20 may indicate the necessity
prognostic, and that patients with no residual disease had a
for a more extensive surgical procedure, and neoadjuvant
better prognosis. In 2009, du Bois et al.27 published data
therapy should be considered.
from a combined exploratory analysis of three prospective
A laparoscopic score was created by Fagotti et al. in
randomised phase 3 trials. The primary goal of EOC
2006, for EOC carcinomatosis evaluation19,20 and was
cytoreductive surgery is no visible residual disease.
updated in 2015.21 It is a binary system, in which each of
As previously mentioned, the PCI of Sugarbaker28 is a
the following laparoscopic parameters score two points:
good tool for describing the extent of disease and the resid-
massive peritoneal involvement and/or a miliary pattern
ual tumour volume (Table 2).
parietal peritoneal carcinomatosiswidespread infiltrating
carcinomatosis, and/or confluent nodules to most parts of
the diaphragmatic surface; tumour diffusion along the
Table 2. Sugarbaker’s completeness of cytoreduction score
omentum up to the large stomach curvature possible large/ (modified from reference 27)
small bowel resection (excluding rectosigmoid involvement,
where posterior exenteration is considered a standard surgi- Completeness of Volume of disease at the end of
cal procedure) obvious neoplastic involvement of the stom- cytoreduction score surgical procedure
ach, and/or lesser omentum, and/or spleen liver surface
lesions larger than 2 cm As mesenteric retraction and mil- CC-0 No visible peritoneal carcinomatosis after
iary carcinomatosis on the serosa of the small bowel are CRS
CC-1 Nodules persisting <2.5 mm after CRS
widely recognised as absolute criteria of unresectability,
CC-2 Nodules persisting between 2.5 mm and
these criteria were excluded from the score.21 The higher 2.5 cm
the score, the less likely that the patient will be optimally CC-3 Nodules persisting >2.5 cm
debulked. Patients with ten or more points had no chance
of complete cytoreduction with primary surgery; of those CRS, cytoreductive surgery.

ª 2018 Royal College of Obstetricians and Gynaecologists 1245

 Tsunoda et al.
Two major randomised trials proved that in patients
with stage IIIC–IV EOC, PDS patients achieved oncological
outcomes comparable to interval debulking surgery (IDS)
patients.29,30 Most patients from both studies were ECO
grade PS0 or 1. PDS was related to more multiorganic
resections and morbidity. In both studies, R0 rates in both
arms were comparable to those in nonspecialists perform-
ing surgery in nonspecialised centres (18.3 and 16%
upfront, versus 48 and 43% neoadjuvant chemotherapy,
respectively). Median OS was 29 and 30 months, and 22.6
and 24.1 months, respectively.29,30
The morbidity of an extensive cytoreductive surgery var-
ies from 30 to 60% and should be balanced, with a target
of starting adjuvant chemotherapy within 4–6 weeks after
an operation.
Although complex and extensive surgical approaches
may enhance rates of completeness of cytoreduction,
tumour load remains an independent poor prognostic fac-
tor and probably reflects a more aggressive biological beha-
viour.31,32
What is the role of chemotherapy in EOC and
how does it fit with surgical treatment?
Consensus: Chemotherapy is offered to most patients with
EOC. Platinum-based regimens are preferred as a first-line
therapy, and for recurrence in platinum-sensitive or plat-
inum-naive patients (Category 1). Intraperitoneal (IP)
chemotherapy can be offered to selected patients with primar-
ily complete cytoreduction (Category 1).
Patients with initial EOC stage I and grade 3, or stage IC
should be completely staged, and will benefit from three
cycles of platinum-based chemotherapy.33 When consider-
ing a serous histology, there is a potential benefit from six
cycles for these early-stage, high-risk patients.34
Primary debulking surgery followed by platinum-based
systemic chemotherapy is the initial recommendation for
medically fit patients with EOC stages II–IV. Adjuvant
therapy is platinum-based and is less morbid when carbo-
platin is associated with paclitaxel for a mean of six
cycles.35 The combination of pegylated liposomal doxoru-
bicin with carboplatin was not superior to a standard-care
carbo-taxol regimen.36
Patients with bulky stages III–IV disease, poor surgical
candidates, and/or tumour load unlikely to be optimally
debulked, as assessed by a specialist gynaecological oncol-
ogist, are potential candidates for IDS. Morbidity is
reduced in this approach, with a comparable DFS and
OS.29,37
Intraperitoneal (IP) chemotherapy combined with sys-
temic platinum-based chemotherapy may confer an OS
benefit for patients medically fit enough to receive adjuvant
therapy.38 This effect is associated with the number of
cycles, and toxicities are frequently related to fatigue,
1246
neuropathy, renal function, and abdominal discomfort, and
are catheter-related.39
Hyperthermic perioperative chemotherapy (HIPEC) with
cisplatin (100 mg/m2) can be offered to IDS patients com-
pletely or optimally debulked. In a recent RCT, morbidity
was comparable and a significant 3.5-month median DFS
improvement was achieved with HIPEC (14.2 versus
10.7 months).40 HIPEC seems to be a promising tool. It
can be an option for medically fit patients, treated in cen-
tres of excellence, by trained surgeons, after a multidisci-
plinary tumour board meeting and at least stable disease
after neoadjuvant chemotherapy (Category 3).
What are the main quality characteristics to be
assessed?
Consensus: Quality assessment is paramount for achieving
better outcomes. PDS (>50%), procedures performed by spe-
cialists (>90%), rate of R0 resections (>65%), completeness
of surgical, pathological and morbidity records, operative
structure, and multidisciplinary treatment planning are the
recommended performance indicators for quality assurance in
EOC surgery (Category 2).
Quality of care is defined as ‘the degree to which health
services for individuals and populations increase the likeli-
hood of desired health outcomes and are consistent with
current professional knowledge’. Good quality means pro-
viding patients with appropriate services in a technically
competent manner, with good communication, shared
decision-making, and cultural sensitivity.41
In EOC, the quality of the surgical procedures (staging and
cytoreductive surgeries) is the cornerstone of patient care.
Although solid data have shown that patients treated by
gynaecological oncologists and in specialised centres have bet-
ter outcomes, heterogeneity in surgical care still exists.42–44
The identification of surgical quality indicators is chal-
lenging due to the lack of qualitative parameters.45
In 2009, the European Organisation for Research and
Treatment of Cancer (EORTC)46 proposed quality indicators
for staging laparotomy and for PDS for stage III–IV EOC. In
2016, the European Society of Gynaecological Oncology
(ESGO)47 proposed a complete list that included ten quality
indicators (QIs) for advanced EOC surgery that can be used
to audit and improve clinical practice (Table 3).48
Surgical major technical issues
Consensus: Advanced surgical skills provided by surgical spe-
cialists in a referral centre with a multidisciplinary approach
are the best combination to reduce morbidity and enhance
surgical objectives of cytoreduction (Category 2).
Surgeons must provide a detailed surgical report describing
the extent of disease before debulking pelvis, mid-abdomen,
and/or upper abdomen, and the amount of residual disease
in the same areas after debulking. Reports of complete or
ª 2018 Royal College of Obstetricians and Gynaecologists
 Surgery in ovarian cancer – Brazilian consensus

Table 3. Advanced (stage III–IV) ovarian cancer surgery quality indicators, modified from ESGO47,48

Indicator Target Observation

Rate of complete surgical resection
Number of cytoreductive surgeries
performed per centre and per
surgeon per year
Surgery performed by a
gynaecological oncologist or trained
surgeon specifically dedicated to
gynaecological cancer management
Centre participating in clinical trials
in gynaecological oncology
Treatment planned and reviewed at
a multidisciplinary team meeting
Required preoperative workup
Pre-, intra-, and postoperatory
management
Minimum required elements in
operative reports
Minimum required elements in
pathology reports
Existence of a structured prospective
reporting of postoperative
complications
Optimal target: ≥65%Minimum required
target ≥50%Proportion of primary
debulking surgeries: ≥50%
Number of surgeries performed per centre
per year: Optimal target:
N ≥ 100Intermediate target:
N ≥ 50Minimum required target:
N ≥ 20Minimum required target: N ≥ 20
≥90%
Yes
≥95%
≥95%
Not applicable
90%
≥90%. The flexibility within this target
reflects situations where it is not possible
to report all components of the data set
due to poor quality of specimen
Optimal target: 100% of complications are
prospectively recordedMinimum required
target: selected cases are discussed at
morbidity and mortality conferences
Complete abdominal surgical resection is defined by the
absence of remaining macroscopic lesions after careful
exploration of the abdomen
Only surgeries with an initial objective of complete
cytoreduction are recorded. ≥95% of surgeries are
performed or supervised by surgeons operating at least
10 patients a year
Surgery is performed by a certified gynaecological
oncologist or, in countries where such certification does
not exist, by a trained surgeon dedicated to the
management of gynaecological cancer (accounting for
over 50% of his practice) or having completed an
accredited fellowship
The centre actively collects patients for clinical trials in
gynaecological oncology
The decision for any major therapeutic intervention has
been taken by a multidisciplinary team (MDT) including at
least a surgical specialist, a radiologist, a pathologist (if a
biopsy is available), and a physician certified to deliver
chemotherapy
Unresectable parenchymal metastases have been ruled out
by imaging. Ovarian and peritoneal malignancy secondary
to gastrointestinal cancer has been ruled out by suitable
methods, for example plasma CA 125 and CEA levels,
and/or by biopsy under radiological or laparoscopic
guidance
The minimal requirements are as follows: (1) intermediate
care facility, with access to an intensive care unit in the
centre, is available, (2) an active perioperative
management programme is established
Operative report is structured. Size and location of disease
at the beginning of the operation must be described. All
the areas of the abdominal cavity must be described. If
applicable, the size and location of residual disease at the
end of the operation, and the reasons for not achieving
complete cytoreduction must be reported
Numerator: number of patients with advanced ovarian
cancer undergoing cytoreductive surgery who have a
complete pathology report. Denominator: all patients
undergoing cytoreductive surgery
Data to be recorded are reoperations, interventional
radiology, readmissions, secondary transfers to
intermediate or intensive care units, and deaths

incomplete resection, and if it is incomplete the reasons for
this, should indicate the size of the major lesion and total
number of lesions (Category 2).
Surgical aims in EOC include diagnosis for adnexal mass
or carcinomatosis, accurate staging for limited disease, peri-
toneal extension assessment or cytoreduction for advanced
or metastatic disease.
Patient and anaesthesia requirements
Any institution interested in performing EOC surgery must
have an intermediate high-dependency care facility and
access to an intensive care unit in the centre. An active
perioperative management programme should include pre-
operative nutritional and haemoglobin optimisation, with
iron deficit correction. According to the current guidelines,

ª 2018 Royal College of Obstetricians and Gynaecologists 1247

 Tsunoda et al.
fluid management (goal-directed therapy) and pain man-
agement should include an option of epidural analgesia to
reduce opioid demand. Routine premedication is no longer
recommended. Preemptive nausea and vomiting medica-
tions should be systematically given.47
Surgical initial technical aspects
After a multidisciplinary meeting, and if the disease
is considered potentially resectable in the preopera-
tive imaging review, a staging laparoscopy is advis-
able.
All patients with Eastern Cooperative Oncology Group
(ECOG) Performance Status 2 (PS2) or higher, but medi-
cally fit for general anaesthesia, should be scheduled for
diagnostic laparoscopy first.
Patients with good PS, but high tumour load, should also be
scheduled for staging laparoscopy only. The multidisciplinary
team then provides details regarding organs to be spared or
resected, and morbidity and mortality in PDS versus IDS.
Patients with a good PS and potentially resectable dis-
ease, with few or no organs to be resected, can be sched-
uled for staging laparoscopy followed by cytoreductive
procedure, under a single anaesthetical procedure.
Adequate patient selection reduces unnecessary complex
anaesthetical procedures for patients that are not suitable
for a PDS, and improves operating room timetables. Diag-
nostic laparoscopy with a Fagotti score49 may improve
selection to PDS or IDS.
Surgery should start with an umbilical incision for
laparoscopic inspection. A second port is inserted in the
lower abdomen to help with bowel manipulation. In the
case of advanced disease, an extra 5-mm port should be
inserted in the midline in the upper abdomen.50
Role of surgical staging
For initial EOC, stages I and II, the accuracy and adequacy of
surgical staging by laparotomy or by minimally invasive sur-
gery (MIS) appear to be oncologically equivalent. MIS
approaches result in lower postoperative complication rates,
shorter hospital stay,51 and less blood loss.52 However, intra-
operative tumour rupture has been reported to occur more
frequently in patients undergoing laparoscopy during an
MIS learning curve.53 There are no randomised data com-
paring laparotomy with laparoscopy staging for EOC.54
Surgical technical details
Surgical staging starts with aspiration of ascites or peri-
toneal lavage for peritoneal cytological examinations and
complete peritoneal surface evaluation, followed by excision
of any peritoneal surface or adhesion suspicious for metas-
tasis. In the absence of any suspicious areas, random peri-
toneal biopsies should be taken from the pelvis, paracolic
gutters, and both diaphragmatic surfaces.
1248
Bilateral salpingo-oophorectomy and hysterectomy
should be performed, making every effort to keep an
encapsulated mass intact during removal. For selected
patients desiring to preserve fertility, uterine and contralat-
eral adnexal preservation may be considered. Infracolic
omentectomy should be performed.55
Retroperitoneal lymphadenectomy includes removal of
nodal tissue from the vena cava and the aorta bilaterally,
up the left renal vein. Systematic pelvic lymphadenectomy
includes nodal tissue from the common, internal, and
external iliac vessels and obturator fossa, superficial to the
obturator nerve. In a recent trial presented in an oncologi-
cal meeting (LION trial, ASCO 2017, Chicago, IL, USA)
systematical lymphadenectomy increased morbidity without
OS benefit for advanced stage disease and, in the absence
of macroscopic and preoperative imaging of suspicious
lymph nodes, after complete cytoreductive surgery. The
goal of cytoreductive surgery in EOC should be R0 resec-
tion.27 Therefore, advanced techniques of peritoneal strip-
ping, multivisceral resection, and upper abdominal
management56,57 have been standardised and combined
with surgical staging techniques (Tables 4 and 5).
Video-assisted thoracic surgery (VATS) should be con-
sidered for patients with advanced EOC and pleural effu-
sion. VATS allows assessment of intrathoracic disease and
may select candidates for PDS with possible intrathoracic
cytoreduction versus IDS.61,62
Table 4. Epithelial ovarian cancer surgical treatment according to
clinical stages
Stages IA or IC fertility- Unilateral salpingo-oophorectomy
preserving desire and comprehensive surgical
staging***
Stage IB fertility-preserving Bilateral salpingo-oophorectomy and
desire comprehensive surgical staging***
Stages I–IV good Total hysterectomy with bilateral
performance status and salpingo-oophorectomy and
mild* to moderate tumour comprehensive surgical staging***
load, no fertility-preserving and debulking with complete (or
desire optimal) cytoreduction as a surgical
goal
Stages III–IV high tumour Neoadjuvant chemotherapy followed
load and/or poor surgical by surgical reassessment for interval
candidate** debulking surgery
*Adnexal mass with limited disease and no fertility desire could
benefit from frozen section and a proceed-as-indicated approach.
**Poor surgical candidates may benefit from percutaneous biopsy
with histological diagnosis or a combination of diagnostic cytology
and CA125/CEA ratio >25.
***Laparoscopic or robotic approach acceptable and advisable,
preserving oncological principles of avoiding tumour spillage and
performance of a comprehensive peritoneal cavity inspection.
ª 2018 Royal College of Obstetricians and Gynaecologists
 Surgery in ovarian cancer – Brazilian consensus

Table 5. Peritonectomy step-by-step technique

Greater/infracolic The greater omentum is elevated off the transverse mesocolon by stripping the entire surface of the mesocolon. The
omentectomy dissection includes separation of the specimen from the gastroepiploic vessels (preserved if possible) and division of the
short gastric vessels. The omentum is dissected and detached from the splenic hilum and the anterior surface of the
pancreas. Meticulous dissection of the omentum is essential for complete tumour removal
Epigastric The falciform ligament is separated from the umbilicus along with the anterior peritoneum and resected flush with the
peritonectomy liver surface to include the ligamentum teres hepatis. A bridge of liver may be divided to access the left portal vein if
necessary
Right Diaphragmatic peritoneum is stripped along its entirety after making a cruciate incision in the anterior peritoneum. The
hemidiaphragmatic peritonectomy may include stripping the Gerota fascia, the right adrenal gland surface, and the liver Glisson capsule. A
peritonectomy ventral liver mobilisation technique for cytoreduction of diaphragmatic tumours with involvement of the liver is feasible
and safe. Recognition of upper abdominal anatomy and liver mobilisation manoeuvres are fundamental to allow
exploration and debulking of the diaphragm, reducing the risk of major vessel injuries (retrohepatic caval vein, hepatic
hilum, suprahepatic veins, diaphragmatic vessels).58 The specific sequence of liver mobilisation varies from patient to
patient according to the tumour distribution and extension.58 The retrohepatic inferior vena cava (IVC) is the medial
border of the dissection. This surgical procedure can be adopted for the management of bulky diaphragmatic tumours in
select patients59
Left The upper left portion of a cruciate incision is used to initiate the left hemidiaphragmatic peritonectomy. Complete
hemidiaphragmatic stripping of the diaphragmatic fibres with skeletonisation (or ligation) of the inferior phrenic vessels may be undertaken.
peritonectomy Dissection may include stripping the adrenal gland surface and Gerota fascia
Lesser omentum The hepatoduodenal ligament and the pars flaccida are dissected from the caudate lobe of the liver and the porta
resection hepatis. Careful dissection of the coeliac axis branches and the right gastric arteries can elevate the tumour off the lesser
omentum. The IVC bursa is occasionally stripped, using the IVC, caudate lobe of the liver, and the left limb of the right
crus as anatomical landmarks
Pelvic peritonectomy Pelvic peritonectomy includes resection of the anterior peritoneum with or without the urachus and the medial umbilical
ligaments. A rectal and Douglas pouch shaving may reduce morbidity with a complete pelvic peritoneal clearance.
Visceral resections of the uterus and ovaries are performed as necessary
Anterior Scar excision and resection of the anterior peritoneum are carefully undertaken with preservation of the rectus muscle
peritonectomy fascia as the procedure starts. This becomes contiguous with the other peritonectomy specimens in the presence of
extensive peritoneal disease60

Is genetic counselling mandatory? hybridisation or multiplex ligation-dependent probe ampli-

Consensus: There is a formal recommendation to refer all
patients with EOC to a genetic counselling evaluation, regard-
less of age or family history (Category 2). In the absence of a
specialised geneticist, all oncologists should be trained to offer
BRCA 1 and 2 testing (Category 2).
Approximately 24% of all patients with nonmucinous
ovarian, peritoneal or fallopian tube carcinoma carried
germline loss-of-function mutations, 18% in BRCA1 or
BRCA2.63 More than 30% of patients have no family his-
tory of breast or ovarian carcinoma, and more than 35%
are 60 years or older at diagnosis.63 Among EOCM Brazil-
ian patients unselected for family history of cancer, approx-
imately 19% are BRCA1/2 germline mutation carriers.64
Therefore, comprehensive genetic testing for inherited
carcinoma is highly recommended for all women with
ovarian, peritoneal or fallopian tube carcinoma, regardless
of age or family history.
The overall rearrangement frequency is relatively uncom-
mon in Brazil,64,65 but if NGS or Sanger sequencing does
not confirm single nucleotide variants, or small insertions
and deletions, then array comparative genomic
fication should be used for rearrangement diagnosis.
Despite negative BRCA test results, if clinicians remain
suspicious of another hereditary cancer syndrome, a multi-
gene panel testing should be considered.66
Risk-reducing salpingo-oophorectomy remains the stan-
dard care for reducing EOC mortality among high-risk
women. Salpingectomy in women BRCA carriers should be
offered only in a clinical trial.67
Is there a role for surgery in EOC recurrence?
Consensus: All patients with recurrence should be referred to
a multidisciplinary tumour board for case review and best
management decision (Category 2).
Cases for salvage surgery should be offered for surgi-
cally fit patients, considering the following: platinum sen-
sitivity, PS, tumour load, resectability, and the absence of
ascites.68
Platinum-sensitive patients with relapses are potential
candidates for surgery and should be referred for a spe-
cialised surgical evaluation. R0 resection in platinum-sensi-
tive patients significantly improves OS. When it is not

ª 2018 Royal College of Obstetricians and Gynaecologists 1249

 Tsunoda et al.
feasible, optimal cytoreduction (0.5–1 cm residual tumour)
should be considered.69
When is palliative surgery indicated?
Consensus: Patients with significant symptoms that may be
relieved by surgery should be referred for surgical evaluation
and a tumour board meeting (Category 2).
Patients with pain due to a resectable metastatic tumour
or bleeding may benefit from palliative surgery.70
Patients with EOC frequently experience bowel occlu-
sion. Palliative surgery for bowell obstruction (limited
resection and/or stoma) is indicated in surgically fit
patients with a segmental occlusion and without extensive
carcinomatosis, and preferably with no ascites.71
Incomplete resections are not curative and may adversely
impact time to systemic therapy and quality of life, due to
surgical complications.
Future perspectives and key questions
This consensus supports significant policies for the public
healthcare system in the country, including:
 centralisation of EOC cases in cancer centres
 multidisciplinary tumour boards and patient-driven deci-
sions
 quality assurance in EOC surgery
Some questions will need to be addressed after this con-
sensus:
 is laparoscopy the best tool to access resectability?
 what do the national quality assurance data indicate?
 what is the genetic profile?
 what are the limitations for adequate treatment?
Conclusions
Surgery has a significant impact on EOC outcomes. This
consensus provides answers to key questions related to sur-
gical management of patients with EOC. The surgical aim
is complete cytoreduction with acceptable morbidity. This
document is a Brazilian guideline and may serve as a tool
for governmental decisions regarding new technology and
resource acquisition.
Disclosure of interests
The authors do not have relevant financial, personal, politi-
cal, intellectual or religious interests. A Tsunoda received
honorary for educational lectures for Roche, from 2015 to
2017, R Marques received honorary for educational lectures
for Roche and Astra Zeneca, R Ribeiro received honorary
for educational lectures and material development, and
consulting from Roche, and educational lectures from
Johnson&Johnson, without competing interests. Full disclo-
sure of interests available to view online as supporting
information.
1250
Contribution to authorship
ATT and RR were responsible for the conception, planning,
and carrying out the study, structuring the group discus-
sions, reviewing the literature, analysing, and writing up
and reviewing this manuscript, and participated equally,
with the same workload. RJR, CEMCA, RMM, GB, FF,
PHZ, DF, TB, BRBA, GG, SAP, JSN, LC, VC, and JCL were
responsible for discussing, reviewing the literature, analys-
ing, partially writing up and final review of this manu-
script. FJFC was responsible for the conception and final
review of this manuscript.
Details of ethics approval
Due to the scientific review nature of this study and spe-
cialists’ consensus, there was no need for ethics committee
approval. This study was approved by the Brazilian Society
of Surgical Oncology (BSSO) board of directors and educa-
tional members.
Funding
There was no funding for this work.
Acknowledgements
We would like to thank the following societies and institu-
tions for supporting discussions and members’ collabora-
tion: Brazilian Society of Surgical Oncology/BSSO
(Sociedade Brasileira de Cirurgia Oncol
ogica—SBCO), Brazil-
ian Society of Clinical Oncology (Sociedade Brasileira de
Oncologia Cl
ınica—SBOC), and the Brazilian Federation of
Obstetrics and Gynaecology (Federacß~ao Brasileira de Gine-
cologia e Obstetr
ıcia—FEBRASGO).
Supporting Information
Additional supporting information may be found online in
the Supporting Information section at the end of the article.
Video S1. Author insights. &
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