Ovarian Cancer surgery & treatment Dr Jérémie Zeitoun · Gynaecological Surgeon Paris 8th

What it is for. Diagnostic laparoscopy is a small camera introduced into the abdomen through tiny incisions. It allows visualisation of the extent of disease, sampling for analysis, and most importantly assessment of whether complete resection is feasible upfront.

Why we do not biopsy through the skin. Puncturing a suspicious ovarian mass through the skin would risk disseminating tumour cells in the abdomen. This procedure is contraindicated if surgery is accessible.

What it decides. At the end of the laparoscopy, we know whether to operate directly (upfront surgery) or to start with chemotherapy to reduce disease before operating. This is the most important decision of the pathway — it is taken at the MDT.

The Fagotti laparoscopic score quantifies the extent of peritoneal disease. A PI score above a certain threshold indicates that upfront complete resection is not achievable — chemotherapy first is then the recommended strategy.

The aim is to remove all visible tumour in the abdomen — leaving no residue. This is open abdominal surgery (laparotomy), often long, which may include the uterus, ovaries, fallopian tubes, omentum, portions of peritoneum, bowel or other organs depending on disease extent.

It can be performed upfront if disease is resectable, or after a few cycles of chemotherapy to reduce the tumour before operating. In both cases, the goal remains the same: leave nothing.

It must be performed in an authorised specialised centre — this is a requirement under French regulation, because the quality of this procedure directly impacts prognosis.

Reference chemotherapy combines two drugs: carboplatin and paclitaxel, administered intravenously every 3 weeks for 6 cycles. A third drug, bevacizumab, may be added — it works by cutting off the tumour's blood supply.

Before surgery (neoadjuvant chemotherapy): 3 to 4 cycles to reduce disease and allow complete resection that would not have been possible upfront.

After surgery (adjuvant chemotherapy): to eliminate microscopic residual cells that surgery cannot see.

The most frequent side effects are fatigue, nausea, temporary hair loss, and increased susceptibility to infections. They are managed by the medical team throughout treatment.

Once chemotherapy is completed, maintenance treatment is often offered to prolong remission. It does not cure on its own — it prevents or delays disease recurrence.

PARP inhibitors (olaparib, niraparib, rucaparib) are tablets that prevent tumour cells from repairing their damaged DNA. They are particularly effective if the tumour carries a BRCA mutation or genomic instability. They are taken daily for several months to years.

Bevacizumab may also be used in maintenance, as injections every 3 weeks. It is often combined with olaparib or used alone depending on tumour profile.

The choice of maintenance treatment depends on BRCA status, tumour genomic instability, and what was used during chemotherapy. It is decided at the MDT after molecular workup results.

Clinical trials test new drugs or new combinations, often before they are available outside hospital. Participating means accessing innovative treatments while contributing to progress for future patients.

They are offered at every stage: at diagnosis, first line, and especially in case of recurrence. Your team will inform you of trials for which you are eligible. It is never an obligation — it is always an informed choice.

In ovarian cancer, clinical trials have produced the most important advances of the last 20 years — particularly the validation of PARP inhibitors.

In all cases, we remove the uterus, both ovaries and both fallopian tubes, as well as the abdominal omentum (often involved). All visible suspicious lesions are removed at the same time — that's the goal of leaving no residue.

Depending on disease extent, surgery may include: peritoneal resections (the membrane lining the abdomen), part of the bowel, the spleen, lymph nodes along the major vessels. These procedures are decided during the operation according to what is found.

This is open abdominal surgery (laparotomy). Unlike other gynaecological operations performed by laparoscopy with small incisions, ovarian cytoreduction usually requires complete abdominal opening — to allow exploration and treatment of the entire abdomen.

The risk of stoma. If a portion of bowel must be removed and immediate junction is not possible in the safest conditions, a temporary stoma may be necessary — this is an opening of the bowel onto the abdomen to allow healing. It is most often closed a few weeks to months later. This risk is discussed with you before the operation.

Why this is demanding surgery. It is long, technically difficult, and carries non-negligible risks. This is why it must be performed in a B5-authorised centre with specific ovarian cancer experience — this is French regulation.

Upfront surgery — if complete resection is judged feasible at the start (stages III-IVA). We operate, then give adjuvant chemotherapy.

Chemotherapy first — if disease is too extensive for upfront complete resection, or if general condition requires it. 3 to 4 cycles of chemotherapy first, then interval surgery if disease responds. For stage IVB (distant metastases), chemotherapy first is systematic.

It is not a compromise. Doing chemotherapy first is not a second-choice option — it is the appropriate strategy when it allows complete resection that would not have been possible otherwise.

What it is. At the end of surgery, heated chemotherapy is infused directly into the abdomen for 30 to 90 minutes. It aims to eliminate microscopic residual cells that surgery alone cannot reach.

In what cases. HIPEC is mainly discussed in platinum-sensitive recurrence, when complete resection is possible and disease responds to chemotherapy — according to CHIPOR trial criteria. It is not systematic in first line.

It is a specialised technique performed only in centres trained in this procedure.

For the vast majority of epithelial ovarian cancers (advanced stage, post-menopausal patient or no desire for pregnancy), surgery includes removal of both ovaries, fallopian tubes and uterus. This is not a question of choice — it is the condition for achieving complete resection.

In young women with stage IA well-differentiated cancer or a germ cell tumour, preservation of the uterus and contralateral ovary is sometimes discussed at the multidisciplinary team meeting. This is not the rule — it is a carefully framed exception.

Borderline tumours are a category of their own. They often affect young women, their prognosis is favourable, and fertility preservation is frequently possible. → Read the dedicated page on borderline ovarian tumours

Removal of both ovaries causes immediate menopause in pre-menopausal women. Hot flushes, sleep disturbances, vaginal dryness, mood changes — these effects are real and can be significant.

Hormone replacement therapy (HRT) is discussed on a case-by-case basis. It is not contraindicated in principle in non-hormone-dependent ovarian cancers — but the decision belongs to the oncology team. The aim is to find the right balance between quality of life and safety.

This question is addressed during the pre-operative consultation and revisited at follow-up. It deserves to be raised explicitly — don't wait for it to come up.

Before treatment begins, an oncofertility consultation can be organised at short notice to discuss oocyte or embryo cryopreservation if relevant.