Introduction
Debulking surgery is done to alleviate symptoms caused by tumors and to halt the progression of advanced malignancies, such as some forms of ovarian cancer, endometrial or uterine cancer, and cancers that have progressed to the lining of the abdomen. It is often used as the initial line of treatment for many ovarian malignancies in conjunction with chemotherapy. Most patients are diagnosed with advanced ovarian cancer, so debulking surgery is a therapy cornerstone. In addition, advanced ovarian cancer responds better to debulking surgery and chemotherapy than other advanced malignancies.
What Is Debulking Surgery?
Debulking surgery, also known as cytoreduction, is a procedure that reduces the quantity of cancer in the body. The best surgical technique for many kinds and stages of cancer is to remove the entire tumor or all tumors. However, certain malignancies are too extensive or near vital organs, making total removal problematic. Debulking surgery aims to remove as much cancer as possible while remaining safe. Other treatments, such as chemotherapy or radiation, are frequently used to treat residual malignancy.
How Long Does It Take To Have Debulking Surgery?
The resection pattern for debulking surgery is categorized into three types based on the presence or absence of metastatic lesions and the resectability of the primary tumor.
Type 1 - It is a common and essential form of debulking surgery, coupled with or without metastatic resection to the greatest extent. In this category, the primary tumor itself is fully removed. However, metastasis cannot be entirely removed, and it is unknown how much metastatic disease exists.
Type 2 - This debulking resection is a primary tumor with no metastasis or dissemination but invades irreversible anatomical structures.
Type 3 - It is a hybrid of types 1 and 2.
What Are the Types of Debulking Surgeries for Ovarian Cancer?
Regarding the least required for resected tumor volume, two categories, optimal and suboptimal surgery, are employed in ovarian cancer to identify residual tumor volume based on evidence demonstrating a clear link between the maximal size of remaining lesions and survival. Therefore, for the treatment of ovarian cancer, three types of debulking surgery have been defined:
- Primary Debulking Surgery (PDS) - Initial treatment.
- Interval Debulking Surgery (IDS) - Debulking followed by neoadjuvant chemotherapy.
- Secondary Debulking Surgery (SDS) - Debulking for recurrent or residual tumors developed after systemic chemotherapy.
What Is the Role of Radiotherapy in Debulking Surgery?
The ability of implicated anatomical structures to be resected with prolonged surgery depends on the structure's location and the patient's physical condition. Radiotherapy is required in this circumstance; however, debulking surgery may be suggested if radiotherapy is inappropriate due to the large tumor size, incorrect tumor placement, and radioresistant histology. The remaining tumor in this type 2 is only localized. A cure may be possible if the remaining tumor volume is modest and postoperative radiation is highly effective.
What Is Debulking Surgery for Ovarian Cancer?
Various criteria, including patient selection, tumor location, and surgeon ability, determine the operation's outcome. To provide a survival advantage, the procedure should result in no residual tumors larger than two centimeters. The Gynecologic Oncology Group (GOG) has defined optimum debulking as implants smaller than one centimeter in length for consistency. After the operation, such measures are decided subjectively. Assessments of residual tumor size are frequently inaccurate because of tissue induration or preliminary investigation. Regardless, the ultimate aim is total resection with no visible or palpable illness left in the abdomen.
What Is Interval Debulking Surgery?
Interval debulking surgery is only effective in individuals who can be optimally debulked. Unfortunately, preoperative CA 125 levels, computed tomography (CT) scans, and physical exams are frequently insufficient to anticipate intraoperative findings. As a result, many patients transferred to the operating room may be left with severe residual disease. In addition, postoperative recovery can be lengthy if the patients are adequately debulked. As a result, the start of chemotherapy is delayed or postponed indefinitely.
An experiment found that patients re-examined after three chemotherapy cycles had a six-month median survival benefit. A comparative trial was undertaken; however, it found no survival benefit. These contradictory claims are best explained by determining who conducted the first operation. Almost all patients had their first surgery performed by a gynecologic oncologist, but in the experiment, only a small number of patients had their first surgery performed by a subspecialist. Thus, interval debulking benefits only individuals whose original surgery was not conducted by a gynecologic oncologist, whose first attempt was not meant to be a maximum resection of all gross disease, or who had no upfront surgery.
What Is Interval Debulking Surgery With Neoadjuvant Chemotherapy?
Some patients are too sick to have any form of abdominal surgery. At the same time, others have a disease that is too advanced to be resected by an experienced ovarian cancer surgical team. In these cases, neoadjuvant chemotherapy (NACT) is commonly performed after a paracentesis (drainage of ascitic fluid ) or CT-guided biopsy has verified the diagnosis. The viability of surgery can be evaluated after a few sessions of therapy. Neoadjuvant chemotherapy (NACT) followed by interval debulking results in survival rates equivalent to those for major surgery. Furthermore, fewer invasive treatments were required, the incidence of attaining minimum residual illness increased, and patients suffered reduced morbidity.
Conclusion
Although debulking surgery is a deliberate imperfect resection that violates surgical oncology principles, it has been clinically supported in several malignant tumors. Positive results have been reported for ovarian cancer spread and breast cancer, primarily based on the survival benefit of nonsurgical systemic treatment alone. However, debulking surgery can still treat slow-growing borderline malignant tumors like thymomas. Survival from the synergistic effect of debulking surgery and new therapies in systemic treatment is beneficial. Future research is being planned to determine the best candidates and time for debulking operations and determine the predicted survival advantage in each tumor.
