Optimal primary management of bulky stage IIIC ovarian, fallopian tube and peritoneal carcinoma: Are the only options complete gross resection at primary debulking surgery or neoadjuvant chemotherapy?

•PDS to no gross RD confers the best survival outcomes.•PDS to RD of 1-10 mm is associated with survival benefit compared to RD of > 10 mm.•IV/IP chemotherapy use is associated with better OS in patients with RD of 1-10 mm.

ObjectiveTo explore the impact of primary debulking surgery (PDS) to minimal but gross residual disease (RD) in women with bulky stage IIIC ovarian, fallopian tube, or primary peritoneal cancer.MethodsWe retrospectively reviewed all patients with the aforementioned diagnosis who underwent PDS at our institution from 01/2001-12/2010. Those with disease of non-epithelial histology or borderline tumors were excluded. Clinicopathologic data were abstracted, and appropriate statistical tests were used.ResultsWe identified 496 eligible patients. Median age was 62 years; 91% had disease of serous histology. Patients were grouped by RD status: no gross RD, 184 (37%); RD of 1-5 mm, 127 (26%); RD of 6-10 mm, 54 (11%); and RD > 10 mm, 131 (26%). With a median follow-up of 53 months, the median progression-free survivals (PFS) were: 26.7, 20.7, 16.2, and 13.6 months, respectively (p < 0.001). The median overall survivals (OS) were 83.4, 54.5, 43.8, and 38.9 months, respectively (p < 0.001). Among patients with RD following PDS, those with RD of 1-10 mm had improved PFS (p < 0.001) and OS (p = 0.001) compared with those with RD > 10 mm. Patients with RD 1-10 mm who received intravenous/intraperitoneal (IV/IP) chemotherapy were younger and had prolonged OS compared with those solely exposed to IV chemotherapy (p < 0.001 and p = 0.002, respectively).ConclusionsPDS to no gross RD was associated with the longest PFS and OS. However, cytoreduction to 1-10 mm of RD was also associated with better survival outcomes compared with cytoreduction to > 10 mm of RD. We conclude that PDS remains an appropriate option for patients with a high likelihood of achieving RD 1-10 mm, especially for younger patients who can receive IV/IP chemotherapy after PDS.