Ovarian cancer remains the most lethal gynaecological malignancy, largely because many women present with advanced disease and relapse despite aggressive treatment. While initial cytoreductive surgery and platinum‑taxane chemotherapy offer the best chance of remission, most tumours eventually recur and develop resistance to platinum drugs. Platinum‑resistant ovarian cancer (PROC) – defined as disease progression within six months of the last platinum‑based regimen – confers a dismal prognosis and limited therapeutic options. Standard care relies on non‑platinum chemotherapy such as liposomal doxorubicin, paclitaxel, gemcitabine or topotecan, with or without bevacizumab, but objective response rates rarely exceed 13 % and median progression‑free survival is less than six months. In this bleak landscape, the potential role of surgery has come under renewed scrutiny.
The rationale for secondary cytoreductive surgery in PROC mirrors that for platinum‑sensitive disease: removing all visible tumour can alleviate symptoms, restore organ function and possibly re‑sensitize tumours to chemotherapy. However, evidence is far from definitive. A recent systematic review identified only six retrospective studies, totalling 155 patients, that reported outcomes of cytoreductive surgery in platinum‑resistant recurrence. Definitions of platinum resistance varied across studies, but most considered relapse within six months of chemotherapy.
Across these small cohorts, surgery combined with non‑platinum chemotherapy appeared to prolong survival compared with chemotherapy alone, provided a complete resection (R0) was achieved. In one comparative study, patients undergoing surgery plus chemotherapy had a median post‑relapse survival of 32 months versus 8 months in the chemotherapy‑only group. Another report found a progression‑free survival of 10.6 months versus 5.1 months and a post‑relapse survival of 32.6 months versus 16.3 months, favouring the surgical group. Musella and colleagues described a median overall survival of 67 months in patients who underwent complete cytoreduction, compared with 24 months in a historical cohort treated non‑surgically. Observational series likewise highlighted that patients with no residual disease experienced significantly longer survival; for instance, Zhao et al. reported median overall survival of 39 months after R0 resection versus 15 months when residual disease remained. These benefits were not universal. High morbidity tempered enthusiasm: Tuninetti and co‑workers documented 38 % complication rates and an 8 % 30‑day postoperative mortality. Complications included pneumothorax, intra‑operative vessel injury, lymphoceles and wound dehiscence, underscoring the surgical challenges in heavily pre‑treated patients. Most included studies were retrospective and prone to selection bias. Importantly, none assessed quality of life after surgery.
Patient selection emerges as the critical determinant of success. The review suggests that cytoreduction may be worthwhile for women with isolated nodal recurrences or limited disease, good performance status and no peritoneal carcinomatosis. Achieving R0 resection was consistently associated with improved survival. Conversely, extensive disease or poor functional status conferred little gain, and the operative risks may outweigh potential benefits. Some investigators explored minimally invasive approaches, such as laparoscopy or robotic surgery, to reduce morbidity, yet these techniques remain experimental and suitable only for carefully chosen patients.
Given the paucity of robust data and the considerable risk, decisions about surgery in PROC should be made in specialist gynaecological oncology centres through multidisciplinary discussion. Pre‑operative imaging, assessment of tumour biology and patient fitness, and candid counselling about potential outcomes are essential. Management strategies should also consider novel systemic therapies. Targeted drugs such as bevacizumab improve response rates when added to chemotherapy, and newer agents like PARP inhibitors and antibody–drug conjugates (e.g., mirvetuximab soravtansine) offer hope for subgroups of patients. Surgery must therefore be integrated with systemic therapies rather than viewed in isolation.
Surgery for recurrent platinum‑resistant ovarian cancer remains controversial. Current evidence, albeit limited and retrospective, indicates that carefully selected patients with isolated or low‑volume disease may enjoy meaningful prolongation of survival when complete cytoreduction is feasible. However, high complication rates and the lack of quality‑of‑life data demand caution. Until prospective trials establish clear criteria, cytoreductive surgery in PROC should be confined to specialized centres and considered only after thorough evaluation of risks, expected benefits and alternative therapies.
