Gynecologic Oncology 114 (2009) S15–S21

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Gynecologic Oncology

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Advanced cytoreductive surgery: Asia Pacific perspective

Alexander J. Crandon a,b,⁎, Andreas Obermair a,c,d

a Queensland Centre for Gynaecological Cancer, Brisbane, Australiab Mater Adult Hospital, South Brisbane, Australiac Royal Brisbane and Women's Hospital, Herston, Brisbane, Australiad University of Queensland, Medical School, Herston, Brisbane, Australia

⁎ Corresponding author. Queensland Centre for GyAustralia.

E-mail address: alex@igcs.com.au (A.J. Crandon).

0090-8258/$ – see front matter © 2008 Elsevier Inc. Adoi:10.1016/j.ygyno.2008.11.007

a b s t r a c t

a r t i c l e i n f o

Article history:

The thoroughness of cytore Received 20 October 2008

Keywords:Cytoreductive surgerySurgical skillsDecision makingOvarian cancerPrimary peritoneal cancer

ductive surgery is the largest contributor to survival for patients with advancedovarian and primary peritoneal carcinoma. For many years the surgery undertaken by GynaecologicOncologists has been tailored to match their surgical training. Future surgical training of GynaecologicOncologists needs to be tailored to the surgery required to provide complete tumour removal to no residualdisease. This means the better teaching of anatomy and an increased scope of surgery to include the generaland upper abdominal procedures and management required. This paradigm shift will be a challenge for alland impossible for some. It will require a significant mind-shift not only from our craft group and theprofession at large but especially from the speciality Colleges who will need to take these changes on boardfor future curriculum development.

The development of Advanced Cytoreductive Surgical Units needs to be undertaken in a teamenvironment. This requires a commitment from participants at all levels, from the lead oncology surgeonthrough the hospital administration to the support services involved. While advanced cytoreductive surgeryis feasible, it is only in this team environment, limited to major multidisciplinary hospitals, that it can besafely achieved by meticulous attention to detail at all levels.

© 2008 Elsevier Inc. All rights reserved.

Debulking surgery has for decades played a major part in themanagement of advanced primary ovarian and peritoneal cancer.Many studies have shown a consistent relationship between minimalresidual tumour volume at the end of surgery and improved survival,however, the tendency has been to debulk rather than to cytoreducetumours. Gynaecological Oncologists have become good at removingthe bulky disease whichmainly occupies the pelvis and the omentum.The widespread small tumour nodules frequently found over theperitoneal surfaces especially in the para-colic gutters, under thediaphragm and on the mesentery have tended to be left forchemotherapy to treat. However, accumulating evidence suggeststhat leaving even this level of disease compromises the patient'soutcome as measured by overall or disease free survival. We havetended to rely on new chemotherapy to improve survival, however,while there have been advances in chemotherapy they have not beenof the magnitude that was hoped. If we want to improve the outcomefor these patients thenwe need to go back to the beginning and look atthe problem and the factors that affect the outcome and design a newstrategy for future approaches.

naecological Cancer, Brisbane,

ll rights reserved.

The aim of our management is to maximise survival for patientsaffected by advanced ovarian or peritoneal malignancies whilekeeping treatment-related adverse events at an acceptable minimum.There is also consistent evidence that removing all visible diseaseresults in improved survival. What is required is not just thedevelopment of skills that allow debulking of large tumour masses,but also the development of the surgical skills that allow the removalof widespread peritoneal nodules be they ever so small. On this basisgynaecological oncologists need to not just be able to perform varioustypes of hysterectomies and omentectomies, they need to be able todeal with disease that involves large and small bowel, spleen, liversurface, diaphragm, gallbladder and retroperitoneal nodes. Thismeans they need to have the knowledge, training and skills toperform and manage ureteric/bladder surgery, bowel resections,splenectomies, cholecystectomies, subsegmental liver resections,trans-abdominal thoracotomies and retroperitoneal lymph nodedissections.

In the future we need to tailor our training to the required surgicalprocedures needed to be undertaken, rather than tailor our surgicalprocedures to our training.Why this may sound fairly straight forwardit raises a multitude of issues from anatomy training in medicalschools to cross-specialty surgical training that some will findchallenging and threatening.

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Surgical skill-set requirements

Technical skills

AnatomyIt goes without saying that a detailed knowledge of anatomy is a

prerequisite to surgical training. Anatomy provides the roadmap forthe surgical procedures to be undertaken. In recent years theimportance and level of anatomical knowledge has been progressivelydowngraded while increasing importance has been put on othersubjects. Whatever the merit of these changes, it remains anindisputable fact that a detailed knowledge of anatomy, at leastsurgical anatomy, is an absolute prerequisite for surgical training; andthe commencement of that surgical training is not the time to belearning those detailed facts for the first time. The commencement ofsurgical oncology training is the time to be re-learning anatomy.

Dissection skillsIf onewas going towrite the definitive textbook of surgery it would

be called “The Tissue Planes of Surgical Dissection.” An inability toconsistently find and dissect along tissue planes goes hand in handwith an inability to become a good surgeon. It is impossible forsomeone who cannot find and develop tissue planes to dissect andstrip tumour affected areas of peritoneum. Furthermore, the surgeonneeds to have respect for the tissues being handled. They need to behandled with gentleness, a skill, like tissue plane dissection, that canonly be assessed subjectively by another skilled senior surgeon.

Pelvic surgical skillsThe genital tract represents only one of three systems that occupy

the pelvis, the others being the urinary and the colonic systems, all ofwhich can be affected by female genital tract cancer. In order toundertake the surgical extirpation of advanced gynaecological cancersuch as ovarian or peritoneal malignancy it is necessary to have thetraining to undertake restorative and non-restorative colonic resec-tions, pelvic peritonectomies and on occasions partial cystectomies orureteric re-implantations. While it is possible to have the individualspecialists, each to undertake his or her area of work, this degree of co-ordination is in reality unrealistic.

Upper abdominalSurgical training in the upper abdomen is frequently extremely

limited if present at all in those from a strictly gynaecologicalbackground. While it is fairly easy to undertake an infracolicomentectomy, the performance of a total omentectomy, up to thegreater curve of the stomach and over to both the hepatic and splenicflexures of the colon, is a different matter. Moreover, it is notuncommon for advanced ovarian/peritoneal cancers to involve thespleen, either in its hilum or laterally, necessitating the need for asplenectomy. If the disease is of a reasonable size and in the splenichilum then a distal pancreatectomy may also be required to provideadequate surgical clearance.

Hepato-biliary skillsOne of the commonest patterns of spread for ovarian cancer is up

the right para-colic gutter and under the right diaphragm followingthe peritoneal reflections. The true extent of disease in this area onceestablished can only be accurately quantitated after liver mobilisation.Frequently the volume of disease is significantly greater than was firstappreciated on the basis of manual assessment alone. This is becausedisease on the diaphragmatic peritoneum frequently becomesadherent to the hepatic capsular surface creating a false peritonealreflection with little being felt. It is only when the liver is mobilisedand this area is opened and visualised that the true disease extent isable to be appreciated. Furthermore, peritoneal disease often involvespatches on the liver surface or edge and small subsegmental

resections are required to remove this disease. Widespread peritonealdisease will also occasionally involve the surface of the gallbladderjustifying cholecystectomy.

Thoracic skillsFor a large part of its biological life, ovarian/peritoneal cancer

remains largely a surface disease. The presence of lots of small areas ofdisease under the diaphragm quickly adds up to a volume that affectssurvival unless removed. Stripping the sub-diaphragmatic peritoneumis the only way to adequately tackle this disease. Experience hasshown that once the disease starts to coalesce or has reached a sizegreater than a centimetre in size it has invaded deeply enough toinvolve the underlying diaphragm. If this is the muscular diaphragmthen it can often still be dissected off by taking a layer of muscle whilemaintaining diaphragmatic integrity. If it involves the tendineous partof the diaphragm then it will usually require removal of a segment ofdiaphragm with diaphragmatic reconstruction and drainage of thepleural airspace. If of course lung is adherent above the diaphragm, asis becoming more commonwith patients having pleural drainage andpleurodesis before a diagnosis is established, this is not known untilthe diaphragm is opened and/or the lung is breached. Thegynaecological surgical oncologist needs to be able to address all ofthese issues.

Vascular skillsUndertaking the extent of surgery described above means that it is

only a matter of time before a vascular injury occurs; be it the inferiorvena cava, a supra-hepatic vein or an unnamed pelvic vessel. Whilevascular prosthetic surgery should be left to vascular surgeons, therepair of vascular injury needs to be in the skill-set of a gynaecologicaloncologist.

Decision making and judgement

KnowledgeThis is arguably the hardest area of training; determining what

judgement skills need to be acquired and how they should beassessed. Put simply it is necessary that the gynaecological oncologysurgeon knows:

• What to do,• When to do it,• Why to do it,• How to do it, and probably most importantly,• When not to do it.

These judgement skills are the hardest to teach and there aremany,while being good technical surgeons, are never able to develop thejudgement skills needed to safely undertake this level of advancedsurgery. In part it can be done by working with guidelines ormanagement principles that can be applied over and over again untilthey become an automatic part of patient management.

The close working relationship that needs to exist betweenmembers of an advanced cytoreductive surgical unit cannot be overemphasised, so that members can constantly oversee each othersperformance. Constant checking and double checking of clinicalsituations and patient management paradigms, is of utmost impor-tance. This is a good example of why such personnel cannot work inisolation.

Apprentice systemThe level of surgical skills required for advanced cytoreductive

surgery is such that, at least at present, it cannot be taught or learnedother than on a first hand basis. This means the use of the old surgicalapprenticeship system where a senior and skilled surgeon tutors hisstudents to the appropriate levels. In this regard it is also of paramountimportance that this apprenticeship involves placement rotation so

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that each student is exposed to multiple tutors preferably with one ofthose rotations being overseas.

In the long run it must also be remembered that it is not enoughthat the teacher knows that his/her student is capable of performingthe surgery. The student must also be aware that he/she is alsocapable of undertaking the surgery. This requires the teacher'sjudgment and leap of faith in the student to allow him to operatesolo, but with the teacher available if needed. However, having saidthat, it is worth remembering that the technical complexity, time andlevel of concentration required to undertake advanced cytoreductivesurgery, is such that it should not be undertaken by a single seniorsurgeon with an assistant. Rather it should be undertaken by twoskilled senior surgeons working together plus an assistant.

Assessment of judgment skillsThis is undoubtedly the most difficult part of not only training but

ongoing recertification. One study has clearly demonstrated that basicsurgical trainees are a self-selecting group whose preferred learningtechnique is problem solving and hands on experience (R.Coll.Surg.Edin.,44, Feb 1999, 55–56). However, there is no good information onwhetheror not certain personality traits make better surgeons. While thisapproach with psychological testing has been successfully used inbusiness to avoid appointing people to the wrong positions; the squarepeg in the round hole scenario; this has not been achieved in surgery.

While retrospective performance analysis allows the identificationof outliers in terms of surgical outcomes this is too late if the problemrelates to a basic personality, physical or motor skill deficit.

In aviation and anaesthesia the use of situational simulators hasproved extremely successful. It may be that a large part of this area ofdeveloping clinical judgement, will come down to the use of, as yet tobe developed, situational simulators based on past cases and/orsentinel events.

Establishing an advanced cytoreductive service

The establishment of an Advanced Cytoreductive Surgical Servicerequires the development of some infrastructural requirements that,while nice, are not prerequisites for most surgical services. Thestructure required is very much akin to that required of a good tissuetransplantation service.

While the provision of an Advanced Cytoreductive Surgical Servicecan run and operate smoothly, this will only happen if the formalstructure and planning is put in place at the outset. There arenumerous places where things can go wrong and with this type ofsurgery the potential for disaster if things start to go wrong isenormous.

A team approach

The Advanced Cytoreductive Surgical Service will need at least onepersonwho is going to lead the establishment and development of theservice. Given the commitments in time required of the surgeon thereare advantages in him/her being the driving force. Having said this itis also important that the members of the team accepts that the teamis more important that any individual. While this surgical team willrequire the usual personnel, e.g., surgical assistant, anaesthetist,preferably with experience in cardiothoracic and hepato-biliaryanaesthesia, senior anaesthetic technician, senior scrub sister, seniorscout nurse; more than in other areas this team needs to get on and towork extremely well together. There needs to be an excellent workingrelationship between the surgeon and the anaesthetist. As mentionedearlier experience has shown that this level of surgery is better donewith two senior surgeons. This significantly reduces the workload andthe stress which would otherwise reside with the lead surgeon. Thereis also a lot to be said for the provision of a dedicated theatre nursingteam who always provide the intra-operative team.

The team leader will need to play an active role in maintaining theteam cohesiveness. He/she will need to promote a team buildingenvironment and be ready and able to deal with the inevitableconflicts that can occur in such diverse multidisciplinary services.

Other important members of this team outside the surgical serviceare those who provide:

• Critical care,• Medical oncology,• Diagnostic imaging,• Haematology,• Infectious diseases,• Gastroenterology,• Physiotherapy,• Nutrition.

The members of this expanded team need to have a reasonablygood appreciation of where they fit in the bigger scheme of things aswell as having aworking understanding of the roles of other membersof the team.

Service coordinator

One the most important people will be the service coordinator. She/he will be the point of first contact with the Advanced CytoreductiveSurgical Service for patients and their carers, as well as being the initialconduit through which communication will take place between thepatient and any individualmembers of the team. Theywill be responsiblefor making certain that all necessary pre-treatment assessments arebooked and completed, and that the results are circulated to the relevantmembers of the team. They will co-ordinate the provision and timing ofthe various aspects of the team's functions.

Support services

The provision of a first class Advanced Cytoreductive SurgicalService will require backup support from a number of other areaswithin the hospital:

• Laboratory (haematology, biochemistry, microbiology),• Blood bank.

It is important that these services have an appreciation of themagnitude of the work being undertaken so that they provideautomatic high priority for any requests from the clinical membersof the Advanced Cytoreductive Surgical Service in respect of patientswho are having advanced cytoreductive surgery.

Concept of an advanced cytoreductive team

Above all, the development of an advanced cytoreductive servicerequires a major commitment on behalf of the institutional manage-ment/administration. This commitment needs to be conceptual inthat the institutional administration has to have an understanding ofthe value of this exercise and a commitment to support itsdevelopment. To a more varied extent they may need to carry asubstantial financial commitment depending on the funding modelthat is used at the institution. For example some Casemixmodels codethis surgery to major gastro-intestinal surgery and the funding allowsfor some four to five hours in theatre with an average of one day, ormaybe less, in ICU postoperatively. This may lead to a significantfinancial shortfall if the operation takes several or more hours andrequires a week in the intensive care unit.

Periodically there needs to be a debriefing session involving themembers of the team to look back on procedures and check on anyproblems that may need to be addressed and rectified. There alsoneeds to be regular reporting of outcomes so that any adverse eventscan be identified and necessary steps taken to optimise patient care.

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Pre-operative workup

The pre-operative workup of patients being considered for ultra-radical cytoreductive surgery is of utmost importance. As alreadymentioned there are numerous areas where things can go wrong and ifthey do they may be of monumental proportions. It is thereforeimportant that no stone be left unturned in the pre-operative patientassessment; 3 h into a 10 h ultra-radical operation is not the time todiscover that the patient has a previously unappreciated co-morbidity.The success of advanced cytoreductive surgery is based on good patientselection. The pre-operative workup has therefore had an empiricalbasis rather than being based on the results of clinical studies.

All patients being considered for advanced cytoreductive surgeryhave the following investigations:

• Full blood count (haemoglobin, white cell and differential count andplatelet count) and serumbiochemistry including liver function tests,

• Coagulation screen (prothrombin time, activated partial thrombo-plastin time, thrombin time and euglobulin clot lysis time),

• Blood group and antibody screen (Coombs' Test),• Respiratory function tests including carbon monoxide (CO) gastransfer,

• Chest X-ray,• Other diagnostic imaging (Computed Tomography scan, MagneticResonance Imaging, Ultrasound, Positron Emission Tomography) —

thiswill be individualised for eachpatient but is designed to establishas best as possible that disease is limited to the abdominal cavity,

• Feeding: Currently we have a randomized phase 3 clinical trial open,whichrandomizesbetween intraoperative feedingwith anasojejunalfeeding tube into the duodenum or jejunum (commence enteralfeeding day 0) versus diet as tolerated from day 1 postoperatively.

When the results of all pre-operative investigations are availableand the patient has been seen and assessed by the keymembers of theteam (surgeon, anaesthetist, medical oncologist and intensivist) adecision is made by this assessment team as to whether or not theadvanced cytoreductive surgery should be carried out. If two or moremembers have reservations that cannot be resolved then theprocedure is not undertaken.

Intra-operative equipment and management

All patients have the following set up prior to surgery:

• Triple lumen central venous catheter,• Arterial line,• Under-patient and over-patient warm air blankets,• Electrocardiograph,• Oxygen saturation monitor,• Trans-oesophageal temperature monitor,

Following induction of anaesthesia and the placement of allnecessary lines the patient is positioned on the operating table. Thearms are out from the patient's side and the legs are placed inadjustable stirrups in a partially abducted, semi-flexed position. A 14gauge urinary catheter is inserted with the collecting bag at theanaesthetic end so that urine output can be monitored..

The performance of advanced cytoreductive surgery requires theprovision of good and reliable equipment:

• Monopolar diathermy — a good quality diathermy with both cutand coagulation modes is required,

• Blood vessel sealing devices— these are useful for performingrepetitive processes such as taking the omentum off the greatercurve of the stomach, taking the short gastric vessels and removingsmall/superficial tumours from the liver,

• Retractor — this is of paramount importance as a poorlyfunctioning retractor can make surgery extremely difficult and

sometimes impossible. We use a BookWalter® Retractor however,for obtaining access to the liver and sub-diaphragmatic areas theGrays® Retractor is preferred,

• Appropriate instrumentation for gastrointestinal, urinary, thoracicand vascular surgery needs to be closely available in the event thatit is required.

The abdomen is opened through a long midline incision. A verycareful inspection is undertaken to evaluate the extent of the diseaseand to determine whether or not the operation is able to beperformed. For example the presence of nodal disease in the root ofthe bowel mesentry or extensive disease involving the serosal surfaceof the bowel may preclude advanced cytoreductive surgery. If it isdeemed that the operation is able to be done then the surgeon notifiesthe anaesthetist and the rest of the surgical team.

The procedure commences in the right upper quadrant of theabdomen. To adequately undertake the stripping of the peritoneum ofthe right sub-diaphragmatic region first the liver needs to bemobilised. A large proportion of the liver's volume is due to itsvenous blood flow. To provide adequate access the anaesthetist willreduce the central venous pressure of the patient and deplete the liverof much of its venous flow. This will reduce the volume of the liver bysome 50% providing excellent access to the right upper quadrant.

If on stripping the sub-diaphragmatic peritoneum there are areasof tumour greater than 1.5 cm in size it is likely that the tumour willhave invaded into the diaphragm. Over the muscular part of thediaphragm some of the muscle can be sacrificed however over thetendinous part of the diaphragm it will often be found necessary toremove part of the diaphragm; in fact it is often easier to resectcoalescing disease by removal of part of the diaphragm than to persistwith trying to strip the disease. It is surprising just how much of thediaphragm can be removed and the remainder will suture backtogetherwith a continuous 1 PDS® suture. Care should be taken not todamage the lung as this can lead to an ongoing air leak. If part of thediaphragm is resected then an intercostal catheter (ICC) should beinserted and connected to an underwater circuit. It is preferable toeither leave the diaphragm open, closing it at the end of the operationor to immediately insert an ICC, to protect against the risk of a tensionpneumothorax. If the diaphragm is to be closed later, then at least putthe sutures in the diaphragm as access will become very much moredifficult later when the liver is re-expanded.

Given that advanced cytoreductive surgery is a long operationtaking anywhere from six to 17 plus hours it is important that intra-operative care be taken of the entire surgical team. Every four to fivehours, at a suitable time, and with the clearance of the anaesthetist,the surgical team unscrubs and retires to the tearoom for refresh-ments. The air-conditioned environment of an operating room has avery low humidity level and it is important to keep the members ofthe team adequately hydrated. As the operation gets longer thesebreaks may become slightly more frequent.

Early in the operation a naso-jejunal feeding tube is inserted forpost-operative nutrition. Post-operative naso-jejunal feeding iscommenced within a relative short time of admission to the ICUregardless of whether or not gastro-intestinal surgery has taken place.

Post-operative management

All patients are admitted to the Intensive Care Unit (ICU) in aventilated fashion. It is preferable that there is a direct handover fromthe anaesthetist to a qualified intensivist in preference to an ICURegistrar or Resident.

These patients will often be prone to large fluid shifts as they re-equilibrate in the post-operative phase. Familiarity with this process isto be preferred so that management can be proactive rather thanreactive. At the risk of oversimplification these patients behave likemajor burns patients.

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Funding

Funding of surgical procedures is a key factor, which can supportthe development of procedures or withdraw the support.

In Australia hospital funding of procedures is based on a Casemixbasis since the 1990s. It essentially means that the budget for ahospital is determined by the types of patients' diagnoses andprocedures treated at this particular hospital. Every procedure isattached to a (diagnosis-related group, DRG) code and that code islinked to a specific dollar amount in funding. This model has beendeveloped on a government level to distribute a set amount of fundingamong different hospitals. The draw backs include that the currentcoding system in Australia does not allow for very big cytoreductiveprocedures, which may take several hours and which leaves ahospital's costs partly uncovered. For example, funding of a majorcytoreductive procedure taking 8 h would attract remunerationequivalent to a standard four hour procedure by a general or colorectalsurgeon. Also, funding does not account for the length of ICU stay.

Remuneration of specialists depends on the contractual arrange-ments of the specific surgeon. In Australia we have a two-tier system:a public (Medicare) hospital system and a private system, in whichpatients, who pay an additional private insurance premium maychoose their practitioner. In the public hospital system a gynaecolo-gical oncologist receives a fixed salary if they are on-staff or hourlyrate if they are a visiting specialist; she/he will get paid by the lengthof surgery independent of the procedure performed. Remuneration inthe private system follows a procedure code system, constituting amajor financial disincentive for long, complex surgery. An example:diaphragmatic peritoneal stripping as part of cytoreductive surgeryfor ovarian cancer, which may take up to a couple of hours, is notremunerated at all as there is no code to cover this procedure. It is aprocedurewhich has only begun to be performed a few years back andno other specialty currently performs this procedure. In essence, inAustralia the financial remuneration is strongly biased in favour ofshort, straight-forward operations with short follow-up care, howeverefforts are underway to rectify this deficiency.

Establishing guidelines

Guidelines to which the major stakeholders have agreed willprovide support, security and safety for the surgeon who is mostexposed.

Patient selection

AgePatients considered for peritonectomy ideally are less than 70

years of age. Patients with advanced ovarian/primary peritonealcancer above the age of 80 years may still undergo cytoreductivesurgery but surgically we would be less aggressive in elderly patientsthan in younger patients. Considering the increased risk of periopera-tive morbidity and mortality, aggressive ultra-radical surgical cytor-eduction in elderly patients requires good justification in ourinstitution.

Absence of disease outside the abdominal cavityPatients considered for advanced surgical cytoreduction ideally

present with disease limited to the abdomino-pelvic area only. Shouldpatients present with distant disease (pleural, lung), the tumourdiameter at the distant site would obviously limit the size ofpostoperative residual tumour. That means that the residual tumourat a distant site would limit what we are aiming for in terms ofpostoperative residual tumour. We do not chase every small pelvic orabdominal tumour residual if distant or unresectable disease ispresent at surgery. In case of distant disease, often, we still manage toclear the abdomino-pelvic disease to no residual tumour with an

acceptable risk of adverse events. If our preoperative work-up revealsdisease outside the abdominal cavity, we would also considerneoadjuvant chemotherapy followed by interval surgery if a responseto chemotherapy was noted.

VATS trial — Video Assisted Thoracoscopic Surgery is regularlyperformed by thoracic surgeons to diagnose and resect pleural andlung disease. Small volume pleural effusions are often considered notdrainable, cytological confirmation of pleural involvement is notpossible and therefore pleural involvement is often under-diagnosed.Pleural involvement is also difficult to visualize on conventionalimaging. Therefore we are in the process of establishing a non-randomised phase 2 clinical trial to evaluate the incidence and growthpatterns of pleural involvement in patients with advanced primaryovarian or peritoneal cancer.

Medical co-morbiditiesIn our institution patients considered for advanced cytoreductive

surgery need to be medically fit enough to tolerate such a procedure.Traditionally we have limited aggressive surgical cytoreduction topatients with two medical co-morbidities or less. In a recentpublication we found that elderly patients with an increasing numberof preexisting co-morbidities had an increasing risk of perioperativedeath and patients with existing renal disease had the worst outcome(Janda et al. 2007). In our institution, patients considered unfit forsurgery will be offered neoadjuvant chemotherapy. Sometimes, ourpatient's medical condition improves to such a degree that intervalsurgical debulking is considered.

Ideally, patients give consent to the administration of blood andblood products. Patients' unwillingness to accept blood products willinfluence the surgeon's willingness to proceed to advanced surgicalcytoreduction. However, patients are not automatically excluded froma surgical approach solely because they refuse to accept transfusionwith blood products; especially if they have minimal volume diseaseonly. Patients considered for peritonectomy need to consent to theadministration of blood and blood products.

Preoperatively, all patients will complete a questionnaire on theuse of blood-thinning medication. Depending on the indication forblood thinners, the management of those patients is stronglyindividualized. A large number of patients take acetylsalicylic acid,supplements or herbs with blood-thinning effect, such as fish oil,garlic, ginger, flax seed and others for lifestyle reasons without strictmedical necessity. Ideally, these patients will discontinue theirmedication 7 to 10 days prior to surgery. Patients who need to be onfractionated heparin or Coumarin derivates for established indica-tions, a decision needs to be made about the patient's medical fitnessfor surgery based on the underlying illness. A patient with a recentpulmonary embolus or a recent myocardial infarct would be deemednot suitable for advanced cytoreductive surgery but a patient whoreceived a heart valve years ago and whose exercise tolerance is closeto normal would be a potential candidate for advanced cytoreductivesurgery.

RecurrencePatients who experience recurrent ovarian/primary peritoneal

cancer may qualify for surgery if the inclusion criteria mentionedabove are fulfilled.

• Ideally, we request a disease-free interval of at least 12 months frominitial surgery to proceed with advanced surgical cytoreduction.

• Preoperative imaging is mandatory to determine the number andthe localization of lesions. In addition to CT scanning, PET scanningincreases the sensitivity to locate lesions missed on conventionalimaging.

• The number of recurrences (1st, 2nd, 3rd, etc.) per se is not anexclusion criteria, provided they are limited to the abdomino-pelvic regions.

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• Palliative surgery may be considered for the palliation of actualsymptoms or for the prevention of anticipated complications (e.g.,bowel diversion). Indications for advanced surgical cytoreductionfor palliative reasons are rare.

Clinical judgmentAll decisions on eligibility and exclusion from surgery are subject

to clinical judgment. In our institution the above criteria are notabsolute but only a guideline for management. Exemptions from thoseguidelines are common but usually gynaecological oncologists wouldseek advice …

-protocols, algorithms, clinical pathways

AlgorithmsIn our institution we use a four (4) step algorithm for the work-up

of all gynaecological cancer patients; whether they have new orrecurrent disease.

Establish a histological diagnosis. Prior to advanced surgical cytoreduc-tion, we seek to confirm the presence of invasive disease. In manycases the presence of primary ovarian/peritoneal cancer is obvious,but sometimes it is unclear if we are dealing with a primary ovarian/primary peritoneal cancer or for example a metastasis originatingfrom the GIT. For metastatic GIT cancer, we would not normallyembark on advanced surgical cytoreduction.

Determine the extent of disease. This is essential as it will determine oursurgical aggressiveness. In cases of distant metastasis (lung, massiveparenchymal liver metastasis) we would be less aggressive surgically.

Determine the aim of treatment. This will be treatment with eithercurative or palliative intent. From #1 and #2 the aim of treatment willbecome obvious. A patient with massive distant disease and a poorfunctional performance status (Karnovski, ECOG) and a clinical bowelobstruction, the aim of treatment would be palliation and not cure. Incontrast, a patient with advanced primary ovarian/peritoneal cancerlimited to the pelvic and abdominal area we would spend some timeintraoperatively to determine resectability. If the tumour seemsresectable, we make all efforts for surgical cytoreduction, as it willgive the patient the best chance of maximizing their survival. Wewould aim for cure in such a case.

Determine the best treatment. From #1, #2 and #3, we will thendetermine the optimal treatment schedule based on the currentliterature. This could be upfront surgery if we aim for cure. It couldalso be neoadjuvant chemotherapy or it may be palliative chemother-apy if we set the aims at palliation rather than cure.

Clinical pathways

All patients are seen in a clinic or in private rooms. We stronglyrecommend multidisciplinary care, which is coordinated by adedicated gynaecological oncology case coordinator. Multidisciplinarycare involves nursing, physiotherapy, social work, psychologists,dietitians and nutritionists, the anaesthetic team and the gynaecolo-gical oncology trainees. The role of the case coordinator is to establish apermanent contact with the patient from prior to being seen at clinic,the perioperative period, the five years' follow up until discharge backinto the GPs' care. The case coordinator will also arrange forinvestigations and consults and by doing so is supported by ourclinical guidelines on the management of gynaecological cancer.

Counseling and psychological services

In our units, counseling services are available for patients admittedand those seen in clinics as well as for relatives. We also work closely

with state-based organizationswhich provide counseling services.Weencourage patients to help themselves with brochures from a bookletstand, which is placed in every one of the clinic waiting rooms andalso in all waiting rooms of the private practices.

Recently an initiative was formed by the Gynaecological CancerSociety of Australia focusing on the needs of patients' partners. Theneed for this program has been established as the statistics onmarriage attrition during a partner's illness is alarming. The role ofthis program is to address the special needs of the partners, therebyassisting them to best support, nurture and care for your patient/partner.

Quality assurance, patient safety and monitoring

In Queensland we offer a state-wide gynaecological cancer service,which is governed by the Queensland Centre for GynaecologicalCancer (QCGC). No other gynaecological cancer centre exists in ourState. We operate from two main hubs (Royal Brisbane and Women'sHospital, Mater Adult Hospital) and due to the regional character ofour state (a population of 1.5 xxx mio people live outside this urbanarea) we also deliver services to several regional and remote areaswithin the state of Queensland.

All patients seen by one of the six QCGC gynaecological oncologistswill be asked for consent that their data is recorded and their casedocumented in our central database. The consent covers use of datafor quality assurance, research and peer review. A dedicated datamanager plus a coder are employed by the QCGC. Currently weoversee the records of 18,000 patients documented in our database.The database covers patients' details, epidemiological data, details ontreatment and histopathology as well as treatment outcomes,including adverse events, recurrences and survival.

Postclinic review meeting — after patients were seen in the clinic,every case will be discussed in the multidisciplinary clinic meeting,where the diagnostic work-up and the proposed management is chartdocumented.

Multidisciplinary Tumour board — all gynaecological cancer casesin the State of Queensland are presented and discussed in ourmultidisciplinary Tumour Board Meeting. This is made up ofgynaecological (surgical) oncologists, medical and radiation oncolo-gists, gynaecological histopathologists, nursing staff and trainees. Inthese sessions, histopathology of every patient will be reviewed andtreatment recommendations will be made and documented.

Morbidity and Mortality meetings are held bimonthly and areextremely confidential. Only senior members of QCGC and ourtrainees are allowed to attend. We discuss privileged information,which enables us to directly report to the Health Minister ofQueensland rather than to hospital authority. Discussions are held ina friendly and constructive manner and the development of learningpoints (individual or system-based) is strongly encouraged.

A new and independent self-audit tool for gynaecological cancersurgeons is online at www.surgicalperformance.com. It is internet-based and compares outcomes of surgery by individual gynaecologicaloncologists with the outcomes from colleagues. All data are de-identified, the surgeon remains anonymous and no one else otherthan the individual surgeon knows what his/her outcome is.SurgicalPerformance also offers a Complications Workshop in whichcommon and rare complications can be discussed amongst surgicalcolleagues in strict confidence.

Credentialing for procedures

Like formost surgical clinical trials, a credentialing systemneeds tobe followed for gynaecological cancer surgery. Surgery for gynaeco-logical cancer in Australia is only supported if it is performed by aCollege Certified Gynaecological Oncologist who has successfullycompleted a three-year dedicated training in gynaecological oncology

S21A.J. Crandon, A. Obermair / Gynecologic Oncology 114 (2009) S15–S21

and passed an exit examination and thus was awarded a Certificate inGynaecological Oncology (CGO). For newer procedures, such asadvanced laparoscopic surgery or advanced surgical cytoreductiveprocedures (e.g., peritonectomy) we suggest 5 to 20 documentedcases (depending on the procedure), followed by a joint case with asenior accredited surgeon as a mentor. Rarely, a new procedure maynot be able to be credentialed; in such a case utmost care needs to betaken to guarantee the patients welfare and safety.

Community outreach, education and management of referral base

The community (specialists, GPs, general surgeons, urologists)will need to be educated about aims of treatment, the availability ofthe treatment, and its possible outcomes in terms of morbidity andsurvival. The medical community also needs to be informed aboutthe importance of performing advanced surgical cytoreduction in asmall number of selected tertiary gynaecological cancer centres.Patients need to be educated about realistic outcomes and timeframes.

Summary

There is consistent evidence that surgically removing all visibledisease results in improved survival. We advocate the development ofskills that not only allow debulking of large tumour masses, but also thedevelopment of the surgical skills that allow the removal of widespreadperitoneal nodules be they ever so small. Thismeans that gynaecologicaloncologists need to have the knowledge, training and skills to performand manage ureteric/bladder surgery, bowel resections, splenectomies,cholecystectomies, subsegmental liver resections, trans-abdominalthoracotomies and retroperitoneal lymph node dissections.

This article outlines the surgical skills, decision making andjudgment required, the steps to develop and maintain an advancedcytoreductive service as well as our guidelines on pre-, intra- andpostoperative management of patients with advanced ovarian orprimary peritoneal cancer.

Conflict of interest statementThe authors have no conflicts of interest to declare.