---

Platinum-Sensitive Ovarian Cancer: Comprehensive Overview

---

1. Definition and Classification

The longer the PFI, the higher the likelihood of response to repeat platinum-based chemotherapy. Median response rates for PFI > 12 months approach 50-60%, vs ~20-30% for PFI 6-12 months.

---

2. Epidemiology and Context

• ~70% of women with advanced ovarian cancer will relapse after first-line treatment
• Of relapsed patients, approximately 50-60% will be platinum-sensitive at first relapse
• Median PFS after platinum rechallenge in PSROC: ~8-12 months
• The primary histology is high-grade serous carcinoma (HGSC) in ~70% of cases
• BRCA1/2 mutation status (germline or somatic) and HRD (Homologous Recombination Deficiency) status are critical biomarkers for treatment selection

---

3. Diagnosis of Recurrence

3.1 Biochemical Recurrence

• CA-125 rise: Defined as a doubling from the upper limit of normal, or a 25% rise above nadir confirmed on repeat testing (GCIG criteria)
• Asymptomatic CA-125 rise alone: Treatment may be deferred until symptomatic or radiologic progression (MRC OV05 trial showed no OS benefit from early treatment)

3.2 Radiologic Workup

3.3 Biomarker Testing at Recurrence

Critical - must be performed if not done previously:

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4. Management Algorithm - Platinum-Sensitive Recurrent Ovarian Cancer (PSROC)

CONFIRMED RECURRENCE (PFI > 6 months)
              |
              v
    ASSESS SURGICAL CANDIDACY
              |
    +---------+----------+
    |                    |
 RESECTABLE            NOT RESECTABLE
 (iMODEL score +       |
  PET-CT favorable)    |
    |                  |
    v                  |
  Secondary            |
  Cytoreduction        |
  (complete            |
   resection goal)     |
    |                  |
    +---------+--------+
              |
              v
    PLATINUM-BASED CHEMOTHERAPY
    (6 cycles, combination preferred)
              |
      +-------+--------+
      |                |
  RESPONSE?          ASSESS BRCA/HRD
  (CR/PR/NED)        STATUS
      |
      v
 MAINTENANCE THERAPY DECISION
   (see table below)

4.1 Surgical Candidacy Assessment

Current guidance (ESMO/NCCN 2024-2025): Surgery should only be offered when complete (R0) resection is anticipated, using iMODEL scoring + PET-CT. The SOC-1 trial confirms benefit is concentrated in complete resection patients.

• HORSE/MITO-18 trial (Fagotti et al., JCO 2025, PMID 39571127): Phase 3 RCT; HIPEC (cisplatin 75 mg/m² at 41.5°C) added to SCS did NOT improve PFS vs SCS alone (median PFS 25 vs 23 months). HIPEC is NOT routinely recommended at secondary cytoreduction for PSROC.

---

5. Chemotherapy Regimens

5.1 Platinum-Based Combinations (Standard of Care)

5.2 Addition of Bevacizumab to Chemotherapy

NCCN 2024-2025 Recommendation: Carboplatin + gemcitabine or carboplatin + PLD or carboplatin + paclitaxel, with or without bevacizumab, for 6 cycles. Bevacizumab can be continued as maintenance.

ESMO/ESGO 2024 Recommendation: Preferred chemotherapy partner for bevacizumab in recurrent setting is carboplatin + PLD.

5.3 Non-Platinum Options (for Platinum-Intolerant Patients, PFI > 6 months)

---

6. Maintenance Therapy - PARP Inhibitors

6.1 Overview of PARP Inhibitors Approved for PSROC

Note: Rucaparib was voluntarily withdrawn from the US market in 2023 by AstraZeneca following ARIEL4 final results. ARIEL4 final analysis (PMID 39914419, Lancet Oncol 2025) confirmed rucaparib as inferior to chemotherapy for treatment (not maintenance) in BRCA-mut relapsed OC. Rucaparib remains approved in Europe as maintenance therapy.

6.2 Key PARP Inhibitor Trial Data

SOLO2/ENGOT-ov21 (Olaparib, BRCA-mutated PSROC)

• 295 patients, BRCA1/2-mutated PSROC, ≥2 prior lines
• Olaparib 300 mg BD vs placebo
• Median PFS: 19.1 vs 5.5 months (HR 0.30, 95% CI 0.22-0.41)
• OS: 51.7 vs 38.8 months (HR 0.74, 95% CI 0.54-1.00, p=0.054)

ENGOT-OV16/NOVA (Niraparib) - Long-term data (PMID 40139026)

• 553 patients; gBRCA-mutated and non-gBRCA cohorts
• gBRCA cohort: Median OS 40.9 vs 38.1 months (HR 0.85, non-significant)
• Non-gBRCA cohort: Median OS 31.0 vs 34.8 months (HR 1.06, non-significant)
• Significant PFS benefit maintained; OS benefit not demonstrated
• Long-term safety consistent with established profile

ARIEL3 (Rucaparib) - Final results (PMID 40580808, Eur J Cancer 2025)

• Phase 3, placebo-controlled; PSROC with ≥2 prior lines
• PFS benefit confirmed across BRCA-mut, HRD+, and ITT populations
• Final OS data published 2025; no significant OS benefit overall

Network Meta-Analysis (PMID 39885555, J Ovarian Res 2025)

• Compared olaparib, niraparib, rucaparib, and fuluzolparib in PSROC
• All PARPis significantly improved PFS vs placebo
• Only olaparib demonstrated significant OS improvement (HR 0.73, 95% CI 0.60-0.90)
• Olaparib had the least hematological grade 3-4 toxicities

6.3 Maintenance Therapy Decision by BRCA/HRD Status (ESMO/ESGO 2024-2025)

NCCN 2025: Supports PARPi maintenance if no prior progression on PARPi therapy. Olaparib preferred in gBRCA-mutated patients; niraparib (HRD-positive, US label restriction) or olaparib for HRD+ BRCA-wt.

6.4 PARPi Rechallenge Criteria (ESMO/ESGO 2024)

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7. Bevacizumab in PSROC

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8. Immunotherapy - Current Status

Conclusion: Checkpoint inhibitors are NOT currently recommended as standard therapy in PSROC outside clinical trials. The immunosuppressive tumor microenvironment in HGSC limits IO efficacy. Ongoing research focuses on patient selection (dMMR/MSI-high, specific histologies like clear cell, OCCC).

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9. Emerging and Novel Therapies

---

10. Special Populations

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11. Toxicity Management

PARP Inhibitor Toxicities

Niraparib individualized starting dose (ISD): Patients weighing < 77 kg OR platelet count < 150,000/µL should start at 200 mg/day (not 300 mg) to reduce hematologic toxicity.

---

12. Follow-up and Surveillance

ESMO/ESGO 2024: Routine imaging and/or CA-125 as per local practice and after discussion with patient. CA-125 alone should not trigger treatment initiation in asymptomatic patients (MRC OV05 evidence).

---

13. NCCN vs ESMO/ESGO 2024-2025 Comparison

---

14. Key Pivotal Trials Summary Table

---

15. Evidence Synthesis and Clinical Decision Algorithm

PLATINUM-SENSITIVE RECURRENT OC (PFI > 6 months)
                    |
                    v
          ASSESS SURGICAL CANDIDACY
          iMODEL score + PET-CT
                    |
        +-----------+-----------+
        |                       |
   FAVORABLE                UNFAVORABLE
   (R0 likely)              (widespread disease)
        |                       |
        v                       |
  SCS (goal: R0)                |
  +Postoperative chemo          |
        |                       |
        +----------+------------+
                   |
                   v
       PLATINUM-BASED DOUBLET CHEMOTHERAPY
            6 cycles
       (Carbo/PLD, Carbo/pac, Carbo/Gem)
                   |
       +-----------+-----------+
       |                       |
 Bevacizumab          No Bevacizumab
 added/continued      (prior Bev or patient choice)
                   |
                   v
          ASSESS RESPONSE (CR/PR/NED)
                   |
                   v
         MAINTENANCE THERAPY
                   |
        +----------+----------+
        |          |          |
    BRCAm      HRD+       HRD-/
    tumors     BRCA-wt    Unknown
        |          |          |
        v          v          v
    Olaparib   Niraparib  Bevacizumab
    ±Bev       or         alone
    Niraparib  Olaparib+  (or niraparib
    Rucaparib  Bev        if prior Bev)
    (Europe)   (Europe:
               rucaparib)
                   |
                   v
             PROGRESSION?
                   |
        +----------+----------+
        |                     |
  PFI > 6 months again   PFI < 6 months
  (PSROC again)          (platinum-resistant)
        |                     |
        v                     v
  Reassess BRCA/HRD      Non-platinum
  Rechallenge algorithm   regimens

---

16. References and Evidence Sources

• CALYPSO trial: Carbo/PLD superiority over carbo/pac in PSROC (Lancet Oncol 2010)
• OCEANS: Bevacizumab + carbo/gem in PSROC (JCO 2012)
• SOLO2/ENGOT-ov21: Olaparib maintenance in BRCA-mut PSROC (Lancet Oncol 2017)
• ENGOT-OV16/NOVA: Niraparib long-term OS data (PMID: 40139026, Gynecol Oncol 2025)
• ARIEL3 final results (PMID: 40580808, Eur J Cancer 2025)
• SOC-1 final OS analysis (PMID: 38824243, Nat Med 2024)
• HORSE/MITO-18 HIPEC trial (PMID: 39571127, JCO 2025)
• OReO/ENGOT-ov38 olaparib rechallenge (PMID: 37797734, Ann Oncol 2023)
• ATALANTE/ENGOT-ov29 atezolizumab (PMID: 37643382, JCO 2023)

• PARP inhibitors network meta-analysis (PMID: 39885555, J Ovarian Res 2025)
• BRCA-wt PSROC network meta-analysis (PMID: 37201444, Cancer Treat Rev 2023)
• Secondary cytoreduction meta-analysis (PMID: 37567595, Int J Gynecol Cancer 2023)
• HIPEC systematic review (PMID: 40763418, Gynecol Oncol 2025)

• ESMO/ESGO Ovarian Cancer Pocket Guidelines 2024-2025
• International guidelines comparison (AIOM/BGCS/ESGO/ESMO/JGSO/NCCN/NICE)
• Berek & Novak's Gynecology (textbook)

---

Summary of Key Clinical Takeaways

1. PFI > 6 months defines platinum sensitivity; the longer the PFI, the better the expected response.
2. Biomarker testing (BRCA, HRD, FRα, HER2) must be updated at recurrence to guide maintenance therapy and emerging ADC eligibility.
3. Surgery (SCS) is appropriate only when complete (R0) resection is achievable, guided by iMODEL + PET-CT scoring. HIPEC adds no benefit at SCS.
4. Carboplatin + PLD is the preferred doublet when combining with bevacizumab (ESMO/ESGO); carbo/pac or carbo/gem are NCCN-equivalent options.
5. Bevacizumab adds ~4 months PFS when combined with platinum doublet; rechallenge is appropriate in bevacizumab-pretreated patients.
6. PARPi maintenance is standard after response to platinum: olaparib has the strongest OS data (HR 0.73) per network meta-analysis; niraparib has broader label coverage in Europe.
7. Checkpoint inhibitors show no significant benefit in PSROC in phase 3 trials (ATALANTE negative); not currently recommended outside trials.
8. PARPi rechallenge is feasible after adequate prior PARPi exposure per ESMO/ESGO duration thresholds.
9. Novel ADCs (mirvetuximab, T-DXd, raludotatug) represent the next major frontier, particularly after PARPi failure.

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Secondary Cytoreductive Surgery (SCS) in Recurrent Ovarian Cancer: Comprehensive Overview

---

1. Definition and Scope

The focus of modern evidence is emphatically on complete (R0) resection as the only surgically meaningful endpoint.

---

2. Rationale for Secondary Cytoreduction

1. Debulking reduces tumor burden - removes chemotherapy-resistant clones, reduces ascites, improves drug delivery
2. Restores sensitivity - platinum-sensitive recurrence implies residual drug-sensitive cells; eliminating gross tumor maximizes response to rechallenge
3. Solitary/oligometastatic disease - some recurrences represent focal regrowth amenable to complete resection
4. Prolonged disease-free interval - longer PFI suggests biologically less aggressive disease, better surgical candidates

---

3. Absolute and Relative Indications

3.1 Indications for SCS

3.2 Absolute Contraindications

3.3 Relative Contraindications

---

4. Patient Selection Scoring Systems

4.1 AGO (Arbeitsgemeinschaft Gynäkologische Onkologie) Score

• Positive AGO score = ALL 3 criteria met → ~76% probability of complete resection at SCS (validated in DESKTOP II)
• Negative AGO score = ANY criterion NOT met → ~41% probability of complete resection

DESKTOP I (2006): Established that complete resection at recurrence was the strongest predictor of survival. DESKTOP II (2011): Prospectively validated the AGO score with 76% complete resection rate in positive-score patients; confirmed its predictive value in a prospective cohort of 516 patients. DESKTOP III used positive AGO score as the inclusion criterion.

4.2 iMODEL Score (International Model)

Protocol amendment in SOC-1: Patients with iMODEL > 4.7 could still be included if CA-125 > 105 U/mL AND PET-CT demonstrated resectability.

4.3 Combined iMODEL + PET-CT Strategy (SOC-1 Approach)

Step 1: Calculate iMODEL Score
         |
    Score ≤ 4.7?
    /           \
  YES           NO
   |             |
Step 2:      Step 2 (amended):
PET-CT        If CA-125 > 105 AND
assessment     PET-CT shows resectable
   |           disease, include patient
   |
Resectable on PET-CT?
   |
  YES → Eligible for SCS
   |
  NO → Chemotherapy alone

4.4 Chi Score (Memorial Sloan Kettering Score)

Less commonly used than AGO/iMODEL in current practice, but historically important.

4.5 Tian Score / Chinese Scoring System

Score 0-1 = favorable (surgery appropriate); Score ≥ 2 = poor outcome with SCS

4.6 Comparison of Selection Tools

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5. Preoperative Assessment

5.1 Workup Before SCS

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6. Surgical Technique Considerations

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7. Pivotal Clinical Trial Evidence for SCS

7.1 GOG-0213 Trial (NEJM 2019) - NEGATIVE for SCS

Why was GOG-0213 negative? Key explanations: (1) No validated patient selection criteria used - surgery offered to unselected patients; (2) Bevacizumab in both arms may have negated surgical benefit; (3) High dropout rate (46 patients assigned surgery did not undergo it); (4) Lower R0 rate than DESKTOP III (67% vs 75.5%).

---

7.2 DESKTOP III Trial (NEJM 2021) - POSITIVE for SCS

---

7.3 SOC-1 Trial (Lancet Oncol 2021 + Nat Med 2024 Final OS)

Final OS analysis was not statistically significant in ITT analysis (p=0.11), largely due to 35% crossover in the control arm. Adjusted analysis favored surgery (HR 0.76).

---

7.4 Head-to-Head Comparison of the Three Pivotal RCTs

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7.5 Meta-Analyses

Marchetti et al. 2021 (Ann Surg Oncol, [PMID 33067742]) - Phase 3 RCTs only

• 3 RCTs (n=1250 patients)
• SCS associated with significantly better PFS (HR 0.70; 95% CI 0.61-0.78; p<0.001)
• OS HR: 0.93 (CI 0.78-1.10; p=0.37) - not significant overall
• Complete resection subgroup: OS HR 0.73 (95% CI 0.59-0.91) - significant
• Conclusion: PFS benefit established; OS benefit only in R0 patients

Baek et al. 2022 (JCO, [PMID 35188810]) - 80 studies, 2,805 patients

• Pooled death rate: 44.2%
• Complete cytoreduction: OS improved by 8.97% per 10% increase in R0 rate
• Optimal cytoreduction: OS improved by 7.04% per 10% increase
• Strong heterogeneity (I² = 86%)
• Conclusion: SCS resulting in maximal tumor resection significantly prolongs OS

Gulia et al. 2023 (Int J Gynecol Cancer, [PMID 37567595]) - Individual patient data

• 3 RCTs, n=1249 patients; 427 (34.2%) achieved complete resection
• ITT analysis: No significant OS difference (median 52.8 vs 52.1 months; HR 0.94, p=0.5)
• PFS: Significantly longer with surgery (18.3 vs 14.4 months; HR 0.70, p<0.001)
• Complete resection subgroup: OS significantly longer (62.0 vs 52.1 months; HR 0.70, p<0.001)
• Incomplete resection subgroup: OS significantly WORSE (34.2 vs 52.1 months; HR 1.72, p<0.001)
• Conclusion: Surgery does not benefit unselected patients; benefit is entirely concentrated in R0 patients; incomplete resection is actively harmful

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8. The Complete Resection Paradox - The Most Important Insight

INCOMPLETE RESECTION
     HR = 1.72 (WORSE than no surgery)
     Median OS: 34.2 months
           ↑
           |  ← surgery must achieve this
           ↓
NO SURGERY (Control)
     Median OS: 52.1 months
           ↑
           |  ← only if R0 achieved
           ↓
COMPLETE RESECTION (R0)
     HR = 0.70 (BETTER than no surgery)
     Median OS: 62.0-73.0 months

Clinical implication: If complete resection cannot be guaranteed preoperatively, surgery should NOT be performed. Partial cytoreduction is worse than no surgery at all.

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9. NCCN and ESMO/ESGO 2024-2025 Recommendations for SCS

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10. Special Situations

10.1 Tertiary and Subsequent Cytoreduction

• Data exclusively retrospective; RCT evidence absent
• ESMO/ESGO 2024: "Cytoreductive surgery could be offered to patients with subsequent relapses in whom complete resection appears feasible"
• Guiding principle remains the same: R0 only, PFI > 6 months, positive AGO/iMODEL

10.2 Low-Grade Serous Carcinoma (LGSC)

• Meta-analysis (Goldberg et al., Gynecol Oncol 2022, [PMID 34756470]): SCS improves OS in LGSC
• Responds poorly to chemotherapy; surgery may be especially beneficial
• Same R0 principle applies

10.3 SCS in the Era of PARP Inhibitors

• PARPi maintenance has extended PFS after first-line treatment; many patients now have longer PFI
• When recurrence occurs after PARPi maintenance, BRCA/HRD status influences whether SCS + rechallenge or novel agents are preferred
• Review by Duchon et al. 2025 ([PMID 40002241]): AGO/iMODEL criteria remain applicable even in PARPi-pretreated patients

---

11. HIPEC (Hyperthermic Intraperitoneal Chemotherapy) with Secondary CRS

11.1 Mechanism of Action

11.2 HIPEC Protocol Parameters

11.3 HIPEC Evidence in the PRIMARY Setting (for Context)

OVHIPEC-1 Trial - Final 10-year Analysis (Lancet Oncol 2023, [PMID 37708912])

Multisocietal Consensus 2025 (Brennan et al., J Surg Oncol, [PMID 40776838]): Strongly recommends HIPEC in addition to interval CRS for stage III primary HGSOC, based on OVHIPEC-1 results.

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12. HIPEC Evidence in the RECURRENT Setting - The Pivotal Trials

12.1 HORSE/MITO-18 Trial (JCO 2025, [PMID 39571127])

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12.2 CHIPOR Trial (Lancet Oncol 2024, [PMID 39549720]) - POSITIVE

Key differentiator from HORSE: CHIPOR patients received 6 cycles of platinum-based chemotherapy BEFORE surgery; HORSE used upfront SCS without prior chemotherapy for recurrence. This is the major explanation for divergent results.

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12.3 Why Did CHIPOR and HORSE Give Different Results?

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12.4 Meta-Analyses on HIPEC + SCS in Recurrent OC

Liu et al. 2025 (World J Surg Oncol, [PMID 41214655]) - SCS+HIPEC vs SCS alone

• 7 studies, 1,136 patients (563 HIPEC, 573 no HIPEC)
• OS: HR 0.76 (95% CI 0.62-0.94; p=0.01) - significant improvement
• PFS: HR 0.91 (95% CI 0.72-1.15; p=0.43) - NOT significant
• Grade ≥ 3 complications: RR 1.42 (CI 1.00-2.01; p=0.05) - borderline increase
• Nephrotoxicity: RR 1.71 (CI 1.20-2.43) - significantly higher with HIPEC
• Anemia: RR 1.38 (CI 1.18-1.62) - significantly higher with HIPEC

Taliento et al. 2025 (Ann Surg Oncol, [PMID 39904852]) - RCTs only

• 6 RCTs
• In recurrent OC: No PFS benefit (HR 1.22; 95% CI 0.82-1.83; p=0.32)
• In primary OC (NACT setting): Significant PFS benefit (HR 0.59; p=0.01)
• Acute kidney failure: 10.6% overall; significantly higher with HIPEC (p=0.003)
• Platelet count decrease: More frequent with HIPEC (p=0.03)

Guerra et al. 2025 (Eur J Surg Oncol, [PMID 40916270]) - 8 RCTs, 1259 patients

• HIPEC significantly improved OS overall (HR 0.79; p=0.006)
• Primary OC: OS HR 0.75 (p=0.01) - significant
• Recurrent OC: OS HR 0.87 (p=0.38) - NOT significant
• Increased operative time (127 min), hospital stay, Grade 3-5 AEs

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13. HIPEC in Recurrent OC - Complete Evidence Summary

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14. Current Guideline Recommendations on HIPEC at SCS

Note: The CHIPOR trial (Lancet Oncol 2024) is the most recent and methodologically robust positive trial. It has changed the discussion but not yet changed major guideline recommendations. Re-evaluation expected in 2025-2026 guideline updates.

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15. Ongoing and Future Trials

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16. Patient Selection Algorithm for SCS ± HIPEC

CONFIRMED FIRST RELAPSE - Platinum-Sensitive (PFI > 6 months)
                         |
                         v
              ASSESS BASIC ELIGIBILITY
              - ECOG 0-1
              - Adequate organ function
              - No contraindication to surgery
                         |
                    ELIGIBLE?
              /              \
            NO               YES
             |                 |
       Chemotherapy        APPLY SELECTION SCORE
        alone               /              \
                      AGO SCORE         iMODEL SCORE
                      (preferred         + PET-CT
                       for DESKTOP        (SOC-1 approach)
                       III approach)
                           |
                   POSITIVE SCORE?
                   /             \
                 YES              NO
                  |                |
              Consider SCS     Chemotherapy alone
                  |             (SCS unlikely to benefit)
                  |
         MDT REVIEW at specialized centre
                  |
          CONFIRM RESECTABILITY
          (PET-CT / diagnostic laparoscopy)
                  |
           R0 ACHIEVABLE?
           /          \
         YES            NO
          |              |
   Proceed with      Chemotherapy alone
   SCS (goal: R0)    (do not operate if
                      R0 not possible)
          |
   POST-OPERATIVE:
   - Platinum-based chemotherapy (6 cycles)
   - Assess BRCA/HRD for maintenance PARPi
   - Bevacizumab if appropriate
          |
   HIPEC CONSIDERATION:
   - CHIPOR approach: 6 cycles chemo FIRST, then SCS + HIPEC at specialist centre
   - Currently: offer within clinical trial or specialized unit only
   - ESMO/ESGO 2024: HIPEC NOT recommended at SCS outside trials

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17. Complications of SCS

17.1 Surgical Complications

17.2 Additional HIPEC-Related Toxicities

Cisplatin-based HIPEC requires mandatory pre-hydration, forced diuresis, and nephroprotection protocols to mitigate renal toxicity.

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18. Key Clinical Messages

1. SCS is beneficial ONLY in patients who achieve R0 (complete) resection. Incomplete cytoreduction is actively harmful (worse OS than no surgery).
2. Patient selection tools (AGO score for DESKTOP III; iMODEL + PET-CT for SOC-1) are mandatory. Offering SCS without validated selection criteria leads to negative outcomes (GOG-0213).
3. AGO score (all 3 criteria: ECOG 0, ascites ≤ 500 mL, complete primary CRS) is the most widely used and validated selection tool.
4. DESKTOP III confirmed OS benefit (HR 0.75) with SCS in AGO-positive patients; SOC-1 showed significant PFS benefit but non-significant OS (affected by 35% crossover).
5. HIPEC at SCS remains investigational per ESMO/ESGO 2024. CHIPOR (Lancet Oncol 2024) showed significant OS benefit when HIPEC follows chemotherapy; HORSE showed no PFS benefit with upfront SCS+HIPEC.
6. The CHIPOR model (6 cycles platinum chemo → complete SCS → HIPEC) is a promising strategy at specialized centres but not yet a global standard of care.
7. Toxicity of HIPEC is substantial (49% Grade ≥3 AEs, 10% renal failure in CHIPOR); patient selection and high-volume expert centres are essential.
8. SCS should be performed at specialized gynecologic oncology centres with multidisciplinary teams experienced in peritoneal surface surgery.

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19. Evidence-Graded Summary

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References

• DESKTOP III: Harter et al., NEJM 2021 (PMID: 34874631)
• SOC-1: Shi et al., Lancet Oncol 2021 (PMID: 33705695); Final OS: Jiang et al., Nat Med 2024 (PMID: 38824243)
• GOG-0213: Coleman et al., NEJM 2019
• CHIPOR: Classe et al., Lancet Oncol 2024 (PMID: 39549720)
• HORSE/MITO-18: Fagotti et al., JCO 2025 (PMID: 39571127)
• OVHIPEC-1 (10yr): Aronson et al., Lancet Oncol 2023 (PMID: 37708912)

• Marchetti et al., Ann Surg Oncol 2021 (PMID: 33067742)
• Baek et al., JCO 2022 (PMID: 35188810)
• Gulia et al., Int J Gynecol Cancer 2023 (PMID: 37567595)
• Liu et al., World J Surg Oncol 2025 (PMID: 41214655)
• Taliento et al., Ann Surg Oncol 2025 (PMID: 39904852)
• Guerra et al., Eur J Surg Oncol 2025 (PMID: 40916270)

• Multisocietal Consensus (PSOGI/IGCS): Brennan et al., J Surg Oncol 2025 (PMID: 40776838)
• ESMO/ESGO Ovarian Cancer Pocket Guidelines 2024
• Management of Recurrence review: Duchon et al., Cancers 2025 (PMID: 40002241)
• Berek & Novak's Gynecology (textbook)