A Narrative Review of Clinical and Molecular Criteria for the Selection of Poor Candidates for Optimal Cytoreduction in Epithelial Ovarian Cancer.

The objective of this paper is to define "poor candidates" and to conduct an analysis of preoperative selection criteria, considering factors related to the patient, tumor burden, and histopathological characteristics, in the case of patients with advanced epithelial ovarian cancer (EOC) FIGO III-IV with a low probability of optimal cytoreduction. The authors of this narrative review conducted an analysis of articles published over a 20-year period (2005-2025), with the following selection criteria for the topics of the papers: advanced epithelial ovarian cancer (FIGOIII-IV), surgical indications in advanced ovarian cancer, poor candidates for surgery, and dependence between surgery and histopathologic and molecular type of EOC. They used using PubMed, Science Direct, and Scopus as databases. The results of the analysis were organized into three large chapters that grouped patient-related factors, tumor burden-specific factors, and histopathological criteria. The authors identify a series of criteria with a high risk of unfavorable postoperative evolution, which led to delayed chemotherapy treatment and suboptimal management. These criteria are related to the patient's field (ECOG > 3, Charlson Comorbidity Index (CCI) > 2, BMI > 25-30, hypoalbuminemia, hypokalemia), imaging or intraoperative factors predictive for residual tumor, and histopathological or genetic factors (presence of BRCA mutation favors optimal cytoreduction even in cases with high tumor burden; in the case of low-grade serous ovarian carcinoma, surgical intervention is recommended even if there are suboptimal resection criteria, accepting resection > 1 cm due to the poor response to specific chemotherapy treatment). Considering all these aspects, patient selection for primary debulking surgery (PDS) or NACT (neoadjuvant chemotherapy) and interval debulking surgery (IDS) should be conducted in oncological surgery centers highly specialized in gynecological neoplasms, thus ensuring an optimal therapeutic pathway for patients with EOC.