The management and the outcome of peritoneal metastases or recurrence from epithelial ovarian cancer are presented. The biology and the diagnostic tools of EOC peritoneal metastasis with a comprehensive approach and the most recent literatures data are discussed. The definition and the role of surgery and chemotherapy are presented in order to focuse on the controversial points. Finally, the paper discusses the new data about the introduction of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in the treatment of advanced epithelial ovarian cancer. 1. Introduction Epithelial ovarian cancer (EOC) affects over 210,000 women and causes 128,000 deaths annually worldwide [1]. This cancer remains the leading cause of death from gynecology malignancy in the USA and was responsible for 14,600 deaths in 2009 [2]. The annual incidence and mortality rates have dropped 1.6% and 0.3% per year on average for the years 1997–2006 [3]. Current standard treatment of EOC is cytoreductive surgery (CRS) in order to remove the primary tumor and debulk any metastatic disease in combination with systemic chemotherapy with paclitaxel and platinum-based agents (carboplatin or cisplatin). Despite this treatment, only 46–49% of women with EOC will survive 5 years [4, 5]. While the incidence is low before the menopause, it rises after that with a median age at the time of diagnosis of 63 years. The lifetime risk of ovarian cancer is 1 in 70, but there are women with much higher risk especially those with germ line mutations of BRCA1 and BRCA2 tumor suppressor genes [6, 7]. If there is a response to systemic chemotherapy, the disease often relapses within 12 to 18 months. The pattern of treatment failure is mostly local-regional, involving only the peritoneum and adjacent intra-abdominal organs. With this natural history, EOC patients may be candidates for local-regional in addition to systemic chemotherapy treatment [8]. 2. Biology of Peritoneal Metastasis from Ovarian Cancer Malignancies that are managed as EOC may have as a primary site the epithelium of the ovary, the peritoneum itself (primary peritoneal adenocarcinoma), or the fallopian tube. They are histologically and clinically similar and are treated in the same fashion [9]. In this paper they are grouped together as EOC. EOC frequently spreads by direct extension from the primary site tumor to neighboring organs such as bladder and large bowel. Also, exfoliated tumor cells detach from the primary tumor and are transported throughout the peritoneal space by peritoneal fluid and disseminate within
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