• 4% of all female cancers

• 25% of all gynecologic cancers

• life time risk: 1/70

•¾ advanced stage

•most lethal

Epithelial Ovarian Cancer:

• serous (75 – 80%)

•mucinous (10%)

•endometrioid (10%)• Brenner, clear cell, undif. (1%)

15% Borderline

Classification of EOC:

100100%%1344134415.3%15.3%206206MetastaticMetastatic

7.2%7.2%9797GermGerm

9.2%9.2%124124Sex-Sex-ccord stromalord stromal

67.6%67.6%908908EpithelialEpithelial

%NTYPE

Ovarian Malignancies in Hacettepe

Ovarian Malignancies in Hacettepe

Stage distribution of EOC(Hacettepe)

Stage distribution of EOC(Hacettepe)

STAGESTAGE

IIIIIIIIIIIIIVIV

235235105105385385186186908908

1.4%1.4%1313OtherOther

2.1%2.1%1919BrennerBrenner

6.2%6.2%5656MixedMixed

5.9%5.9%5454UndifferentiatedUndifferentiated

3.3%3.3%3030Clear CellClear Cell

9.0%9.0%8282EndometrioidEndometrioid

18.7%18.7%170170MucinousMucinous

53.3%53.3%484484SerousSerous

%NTYPES

Histological Subtypes of EOC(Hacettepe)

Histological Subtypes of EOC(Hacettepe)

Therapy in EOC:Therapy in EOC:age, performanceage, performanceage, performanceage, performance

extent of tumorextent of tumorextent of tumorextent of tumor

fertility desirefertility desirefertility desirefertility desire

histologic subtypeshistologic subtypeshistologic subtypeshistologic subtypes

gradegradegradegrade

othersothersothersothers

TreatmentTreatmentM O D A L I T I E SM O D A L I T I E S

SurgerySurgerySurgerySurgery AdjuvantAdjuvantAdjuvantAdjuvant SupportiveSupportiveSupportiveSupportive

Stoma ...Stoma ...Stoma ...Stoma ...

ComplementaryComplementaryComplementaryComplementary

Fertility sFertility savingavingFertility sFertility savingaving

CytoreductiveCytoreductiveCytoreductiveCytoreductive

ChemotherapyChemotherapyChemotherapyChemotherapy

RadiotherapyRadiotherapyRadiotherapyRadiotherapy

StagingStagingStagingStaging

NutritionNutritionNutritionNutrition

Second lookSecond lookSecond lookSecond look

Bowel surgeryBowel surgeryBowel surgeryBowel surgery

PsychosomaticPsychosomaticPsychosomaticPsychosomatic

Whole abd.Whole abd.

32P32P

Platin basedPlatin based

Aim of SurgeryAim of Surgery

AccurateAccurate

DiagnosisDiagnosis

AccurateAccurate

DiagnosisDiagnosisExtent of Extent of

tumortumor

Extent of Extent of

tumortumor

PrognosticPrognosticinformationinformationPrognosticPrognosticinformationinformation

Decision for finalDecision for final

TreatmentTreatmentDecision for finalDecision for final

TreatmentTreatment

Goal of CytoreductionGoal of Cytoreduction

Removal of Removal of ALLALLPrimary & Whole metastaticPrimary & Whole metastatic

tumorstumors

Removal of Removal of ALLALLPrimary & Whole metastaticPrimary & Whole metastatic

tumorstumors

Or at least less than Or at least less than 1cm1cmOr at least less than Or at least less than 1cm1cmOr at least less than Or at least less than 1cm1cm

CytoreductionCytoreduction

PrimaryPrimaryCytoreductionCytoreduction

PrimaryPrimaryCytoreductionCytoreduction

Secondary Secondary CytoreductionCytoreduction

Secondary Secondary CytoreductionCytoreduction

Interval DebulkingInterval DebulkingInterval DebulkingInterval Debulking

Cytoreductive SurgeryCytoreductive SurgeryCytoreductive SurgeryCytoreductive Surgery

What is the Definition of “OPTIMAL STATUS”

and why?

What is the Definition of “OPTIMAL STATUS”

and why?

40 months40 months<5mm<5mm

18 months18 months5-10mm5-10mm

6 months6 months15mm15mm

Median SurvDiameter

At least 1gr or 1cm DiameterGriffiths, Hoskins (GOG), Hacker, Berek...

At least 1gr or 1cm DiameterGriffiths, Hoskins (GOG), Hacker, Berek...

For effective CytoreductionFor effective Cytoreduction

ExperienceExperienceExperienceExperience

Upper Upper

abdominal abdominal

tumor tumor

Upper Upper

abdominal abdominal

tumor tumor

Inherent Inherent factors factors

of tumor of tumor itselfitself

Inherent Inherent factors factors

of tumor of tumor itselfitself

RetroperitonealRetroperitonealtumortumor

RetroperitonealRetroperitonealtumortumor

FixedFixed Pelvic mass Pelvic mass

FixedFixed Pelvic mass Pelvic mass

Cytoreductive SurgeryCytoreductive Surgery

Bowel resectionBowel resection

Liver resectionLiver resection

SplenectomySplenectomy

LymphadenectomyLymphadenectomy

Diaphragmatic peritoneal Diaphragmatic peritoneal resectionresection

Bowel resectionBowel resection

Liver resectionLiver resection

SplenectomySplenectomy

LymphadenectomyLymphadenectomy

Diaphragmatic peritoneal Diaphragmatic peritoneal resectionresection

TAH+BSOTAH+BSOTAH+BSOTAH+BSO

Total Total OmentectomyOmentectomy

Total Total OmentectomyOmentectomy

Resection of all metastatic Resection of all metastatic tumor and related organstumor and related organs

Resection of all metastatic Resection of all metastatic tumor and related organstumor and related organs

4848SplenectomySplenectomy

1010CystectomyCystectomy

1212Ileal/IleacIleal/Ileachhecal resectionecal resection

5757Sigmoid resectionSigmoid resection

NPROCEDURE

Additional Surgical Procedures During Cytoreduction

(Hacettepe)

Additional Surgical Procedures During Cytoreduction

(Hacettepe)

Bowel ResectionBowel Resection

• For Optimal cytoreduction (%87)For Optimal cytoreduction (%87)

• To Prevent or treat obstructionTo Prevent or treat obstruction

DebulkingHacettepe Experience

(N=673)

DebulkingHacettepe Experience

(N=673)

SUBOPTİMALSUBOPTİMAL

22.6%22.6%SUBOPTİMALSUBOPTİMAL

22.6%22.6%

77.477.4%% OPTİMALOPTİMAL

77.477.4%% OPTİMALOPTİMAL

What is the Role of Cytoreduction in Stage IV

What is the Role of Cytoreduction in Stage IV

Bristow 1999Bristow 1999Bristow 1999Bristow 1999

Liver (84 pts)Liver (84 pts)

Optimal DebulkingOptimal Debulking

Liver (84 pts)Liver (84 pts)

Optimal DebulkingOptimal Debulking

Parenchymal Parenchymal debulkingdebulking

Parenchymal Parenchymal debulkingdebulking

No parenchymal No parenchymal debulkingdebulking

No parenchymal No parenchymal debulkingdebulking

50months50months 25months25months

Lymphadenectomy in Advanced Ovarian Cancer

Lymphadenectomy in Advanced Ovarian Cancer

PerformedPerformed

Not performedNot performed

59%

16%

LymphadenectomyLymphadenectomy 2yr Survival2yr Survival

Scarabelli et al, di Re F et al.Scarabelli et al, di Re F et al.Scarabelli et al, di Re F et al.Scarabelli et al, di Re F et al.

OUTCOME OF OPTIMAL CYTOREDUCTION

OUTCOME OF OPTIMAL CYTOREDUCTION

Optimal Optimal CytoreductionCytoreduction Median SurvivalMedian Survival Progression Progression

Free SurvivalFree Survival

+ (n=388)+ (n=388) 36,7 months36,7 months33,5 months33,5 months

(n=200)(n=200)

- (n=537)- (n=537) 16,6 months16,6 months15,0 months15,0 months

(n=374)(n=374)

Hoskins et al., Boardman et al.Hoskins et al., Boardman et al.Hoskins et al., Boardman et al.Hoskins et al., Boardman et al.

CHEMOTHERAPYCHEMOTHERAPY

PLATIN PLATIN BASEDBASED

5858%%

NON-NON-PLATIN PLATIN BASEDBASED

4242%%

EPITHELIAL OVARIAN CANCER5-yr OS (%)

EPITHELIAL OVARIAN CANCER5-yr OS (%)

StageStage

I-III-IIStageStage

I-III-IIStageStage

III-IVIII-IVStageStage

III-IVIII-IV%%8888%%8888 %%3838%%3838

5-yr OS (%) with respect to second look laparotomy

(n=254)

5-yr OS (%) with respect to second look laparotomy

(n=254)

50

38

5

0

10

20

30

40

50

SLL(-) Microscopic(+)

Macroscopic(+)

Interval CytoreductionInterval Cytoreduction

Second look SurgerySecond look Surgery

CytoreductionCytoreduction

Suboptimal SurgerySuboptimal Surgery

3 cycle chemotherapy3 cycle chemotherapy3 cycle chemotherapy3 cycle chemotherapy

3 cycle chemotherapy3 cycle chemotherapy3 cycle chemotherapy3 cycle chemotherapy

EORTC and Ongoing GOGEORTC and Ongoing GOGEORTC and Ongoing GOGEORTC and Ongoing GOG

Cytoreduction after Neoadjuvant Chemotherapy

Cytoreduction after Neoadjuvant Chemotherapy

3 cycle chemotherapy3 cycle chemotherapy

3 cycle chemotherapy3 cycle chemotherapy

Initially inappropriate for SurgeryInitially inappropriate for SurgeryInitially inappropriate for SurgeryInitially inappropriate for Surgery

Tissue diagnosisTissue diagnosisTissue diagnosisTissue diagnosis

CYTOREDUCTIONCYTOREDUCTIONCYTOREDUCTIONCYTOREDUCTION

Park et al, Schwartz et al, ...Park et al, Schwartz et al, ...Park et al, Schwartz et al, ...Park et al, Schwartz et al, ...

CONCLUSION Advanced Stage Ovarian Cancer

CONCLUSION Advanced Stage Ovarian Cancer

Optimal CytoreductionOptimal CytoreductionOptimal CytoreductionOptimal Cytoreduction

Paclitaxel+PlatinPaclitaxel+PlatinPaclitaxel+PlatinPaclitaxel+Platin

CONCLUSION Advanced Stage Ovarian Cancer

CONCLUSION Advanced Stage Ovarian Cancer

Suboptimal surgery: Interval debulkingSuboptimal surgery: Interval debulkingSuboptimal surgery: Interval debulkingSuboptimal surgery: Interval debulking

Poor performance or unresectable tumor: Poor performance or unresectable tumor: Neo-adjuvant chemotherapyNeo-adjuvant chemotherapy

Poor performance or unresectable tumor: Poor performance or unresectable tumor: Neo-adjuvant chemotherapyNeo-adjuvant chemotherapy

Thank you...Thank you...