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INTRODUCTION
Ovarian malignancy is not uncommon in young
women
Initiation of childbearing is delayed to later in life
Stage I borderline or invasive ovarian tumors are
more freuent in childbearing age
These women may benefit from conservative
a!!roach" !reserving their fertility withoutcom!romising long#term survival
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INTRODUCTION
Conservative management of $OT is
becoming a necessity because
Ovarian malignancy is not uncommon in
young women
Delayed childbearing is becoming more
common
Stage I borderline % early invasive ovarian
tumors are more freuent in this age grou!
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The standard treatment for early stage
$OC is radical and includes hysterectomy
with bilateral sal!ingo#oo!horectomy
Conservative treatment denotes surgery
that !reserves the re!roductive !otential
without com!romising long term survival
& staging !rocedure is necessary to
confirm the early stage and to guide
chemothera!y decisions
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'I(O Staging for early ovarian
cancer
Stage ) growth limited to ovaries
Stage )a growth limited to one ovary only
Stage )b growth limited to both ovaries
Stage )c tumor either stage )a or )b
tumor on surface of one or both ovary
ascites containing malignant cells
ca!sule ru!tured
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Criteria for conservative surgical
management of epithelial ovarian cancer
*oung !atient desirous of future childbearing
+atient and family consent and agreement to
close follow u!
&ny unilateral borderline tumor" stage )ae!ithelial tumor
,ultidisci!linary a!!roach with close
collaboration of gynecologist#oncologist"re!roductive endocrinologist and !erinatologist
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Com!rehensive surgical staging
techniue
)- ,idline vertical incision
.- +eritoneal cytology
/- Systematic abdominal e0!loration1- Unilateral sal!hingo#oo!horectomy with
intact ca!sule
2- Random and directed !eritoneal bio!sy3- Omentectomy
4- +elvic and !ara#aortic lym!hadenectomy
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+eritoneal cytology
+eritoneal washing
with )55#)25 ml of
saline solution from
+elvis
+aracolic s!aces
6evel of each
hemidia!hragm
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Systematic abdominal e0!lorationIns!ect and !al!ate
Right !aracolic s!ace
Rt 7idney
Su!ra he!atic s!ace
Rt dia!hragm Rt he!atic lobe
(allbladder
,orison8s !ouch
6t hemidia!hragm
6t he!atic lobe
S!leen
Stomach
Transeverse colon
6t 7idny
6t !aracolic s!ace
6esser sac
!ancreas
Small bowel
Colon ,esentry both surfaces
Retro!eritonial areas along
vascular structure
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,anagement of !rimary tumor
$valuate tumor si9e"
e0ternal e0crescence"
ca!sule ru!ture"
adhesions
Unilateral sal!ingo#
oo!horectomy
'ro9en section
Contralateral ovary if
grossly normal" leave it
undisturbed
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Random and directed !eritoneal
bio!sies
+osterior cul#de#sac
:ladder reflection
:oth !elvic side walls
:oth !aracolic s!aces
&dhesions
&bnormal a!!earing
areas
Undersurface of
dia!hragm
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Omentectomy
Infracolic omentectomyis indicated in theabsence of grossomental disease
In early stage ovariancancer omentaldisease is detected inabout ; 2uvant chemothera!y
Stage I& = I:" grade)
Stage IC" grade/" Stage II
Stage I& = I:" grade .
(ood !rognosis
Surgery only
&d>uvant thera!y not
reuired /5#15< recurrence in 2
years
&d>uvant thera!y reuired
Role of ad>uvant thera!y
not clearly 7nown
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Integration of !rognostic factors
Low risk group :orderline tumors
(rade ) mucinous andendometroid tumors
Di!loid grade ) tumor ofserous" mi0ed andundifferentiated histologicalty!es
'I(O stage )a
Normal !ost o!erative serumC&).2
No ad>uvant chemothera!yafter com!rehensive surgicalstaging
High risk group :orderline aneu!loid tumor
&neu!loid" grade )"of serous"mi0ed and undifferentiated
histological ty!es (rade . and grade / tumors
Clear cell adenocarcinoma
+ersistent elevation of !osto!erative serum C&).2level
'I(O stage )b")c Reuire ad>uvant
chemothera!y
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'ertility !reservation o!tions
'ertility !reserving surgery
Ovarian trans!osition
$mbryo cryo!reservation
Oocyte cryo!reservation
Ovarian cryo!reservation
(nR? analog cotreatment
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Case re!ort@ (overnment ?os!ital"
Udu!i
& .A year old
unmarried lady
,ass abdomen since
. months,enstrual cycles
regular
&bdominal
e0amination@ )2 B )2
cm mobile cystic mass
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Investigations
&bdominal ultrasound@
)2 B )2 cm multi#
loculated cyst with se!tal
thic7ness of /#2 mm No ascites
Uterus normal in si9e
Routine investigationswere normal
C&).2 level # .4-3 U%ml
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Staging la!arotomy
Right ovarian cyst with intact
smooth ca!sule
&scites absent" !eritoneal
cytology done Random !eritoneal and
omental bio!sy ta7en
Right sal!ingo#
oo!horectomy with intactca!sule
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+atient was referred to oncologist
She received !latinum based
chemothera!y
She was advised to marry and conceive
as early as !ossible
Not to conceive within one year ofchemothera!y
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hat was wrong in this case
SU(($STION&s !reo!erative evaluation EUS(F is !resent in
govt hos!i" we should have referred to gyn
oncologist
Com!rehensive surgical staging should be done
by gynonco only
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conclusion
?igh inde0 of sus!icion of ovarian !athology when a
woman !resents with nons!ecific sym!toms
Referral to gynec#oncologist for !rimary surgery
Com!rehensive surgical staging by a gynec#oncologist
'ertility !reservation o!tions should be considered
Surgeon should have
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'ertility !reservation = ovarian
malignancy in young women
Im!rovement in survival rates due to
!rogress in cancer treatment
+artial or com!lete removal of
re!roductive organ" or cytoto0ic treatment"
affects fertility
$arly loss of ovarian function