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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 [email protected] (overnment ?os!ital"

    Udu!i

    & .A year old

    unmarried lady

    ,ass abdomen since

    . months,enstrual cycles

    regular

    &bdominal

    [email protected] )2 B )2

    cm mobile cystic mass

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    Investigations

    &bdominal [email protected]

    )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