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Transcript of 4% of all female cancers 25% of all gynecologic cancers life time risk: 1/70 ¾ advanced stage most...
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• 4% of all female cancers
• 25% of all gynecologic cancers
• life time risk: 1/70
•¾ advanced stage
•most lethal
Epithelial Ovarian Cancer:
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• serous (75 – 80%)
•mucinous (10%)
•endometrioid (10%)• Brenner, clear cell, undif. (1%)
15% Borderline
Classification of EOC:
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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
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Stage distribution of EOC(Hacettepe)
Stage distribution of EOC(Hacettepe)
STAGESTAGE
IIIIIIIIIIIIIVIV
235235105105385385186186908908
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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)
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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
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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
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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
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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
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CytoreductionCytoreduction
PrimaryPrimaryCytoreductionCytoreduction
PrimaryPrimaryCytoreductionCytoreduction
Secondary Secondary CytoreductionCytoreduction
Secondary Secondary CytoreductionCytoreduction
Interval DebulkingInterval DebulkingInterval DebulkingInterval Debulking
Cytoreductive SurgeryCytoreductive SurgeryCytoreductive SurgeryCytoreductive Surgery
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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...
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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
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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
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4848SplenectomySplenectomy
1010CystectomyCystectomy
1212Ileal/IleacIleal/Ileachhecal resectionecal resection
5757Sigmoid resectionSigmoid resection
NPROCEDURE
Additional Surgical Procedures During Cytoreduction
(Hacettepe)
Additional Surgical Procedures During Cytoreduction
(Hacettepe)
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Bowel ResectionBowel Resection
• For Optimal cytoreduction (%87)For Optimal cytoreduction (%87)
• To Prevent or treat obstructionTo Prevent or treat obstruction
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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
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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
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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.
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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.
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CHEMOTHERAPYCHEMOTHERAPY
PLATIN PLATIN BASEDBASED
5858%%
NON-NON-PLATIN PLATIN BASEDBASED
4242%%
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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
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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(+)
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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
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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, ...
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CONCLUSION Advanced Stage Ovarian Cancer
CONCLUSION Advanced Stage Ovarian Cancer
Optimal CytoreductionOptimal CytoreductionOptimal CytoreductionOptimal Cytoreduction
Paclitaxel+PlatinPaclitaxel+PlatinPaclitaxel+PlatinPaclitaxel+Platin
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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
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Thank you...Thank you...