1. Debulking in Ovarian Cancer Ashraf Fawzy Nabhan Assistant Prof. of Obstetrics & Gynecology Ain Shams University, Cairo, Egypt

2. Introduction Surgery is an essential in treating ovarian cancer. Diagnosis, staging, and therapy are performed at the time of laparotomy Debulking (cytoreduction) is the surgical approach for ovarian carcinoma

3. Patterns of spread Direct extension Exfoliation of clonogenic cells Lymphatic spread

4. Rationale of debulking Cell kinetics –Log Cell-kill hypothesis –Gompertizian Growth hypothesis Cell mutations –Goldie-Coldman hypothesis

5. Surgical staging Vertical incision Peritoneal washings TAH plus BSO Pelvic & abdominal biopsies Pelvic and paraaortic lymphadenectomy appendectomy

6. Primary Debulking Early ovarian cancer –the procedure is the operative staging of the cancer Advanced ovarian cancer –In addition to the procedure of the operative staging, some aggressive surgical procedures might be considered

7. Primary Debulking Aggressive surgical procedures –Multiple or extensive bowel resection –Rectosigmoid resection –Resection of ureteral/bladder segment –Diaphragm stripping –Resection of liver, spleen, kidney, diaphragm

8. Primary Debulking optimal primary debulking (residual disease <1 cm) is an independent prognostic factor Even in patients with unresectable liver metastasis, optimal debulking of extrahepatic disease is associated with a significant survival advantage

9. Secondary Debulking Secondary debulking can be grouped into four clinical scenarios 1.Debulking for Recurrent Disease 2.Debulking at Second-look laparotomy 3.Interval “Chemosurgical” Debulking 4.Debulking for Progressive Disease

10. Secondary Debulking Debulking for Recurrent Disease –Those patients who enjoy a prolonged clinical disease free interval (>6 months) after completing primary therapy, and then develop recurrent disease.

11. Secondary Debulking Debulking at Second-look laparotomy – Patients who are clinically and radiologically free of disease after primary surgery and first-line chemotherapy, who are found to have macroscopic disease at second-look laparotomy.

12. Secondary Debulking Interval “Chemosurgical” Debulking –Patients with bulky, unresectable tumor discovered at initial surgery, who then undergo interval debulking surgery after neoadjuvant chemotherapy.

13. Secondary Debulking Debulking for Progressive Disease –Patients who have evidence of clinical disease progression while receiving first line therapy.

14. Complications of Debulking Intraoperative : –enterotomy –cystotomy –laceration of great vessel –coagulopathy

15. Complications of Debulking Postoperative : Infectious: –Urinary tract, –Wound, –Respiratory tract, –Peritonitis

16. Complications of Debulking Postoperative : Noninfectious: –Death, –DVT, Arterial thrombosis, –Fistula, –Prolonged ileus, –Bleeding gastric ulcer, –Intraabdominal bleeding

17. Critique of Debulking Tenets of surgical principles Inherent biologic properties of ovarian cancer Cellular kinetics Fallacies of residual disease Randomized data

18. Conclusion Optimal primary debulking improves response to chemotherapy & overall survival Benefits of secondary debulking have not been clearly established More randomized prospective studies are warranted