1. 4% of all female cancers 25% of all gynecologic cancers life time risk: 1/70 ¾ advanced stage most lethal Epithelial Ovarian Cancer:

2. serous (75 – 80%) mucinous (10%) endometrioid (10%) Brenner, clear cell, undif. (1%) 15% Borderline Classification of EOC:

3. 100 % 1344 15.3%206Metastatic 7.2%97Germ 9.2%124 Sex-cord stromal 67.6%908Epithelial %NTYPE Ovarian Malignancies in Hacettepe

4. Stage distribution of EOC (Hacettepe) STAGE I II III IV 235 105 385 186 908

5. 1.4%13Other 2.1%19Brenner 6.2%56Mixed 5.9%54Undifferentiated 3.3%30 Clear Cell 9.0%82Endometrioid 18.7%170Mucinous 53.3%484Serous %NTYPES Histological Subtypes of EOC (Hacettepe)

6. Therapy in EOC: age, performance extent of tumor fertility desire histologic subtypes gradegrade othersothers

7. Treatment M O D A L I T I E S M O D A L I T I E S SurgerySurgeryAdjuvantAdjuvantSupportiveSupportive Stoma... ComplementaryComplementary Fertility saving CytoreductiveCytoreductive ChemotherapyChemotherapy RadiotherapyRadiotherapy StagingStaging NutritionNutrition Second look Bowel surgery PsychosomaticPsychosomatic Whole abd. 32 P Platin based

8. Aim of Surgery AccurateDiagnosisAccurateDiagnosis Extent of tumor tumor Prognostic information Decision for final Treatment

9. Goal of Cytoreduction Removal of ALL Primary & Whole metastatic tumors Or at least less than 1cm

10. Cytoreduction Primary Cytoreduction Secondary Cytoreduction Interval Debulking Cytoreductive Surgery

11. What is the Definition of “OPTIMAL STATUS” and why? 40 months <5mm 18 months 5-10mm 6 months 15mm Median SurvDiameter At least 1gr or 1cm Diameter Griffiths, Hoskins (GOG), Hacker, Berek... At least 1gr or 1cm Diameter Griffiths, Hoskins (GOG), Hacker, Berek...

12. For effective Cytoreduction ExperienceExperience UpperabdominaltumorUpperabdominaltumor Inherent factors of tumor itself Retroperitoneal tumor Fixed Pelvic mass

13. Cytoreductive Surgery Bowel resection Liver resection SplenectomyLymphadenectomy Diaphragmatic peritoneal resection Bowel resection Liver resection SplenectomyLymphadenectomy Diaphragmatic peritoneal resection TAH+BSOTAH+BSO Total Omentectomy Resection of all metastatic tumor and related organs

14. 48Splenectomy 10Cystectomy 12 Ileal/Ileachecal resection 57 Sigmoid resection NPROCEDURE Additional Surgical Procedures During Cytoreduction (Hacettepe)

19. Bowel Resection For Optimal cytoreduction (%87)For Optimal cytoreduction (%87) To Prevent or treat obstructionTo Prevent or treat obstruction

20. Debulking Hacettepe Experience (N=673) SUBOPTİMAL 22.6% 77.4 % OPTİMAL

21. What is the Role of Cytoreduction in Stage IV Bristow 1999 Liver (84 pts) Optimal Debulking Liver (84 pts) Optimal Debulking Parenchymal debulking No parenchymal debulking 50 months 25 months

23. Lymphadenectomy in Advanced Ovarian Cancer Performed Not performed 59 % 16 % Lymphadenectomy 2yr Survival Scarabelli et al, di Re F et al.

26. OUTCOME OF OPTIMAL CYTOREDUCTION Optimal Cytoreduction Median Survival Progression Free Survival + (n=388) 36,7 months 33,5 months (n=200) - (n=537) 16,6 months 15,0 months (n=374) Hoskins et al., Boardman et al.

27. CHEMOTHERAPY PLATIN BASED 58 % NON-PLATIN BASED 42 %

28. EPITHELIAL OVARIAN CANCER 5-yr OS (%) Stage I-II Stage III-IV % 88 % 38

29. 5-yr OS (%) with respect to second look laparotomy (n=254)

30. Interval Cytoreduction Second look Surgery Second look Surgery Cytoreduction Cytoreduction Suboptimal Surgery Suboptimal Surgery 3 cycle chemotherapy 3 cycle chemotherapy 3 cycle chemotherapy EORTC and Ongoing GOG

31. Cytoreduction after Neoadjuvant Chemotherapy 3 cycle chemotherapy Initially inappropriate for Surgery Tissue diagnosis CYTOREDUCTIONCYTOREDUCTION Park et al, Schwartz et al,...

32. CONCLUSION Advanced Stage Ovarian Cancer Optimal Cytoreduction Paclitaxel+PlatinPaclitaxel+Platin

33. CONCLUSION Advanced Stage Ovarian Cancer Suboptimal surgery: Interval debulking Poor performance or unresectable tumor: Neo-adjuvant chemotherapy

34. Thank you...