This document discusses the management of ovarian cancer. It covers risk-reducing salpingo-oophorectomy (RRSO) for high-risk patients, surgical staging techniques including open and minimally invasive approaches, management of early-stage disease including adjuvant chemotherapy and radiation, cytoreductive surgery and goals for advanced-stage disease, and the role of interval debulking surgery after neoadjuvant chemotherapy. Complete resection of all tumor is the optimal outcome for advanced ovarian cancer to improve survival outcomes.

1. Management of Carcinoma
Ovary

2. Topics
• RRSO
• SURGICAL STAGING
• MANAGEMENT OF EARLY STAGE OVARIAN
CANCER
• CYTOREDUCTIVE SURGERY IN ADVANCED
STAGE OVARIAN CANCER
• INTERVAL DEBULKING IN ADVANCED STAGE
OVARIAN CANCER

3. Operative
RRSO Definitive
BRCA
HNPCC
Diagnosed/ Suspected
malignancy
Staging
Laparotomy
Cytoreductive
Surgery

4. RRSO
• The NCCN, ACOG and SGO have recommended that
prophylactic oophorectomy be considered in women
with ovarian cancer syndromes at age 40 in BRCA
and 35 in HNPCC years or after childbearing is
completed
• Reduces the risk of BRCA-related gynaecologic
cancer by 96%
• Reduced the risk of developing subsequent breast
cancer by 50–80%Berek & Hacker’sGynecologic Oncology
Sixth Edition

5. Protocol
• Perform Operative Laparoscopy
• Survey upper abdomen, bowel surfaces,
omentum, appendix and pelvic organs
• Biopsy any abnormal peritoneal findings
• Total BSO
• Both ovaries and tubes to be placed in
Endobag for retrieval from pelvis .
• HNPCC : TAH HAS TO BE DONE
NCCN

6. Surgical Staging

7. Techniques
Open MIS
Laparoscopic Robotic

9. Open Laparotomy
• Preoperative evaluation suggestive of
malignancy
• Pre op FNAC : no role
• Midline or paramedian incision

10. Protocol
• Aspiration of ascites/ peritoneal lavage
• Visualization of peritoneal surfaces
• Systematic exploration of all the intra-abdominal
surfaces and viscera : Direct visual inspection is
important
• Excision/ biopsy of suspicious deposits on
peritoneum or adhesions
NCCN

11. • Random peritoneal biopsies from pelvis (if no
suspicious areas), paracolic gutters,
undersurfaces of diaphragm, urinary bladder
and POD
• BSO + Hysterectomy : Intact encapsulated
mass
• Infracolic omentectomy
• B/L Pelvic LN dissection
• Para aortic LN dissection : B/L to the level of
Inferior Mesenteric Artery
NCCN

12. Role of Sentinel Node?
• Still experimental
• 10-15% metastasize to paraaortic lymph nodes
• Advantage : Less surgical morbidity, Less
pedal lymphedema and complications, lesser
chances of Nerve injury and vessel injury
• Not done : More than 1 drainage sites

13. Fertility sparing surgery
• Apparent early stage disease
• Good risk tumors
o Unilateral stage I tumors (Ia and Ic)
o Low risk tumors (Grade I, II)
o LMP lesions
NCCN

14. Laparoscopy vs Laparotomy
• Patient comorbidities
• Number of previous abdominal surgeries
• Skills of the surgeon
• Both allow for comprehensive surgical staging.
• Lymph node counts and the size of the omental
specimen obtained are similar for both procedures.
• Port site metastasis : Risk is small (1-3%) and such
metastases are often a sign of disseminated intra-
abdominal disease
• Principles of Oncology need to be followed
NCCN

15. Early Stage Ovarian Cancer

16. • Stage I epithelial ovarian
oLow risk : TAH + BSO + Surgical Staging
oHigh risk : Requires adjuvant treatment
Low risk High risk
Low Grade High grade
Intact Capsule Tumor growth through capsule
No surface excrescences Surface excrescences
No ascites Ascites
Negative peritoneal cytologic findings Malignant cells in fluid
Unruptured Preoperative rupture
No dense adhesions Dense adherence
Berek & Hacker’sGynecologic Oncology Sixth Edition

17. Adjuvant Treatment of patients with
early stage High Risk Ovarian Cancer
• Chemotherapy
• Radiation Therapy

18. CHEMOTHERAPY

20. International Collaborative Ovarian Neoplasm trial 1 and
Adjuvant ChemoTherapy In Ovarian Neoplasm trial
• Preplanned combined analysis in early-stage ovarian cancer that compared
platinum-based adjuvant chemotherapy with observation following surgery
• 925 patients randomly assigned to receive platinum-based adjuvant
chemotherapy (n = 465) or observation (n = 460)
• Overall survival at 5 years was 82% in the chemotherapy arm and 74% in
the observation arm (P =.008)
• Recurrence-free survival at 5 years was also better in the adjuvant
chemotherapy arm than it P =.001).

21. Conclusion
• The benefit of adjuvant chemotherapy was
found to be restricted to patients with
incomplete surgical staging
• Incompletely staged patients with a poorly
differentiated grade III tumor were found to
derive the greatest benefit from adjuvant
chemotherapy.

22. Randomized phase III trial of three versus six cycles of
adjuvant carboplatin and paclitaxel in early stage epithelial
ovarian carcinoma: a Gynecologic Oncology Group study
(GOG 157)
• Randomization was to either 3 or 6 cycles of
chemotherapy consisting of P (175 mg/m2
over 3 h) and C (7.5 AUC over 30 min) every
21 days
• N = 427

23. Results
• Grade 3 or 4 neurotoxicity occurred in 4/211
(2%) and 24/212 (11%) treated patients on the 3-
and 6-cycle regimens, respectively (p<0.01)
• 6 cycles also caused significantly more severe
anemia and granulocytopenia.
• The recurrence rate for 6 cycles was 24% lower
(p=0.18),
• Estimated probability of recurrence within 5 years
was 20.1% (6 cycles) versus 25.4% (3 cycles).
• The overall death rate was similar for these
regimens

24. Conclusion
• Compared to 3 cycles, 6 cycles of C and P do
not significantly alter the recurrence rate in
high risk early stage EOC but are associated
with more toxicity.

25. RADIATION THERAPY

26. • There has been a resurgence of interest in the
role of whole abdominal radiation following
the recent report of a population-based study
from British Columbia that suggested that
whole abdominal radiation provided a survival
benefit when added to chemotherapy,
particularly in low-stage, nonserous cancers
like clear cell, low grade endometrioid,
mucinous cancers confined to the pelvis
Berek & Hacker’sGynecologic Oncology
Sixth Edition

27. Histotype predicts the curative potential of radiotherapy: the
example of ovarian cancers
K. D. Swenerton,J. L. Santos,C. B. Gilks2,M. Köbel3, P. J. Hoskins1,F. Wong1 N. D. Le2,4
• Study population :703 patients with stages I or II
ovarian cancer
• 351 had radiotherapy (based on physician choice)
• Patients were treated with three cycles of
platinum based chemotherapy alone, or followed
by pelvic and whole abdominal radiation at a dose
of 22.5 Gy to the pelvis in 10 fractions and 22.5
Gy in 22 fractions to the whole abdomen.

28. • An additional three cycles of chemotherapy
were administered to patients who did not
receive radiotherapy.
• Results : There was a 40% reduction in
disease-specific mortality and a 43% reduction
in overall mortality in patients with clear cell,
endometrioid, and mucinous cancers.
• Patients with serous cancers did not appear to
benefit from the adjuvant irradiation.

29. ADVANCED STAGE OVARIAN
CANCER

32. CYTOREDUCTIVE SURGERY
• The principal goal of cytoreductive surgery is the removal of
all of the primary cancer and, if possible, all metastatic
disease
• If resection of all metastases is not feasible, the goal should
be to reduce the tumor burden by resection of all individual
tumor nodules to an “optimal” status.
• The goal of “complete resection to no residual disease” is the
most optimal postoperative status
Berek & Hacker’sGynecologic Oncology
Sixth Edition

33. Theoretic Rationale
• More necrotic or hypoxic areas  low growth
fraction
• Smaller postoperative tumor volume may decrease
the chance of acquiring more mutations which
promote chemoresistance.
Berek & Hacker’sGynecologic Oncology
Sixth Edition

34. Resection of the pelvic tumor may include removal of the uterus, tubes, and
ovaries, as well as portions of the lower intestinal tract

35. Separation of the omentum from stomach and transverse colon.

36. Intestinal Resection
• The disease may involve focal areas of the small or
large intestine, and resection should be performed if
it would permit the removal of all or most of the
abdominal metastases
• Apart from the rectosigmoid colon, the most
frequent sites of intestinal metastasis are the
terminal ileum, the cecum, and the transverse colon.
Berek & Hacker’sGynecologic Oncology
Sixth Edition

37. Extensive ovarian carcinoma involving the bladder, rectosigmoid, and ileocecal
area

38. Resection Of Other Metastasis
Omental “cake” densely adherent to the spleen.

39. Peritoneal Cancer Index
• The PCI is an assessment combining lesion size
(0 to 3) with tumor distribution
(abdominopelvic regions 0 to 12) to estimate
the extent of disease within the abdomen and
pelvis as a numerical score
• Completeness of cytoreduction score CC-0 ,
CC-1
Devita, Hellman and Rosenberg’s Principles and Practice of oncology, 10th edition

40. Devita, Hellman and Rosenberg’s Principles and Practice of
oncology, 10th edition

41. Interval Cytoreductive Surgery
• Cytoreductive surgery after a biopsy only or a
primary suboptimal debulking followed by
induction chemotherapy
Principles and Practice of Gynaecologic
Oncology 6th Edition

42. The effect of debulking surgery after induction
chemotherapy on the prognosis in advanced epithelial
ovarian cancer. Gynecological Cancer Cooperative
Group of the European Organization for Research and
Treatment of Cancer.

44. RESULTS

45. Primary chemotherapy versus primary surgery
for newly diagnosed advanced ovarian cancer
(CHORUS): an open-label, randomised,
controlled, non-inferiority trial.

49. Conclusion
• Based on the above considerations, the
performance of a debulking operation as early
as possible in the course of the patient’s
treatment should be considered the standard
of care
• Neoadjuvant chemotherapy followed by
interval debulking should be reserved for
patients with a poor performance and
nutritional status

50. How to approach if patient has come
with incomplete Surgery

52. THANK YOU