Dr. Nabeela Shami HOD & Prof . Ob / Gyn MBBS, FCPS, AD-HPE (AKU), MHPE (Holland)

1. Early Secondary CytoreductionMay Be Associated with BetterSurgicalOutcomes in Recurrent Epithelial Ovarian Cancer Dr. Nabeela Shami HOD & Prof. Ob/ Gyn MBBS, FCPS, AD-HPE (AKU), MHPE (Holland) Lahore Medical & Dental College Lahore-Pakistan

2. Background • Second or third most common female cancer. • Most common cause of death in female malignancies.

3. Outcomeof Primary Treatment • ORR 70 – 80 % • Clinical CR 40 – 50 % • Pathological CR 20 – 30 % • 5 year survival 05 – 20 % • Recurrence rate 40 – 60 %

4. Ovarian Cancer – Treating Relapse Too Early Correct PS 0 - 1 Too Late PS 3 - 4 Serum CA-125 Tumour Bulk Model of optimum timing to treat relapsed ca ovary

5. Primary Surgical Treatment Ovarian cancerMirza Lahore 251005 ConsensusSecondary Debulking Surgery Chi D et al. Society of Gynecologic Oncology, 2005

6. Secondary Cytoreduction- Definations • Removal of recurrent disease after initial optimal cytoreduction. • Interval debulking done after few cycles in responding patients. • Second look laparotomy. • Palliative surgery.

7. Placeand Duration • Ghurki Trust Teaching Hospital, and Surgimed Hospital, Lahore. • Affiliated with Lahore Medical & Dental College, Lahore-Pakistan. • Laison with Clinical Oncology Department KEMU/MAYO Hospital, Lahore. • The duration of the study was from December 1998 to December 2013.

9. Secondary Cytoreduction and Post Operative Second Line Chemotherapy with Gemcitabine and Cisplatin in Recurrent Epithelial Ovarian Cancer N. Shami et al American Society of Clinical Oncology, Florida, USA; May 2005 Proceedings – abstract No. 5161

10. Objective • To evaluate the efficacy of secondary cytoreductive surgery in patients who present with recurrence of epithelial ovarian carcinoma

11. Objective • To assess the morbidity associated with this procedure. • To evaluate the efficacy of 2nd line post operative chemotherapy.

12. Inclusion Criteria • Histopathologic evidence of epithelial ovarian cancer. • Initial optimal cytoreductive surgery (<1cm residual disease). • Initial chemotherapy. • Recurrence of disease after initial response.

13. Exclusion Criteria • Age more than 70 years. • Co-morbidity e.g. Congestivecardiac failure. • Multiple liver or lung metastases.

14. Criteriaof Success • Less than 1 cm or no residual disease. • No mortality.

15. Salient Featuresof Procedure • Vertical midline incision • Ascitic fluid / Peritoneal washings • Adhesolysis • Tumour resection • Biopsy of previous sites • Biopsy of suspicious area • Peritoneal sampling • Inspection and biopsy from diaphragm and gut • Lymph adenectomy of palpable lymph nodes

21. Patient Characteristics

22. Results of Cytoreduction(n = 108)

23. Intra Operative Morbidity (n = 108)

24. Post Operative Morbidity (n = 108)

25. Post Operative 2nd Line Chemotherapy • Gemcitabine, 1250 mg/m2 Day I & 8 • Cisplatin, 70 mgs/m2 Day 1 • Every 22nd day • Response was evaluated after 2 cycles

26. Evaluation Optimal Cytoreduction (n=42) <6 months15/32 (46.87%) > 6 months20/50 (40.00%) >12 months07/26(26.92%)

27. Response Evaluation After Chemotherapy Optimal Cytoreduction (n=42) CR 20 (47.62%) PR 22 (52.40%) NR 00

28. Response Evaluation After Chemotheraphy Sub optimal Cytoeduction (n=66) CR 14 (21.21%) PR 20 (30.30%) <PR32 (48.48%)

29. Response Evaluation Thirty patients are alive at a median follow up of 16 months (range 6-42 months)

30. Conclusion • Secondary cytoreduction and post operative second line chemotherapy with gemcitabine and cisplatin is a reasonable treatment option for patients with recurrent epithelial ovarian cancer.

31. Conclusion • Early cytoreduction seems to confer a favorable surgical outcome. • Further studies are needed to validate our findings in larger patient cohorts.