Debulking in Ovarian Cancer

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 lt1
  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
• Debulking for Recurrent Disease
• Debulking at Second-look laparotomy
• Interval Chemosurgical Debulking
• Debulking for Progressive Disease

10
Secondary Debulking

• Debulking for Recurrent Disease
• Those patients who enjoy a prolonged clinical
  disease free interval (gt6 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