1. David Cibula, VFN Innovation in surgical approach of ovarian cancer David Cibula Gynecologic Oncology Centre General Faculty Hospital in Prague

2. David Cibula, VFN Incidence / mortality SVOD, 2010 39 %

3. David Cibula, VFN Mortality / incidence SVOD, 2009

4. David Cibula, VFN Advanced stage at diagnosis SVOD, 2010

5. David Cibula, VFN Ovarian cancer No specific symptoms No screening method available Early spread by implantation

6. David Cibula, VFN Optimal debulking Hoskins 1994 GOG protocol 97 multivariation analysis < 2 cm RR 1,0 2 – 2,9 RR 1,9 3 – 3,9 RR 1,91 4 – 5,9 RR 1,74 6 – 7,9 RR 1,85 8 – 9,9 RR 2,16 > 10 RR 1,82 (RR deathí) AJOG, 1994, 170, s. 974-980.

7. David Cibula, VFN Increased radicality  prognosis Eisenhauer EL (N.Y.) 1998 – 2003 AOCN = 262 groups I extensive radicality IIstandard radicality IIIsuboptimal cytoreduction Gynecol Oncol, 2006

8. David Cibula, VFN

9. Du Bois Andreas Du Bois Andreas AGO-OVAR 3/5/7 AGO-OVAR 3/5/7 AOCN=3,126 AOCN=3,126 R 0 mm37 % 1-10 mm31 %  10 mm35 % Cancer, 2009, 115, 1234-44

10. David Cibula, VFN

11. Optimal debulking - recurrences Desktop AGO-OVAR retrospective cohort ROC, SCS N = 267 Ann Surg Oncol, 2006, 13, 1702-10

12. David Cibula, VFN Increased radicality of the surgery  achievement of optimal cytoreduction

13. David Cibula, VFN What kind of surgery?

14. David Cibula, VFN

15. 2008 - 2014 N = 520 (AOC) % Peritonectomy 60 % Diaphragm 23 % resection 13% Splenectomy 8% Bowel resection 45 %

16. David Cibula, VFN Achievement of optimal cytoreduction

17. David Cibula, VFN Role of NACT

18. David Cibula, VFN Primary debulking surgery (PDS) Histology / cytology verification Chemotherapy Neoadjuvant chemotherapy (NACT) Interval debulking surgery (IDS)  optimal debulking = NO macroscopic residuum

19. David Cibula, VFN Primary debulking vs NACT/IDS PRT 1998 – 2006 60 institutions N = 718 primary debulking N = 329 NACT + IDS N = 339 PDSIDS IIIC77 % 77 % ≥3c CHT83 % 86 % residuum  1 cm46 % 82 % NO21 % 53 % morbidity and mortality mortality2,7 % 0,6 % hemorrhage7 % 1 % venous G3/G42,4 % 0,3 % NEJM, 2010, 363, 943-53

20. David Cibula, VFN NEJM, 2010, 363, 943-53

21. David Cibula, VFN Primary debulking vs NACT/IDS PRT 1998 – 2006 60 institutions N = 718 primary debulking N = 329 NACT + IDS N = 339 PDSIDS IIIC77 % 77 % ≥3c CHT83 % 86 % residuum  1 cm46 % 82 % NO21 % 53 % morbidity and mortality mortality2,7 % 0,6 % hemorrhage7 % 1 % venous G3/G42,4 % 0,3 % NEJM, 2010, 363, 943-53

22. David Cibula, VFN Canada (Rosen B; Narod S) AOC; N=326 NR07y OS PDS18342%41% NACT-IDS14350%9 % Gynecol Oncol 2014; 134: 462-467

23. David Cibula, VFN Canada (Rosen B; Narod S) AOC; N=326 NR07y OS PDS18342%41% NACT-IDS14350%9 % Gynecol Oncol 2014; 134: 462-467

24. David Cibula, VFN Sehouli J; AOC; 2000-2009 N=372 IDS 11 %PDS 89% R0Compl.mPFS IDS85% 36%15 mo PDS59% 37%33 mo IJGC 2010; 20:1331-40

25. David Cibula, VFN Sehouli J; AOC; 2000-2009 N=372 IDS 11 %PDS 89% R0Compl.mPFS IDS85% 36%15 mo PDS59% 37%33 mo IJGC 2010; 20:1331-40

26. David Cibula, VFN Sehouli J; AOC; 2000-2009 N=372 IDS 11 %PDS 89% (median 5 cycles!!) R0Compl.mPFS IDS85% 36%15 mo PDS59% 37%33 mo IJGC 2010; 20:1331-40

27. David Cibula, VFN Danish nationwide study AOC; 2005-2011; N=1677 PDS 60 %NACT 31%Palliative 10% IDS 65 %No surgery 35 % PDSNACT/IDS mOS/ALL32 mo30 mo mOS/R056 mo37 mo Gynecol Oncol 2014;132: 292-8

28. David Cibula, VFN Danish nationwide study AOC; 2005-2011; N=1677 PDS 60 %NACT 31%Palliative 10% IDS 65 %No surgery 35 % PDSNACT/IDS mOS/ALL32 mo30 mo mOS/R056 mo37 mo Gynecol Oncol 2014;132: 292-8  20 % Excluded from surgery

29. David Cibula, VFN Danish nationwide study AOC; 2005-2011; N=1677 PDS 60 %NACT 31%Palliative 10% IDS 65 %No surgery 35 % PDSNACT/IDS mOS/ALL32 mo 30 mo mOS/R056 mo 37 mo Gynecol Oncol 2014;132: 292-8

30. David Cibula, VFN Danish nationwide study AOC; 2005-2011; N=1677 PDS 60 %NACT 31%Palliative 10% IDS 65 %No surgery 35 % PDSNACT/IDS mOS/ALL32 mo 30 mo mOS/R056 mo 37 mo Gynecol Oncol 2014;132: 292-8

31. David Cibula, VFN Explanation for such disparities?

32. David Cibula, VFN Selection of patients for any treatment for NACT for IDS

33. David Cibula, VFN Selection of pts EORTC 55971; RCT; survival benefit 5y OS PDSNACT IIIC/met tu ≤45 mm45%17% IIIC/met tu >45 mm17%23% IV/met tu ≤45 mm13%22% IVC/met tu >45 mm2%23% Individual treatments27 % All PDS19 % ALL NACT21 % Eur J Cancer 2013; 49: 3191-201

34. David Cibula, VFN Selection of patients for any treatment for NACT for IDS Radicality of the surgery?

35. David Cibula, VFN Optimistic case

36. David Cibula, VFN 40 years Abdominal pressure - 2 months Ca 125 - 1850 US bilat. ovarian mass, pelvic carcinomatosis diaphragm carcinomatosis omental cake ascites Date of surgery: 04/2009

37. David Cibula, VFN

38. Date of surgery: 04/2009 Adjuvant chemotherapy (CBDCA/PTX; 6c) until 08/2009 1st recurrence in the left groin Removal of bulky LN / IFLDN: 09/2009 FU: NED!!

39. David Cibula, VFN Who should do that?

40. David Cibula, VFN ABOG Guide to learning in gynecologic oncology Gastrointestinal, Upper Abdominal - The fellow should be able to perform: 1. placements of feeding jejunostomy/gastrostomy. 2. resections and re-anastomoses of small bowel. 3. bypass procedures of small bowel. 4. mucous fistula formations of small bowel. 5. ileostomies. 6. repair of fistulas. 7. resection and reanastomoses of large bowel 8. bypass procedures of large bowel. 9. mucous fistula formations of large bowel. 10. colostomies. 11. splenectomies. 12. liver biopsies

41. David Cibula, VFN IJGC, 2011, 7, 1264

42. David Cibula, VFN Conclusions Advanced ovarian cancer Goal of the surgery: no residual disease (R0)  significantly better survival Upper abdominal procedures and bowel resections are justified New procedures / new skills / new requirements

43. David Cibula, VFN Conclusions Primary debulking surgery Better survival R0 NACT / IDS Unsuitable for complex surgery Expected suboptimal cytoreduction? Future Prognostic markers – molecular biology

44. David Cibula, VFN Scientific Programme MAIN TOPIC Reconstructive procedures in gynaecologic oncology SESSIONS Reconstructive procedures in gynaecologic oncology Abdominal wall reconstruction Pelvic floor reconstruction after exenteration Vulvar and perineal reconstruction Urinary diversion Neovagina creation Radical hysterectomy Tips and tricks Minimally-invasive surgery in gynaecologic oncology New technology Upper abdominal debulking

45. David Cibula, VFN DEBATES Management of IB2 cervical cancer PRO: Surgery PRO: Chemoradiation Primary cytoreductive surgery in advanced ovarian cancer PRO: In > 90 % of patients PRO: In < 75 % of patients Management of patients with cervical cancer and intraoperative finding of LN+ PRO: Abandoning hysterectomy PRO: Radical hysterectomy Fertility sparing management of 1B1 cervical cancer PRO: conisation/trachelectomy PRO: radical trachelectomy TEACHING SESSIONS Vascular surgery in gynaecology Retroperitoneal paraaortic lymphadenectomy