1. Case report Ovarian cancer Ami Fishman, M.D. Meir Hospital - Sapir Med Center Kfar-Saba, Israel 10.2001 Ovarian cancer Ami Fishman, M.D. Meir Hospital - Sapir Med Center Kfar-Saba, Israel 10.2001

2. 57y-o, G3P2, upper abdominal pain + discomfort - 3mo, abdominal girth increase ~1mo ???

3. 57y-o, G3P2, upper abdominal pain + discomfort - 3mo, abdominal girth increase ~1mo H

4. History General Gynecologic - Reproductive Familial General Gynecologic - Reproductive Familial

5. Physical exam HR -90/min RR -20/min BP -130/70 Lung - Rt. base Abdominal distension / Clinical ascites Abdominal / Pelvic mass HR -90/min RR -20/min BP -130/70 Lung - Rt. base Abdominal distension / Clinical ascites Abdominal / Pelvic mass

6. work-up ? ? ?

7. work-up Blood : - CBC + SMA + Coag. profile - Tu markers - Genetics / molecular

8. work-up Imaging: - Chest X-ray - Abdominal CT - U/S - GITr / GUTr - Mammography

10. Chemotherapy Neo-adjuvant chemotherapy - Taxol + Carboplatin - No. of cycles ? - Interval debulking - Response parameters Neo-adjuvant chemotherapy - Taxol + Carboplatin - No. of cycles ? - Interval debulking - Response parameters

12. Ovarian Ca - advanced disease Treatment Ami Fishman, M.D. Primary surgical cytoreduction followed by platinum-based chemotherapy Standard of care:

13. SurgerySurgery Objective- advanced disease - early disease Objective- advanced disease - early disease

14. Pre-op work-up – Routine blood + Cross & Type – Prophylactic heparin – Anesthesia clearance – G.I.Tr. Prep mechanical antibiotics – Routine blood + Cross & Type – Prophylactic heparin – Anesthesia clearance – G.I.Tr. Prep mechanical antibiotics

15. SurgerySurgery Debulking- rational - definitions - procedures Debulking- rational - definitions - procedures

16. Ovarian Ca - advanced disease Optimal Residual Disease Ami Fishman, M.D. better prognosis no residual tumor <0.5 cm 0.5 - 1.5 cm CORRELATES

17. SurgerySurgery Objective- early disease Staging- rational - procedures Objective- early disease Staging- rational - procedures

18. Ovarian Ca - advanced disease Treatment Ami Fishman, M.D. Rate of achieving optimal primary cytoreductive surgery ~ 40 - 60 %

20. Adjuvant chemotherapy Definitions Protocol Combinations Definitions Protocol Combinations

21. Adjuvant chemotherapy Taxol + Carboplatin Side effects –Systems –Limiting Routine F/U Taxol + Carboplatin Side effects –Systems –Limiting Routine F/U

22. Adjuvant chemotherapy Carboplatin (Calvert AUC = 6-7) Taxol (175 mg/m 2 ) x6 courses q3 weeks Ami Fishman, M.D.

23. Adjuvant chemotherapy Platinum + Taxol Response Rate (clinical) = 70-80% end of Rx - ? ? ? Platinum sensitive Platinum resistant Ami Fishman, M.D.

24. Chemotherapy Response definitions: – Complete – Partial – Stable disease – Progression Response definitions: – Complete – Partial – Stable disease – Progression

25. 15mo following last chemotherapy cycle Asymptomatic CA-125 = 10/2000 => 17 01/2001 => 67 ???

28. Elevated CA-125 Asymptomatic patient –Evaluate disease Asymptomatic patient –Evaluate disease To treat or not to treat ??

30. 2nd line chemotherapy Chemo - sensitive Chemo - resistant Chemo - sensitive Chemo - resistant

31. 2nd line chemotherapy Re - induction Others - old agents - new agents High dose Intra-peritoneal Research protocols Re - induction Others - old agents - new agents High dose Intra-peritoneal Research protocols

35. Research protocol Phase I / II / III protocol end points Phase I / II / III protocol end points

36. 37 y-o 7cm ovarian complex cyst Laparoscopy Procedures : peritoneal washing for cytology Frozen section Procedures : peritoneal washing for cytology Frozen section

37. Frozen section ==> LMPT ??? USO Surgical staging : omentectomy + peritoneal biopsies + retrop. LN sampling USO Surgical staging : omentectomy + peritoneal biopsies + retrop. LN sampling Procedures :

38. 37 y-o, Laparoscopic USO Final histology (after 10 days) ==> Ovarian Ca ??? Review / confirm histology Consider : - grade - age & reproductive plan - site / experience of surgeon at 1st procedure - referral to Gyn-Onc Consider : - grade - age & reproductive plan - site / experience of surgeon at 1st procedure - referral to Gyn-Onc