Ovarian cancer: clinical practice the Arabic perspective

Transcription

1 Lead Group Log Ovarian cancer: clinical practice the Arabic perspective Experience of Hôtel-Dieu de France University Hospital (Beirut, LEBANON) in supraradical surgery for ovarian cancer David ATALLAH M.D. M.Sc. Associate Professor at Saint Joseph University Gynecologic oncologist and breast surgeon at Hôtel-Dieu de France University Hospital

2 Ovarian cancer Standard of care= Primary cytoreductive surgery followed with chemotherapy based on platins and paclitaxel Ozols RF, Bundym BN, Greer BE, et al. Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a gynecologic oncology group study. J Clin Oncol 2003;21(17):

3 Rationale of cytoreductive surgery Impact on survival!

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5 Cytoreductive Surgery : Principles Complete Resection of the carcinosis (R0) Pelvic exenteration in one bloc Bowel resection Upper abdominal surgery (supramesocolic) Extensive lymphadenectomy

6 Pelvic exenteration/ Cytoreduction Resection in one bloc without tumor spillage, free margins Radical hysterectomy with bilateral adnexectomy Ureteral dissection Rectosigmoid resection Peritoneal stripping

7 Hysterectomy with double adnexectomy and peritoneal stripping (resection in one bloc)

8 Pelvic exenteration with peritoneal stripping

9 Prevesical peritoneum with carcinosis

10 Posterior exenteration with peritoneal stripping

11 Pelvic exenteration with peritoneal stripping in one bloc

12 Bowel resection

13 Total colectomy with ileal resection

14 Upper abdominal surgery Diaphragm Stripping Splenectomy with caudal pancreatectomy Omentectomy

15 Left diaphragmatic cupola after stripping and splenectomy

16 Right diaphragmatic cupola after stripping

17 Splenectomy and omentectomy in one bloc

18 Splenectomy and caudal pancreatectomy

19 Splenectomy and caudal pancreatectomy

20 Infragastric omentectomy

21 Great curvature of the stomach after infragastric omentectomy

22 Lesser curvature of the stomach after resection of carcinosis at the level of lesser omentum

23 Control of disease and resection of micronodules at the level of the mesentery

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25 Pelvic and para-aortic lymphadenectomy

26 Our study Retrospective study Concerning 139 patients Undergoing cytoreductive surgery for primary or recurrent disease Primary or interval debulking Between January 2004 and September 2017 at Hôtel-Dieu de France University Hospital

27 Objectives To define predictive factors of better survival and delayed recurrence in ovarian cancer patients undergoing a cytoreductive surgery

28 Results Age Menopause 27% 29% < 50 ans No 73% > 50 ans 71% Yes

29 Stage Stage I Stage II Stage III Stage IV

30 Debulking Primary Debulking Interval Debulking Debulking post Recurrence Debulking post incomplete primary surgery

31 Lymphadenectomy No lymphadenectomy 12% Lymph node N- 42% Lymphadenectomy 88% N+ 58% Mean number of removed lymph nodes (pelvic and para-aortic) = 57 LNs

32 Clearance Ratio 10% < 0.25 > %

33 Bowel resetion 47% 53% No Yes

34 Upper abdominal surgery 37.4 % 62.6 % No Yes

35 Recurrence 44% 56% No recurrece Recurrence Interval of recurrence > 12 months months 20.0 < 6 months 6.7

36 Survival 33% 67% Deceased Survived

37 Primary vs. interval debulking Mean Survival (months) Interval Debulking 36 months Primary Debulking 42 months P = 0.63

38 Primary vs. interval debulking 80.00% 70.00% 61.00% 60.00% 50.00% 40.00% 30.00% 28.60% Recurrence No Recurrence 20.00% 10.00% 0.00% Primary Debulking Interval Debulking P = 0,005

39 Factors for survival

40 Survival and age P = 0,03

41 Survival and stage of disease P = 0.000

42 Total number of removed lymph nodes P = 0.022

43 Survival and nodal status P = 0.001

44 Number of positive lymph nodes P = 0.000

45 Lymph node ratio P = 0.000

46 Recurrence

47 Recurrence and nodal status 70.00% 60.00% 50.00% 40.00% 30.00% No recurrence Recurrence 20.00% 10.00% P = % N + N -

48 Recurrence and stage of the disease % 90.00% 80.00% 70.00% 60.00% 50.00% 40.00% No recurrence Recurrence 30.00% 20.00% 10.00% 0.00% Stage I Stage II Stage III Stage IV P = 0.000

49 Complication factors

50 Lymphadenectomy Lymphadenectomy No Lymphadenectomy P-value postoperative complications rate mean Transfusion (Nb units) mean operative time (hours) 45% 50%

51 Impact of fistula on survival P = 0.015

52 Number of anastomoses Predictive factors of fistula Fistula rate P-value Obesity Fistula rate P-value one anastomosis 6.80% multiple anastomosis 57.10% Non obese 13 % 0.46 obese 6.3 % Comorbidities Fistula rate P-value Neoadjuvant chemotherapy Fistula rate P-value yes 7.7 % No 13.2 % Lymphadenectomy Fistula rate P-value yes 12.2 % No 12 % Colostomy Fistula rate P-value yes 14.3 % yes 0 % No 0 % Parenteral hyperalimentation Fistula rate P-value No 12.9 % Protective ileostomy Fistula rate P-value yes 15.8 % No 10.6 % yes 0 % 0.34 No 13.3 %

53 Conclusion Better survival were seen : In younger patients in case of primary (upfront) cytoreductive surgery In early stages When more than 57 lymph nodes were removed In the presence of only one positive lymph node In case of Lymph node ratio 0.03 In case of negative lymph node status

54 Thank You