First screen that that you see here. Can you see my my screen? okay, and I thought this was a little bit of a history lesson on why and what I do and Somewhat this may be showing my age since I train in the early 2000s, so this is surgery for ovarian cancer At Mayo Clinic in Florida why I do what I do when I see a case that is very Similar to the first case that we saw today So a little bit about surgery and I always bring up this slide Because one of the author is Arlen Fuller and he is now retired But he taught me As a fellow and this is an original article by Tom Griffith and Arlen Fuller I think it's in 1974 and it's one of the first studies that showed the benefit of surgery for ovarian cancer and in this study You can see at that time. They defined it as 1.5 centimeters and if you have a mass that remains more than 1.5 centimeters you This is your survivor curve but if you had masses that are either 1.5 centimeters or less or if you're able to Do surgery and debulk the cancer to 1.5 centimeter or less The two curves are exactly the same and it leads to the thinking that surgery is one of them important mainstay of treatment ovarian cancer And it goes on to cases or or Slides like this where you can see that for every small amount of improvement in in Cytoreduction you do better in terms of overall survival the very top line This is an old slide, but it looked at size of residual for less than 2 centimeters The patient does very well however, if you have tumor that is greater than 2 centimeters or So from 2 to 4 centimeters 4 to 6 centimeters 6 to 10 centimeters or more than 10 Centimeters all the curves are pretty much exactly the same so when I first Was thinking about gynecology oncology the definition was that we have to get it down to 2 centimeters Because this would be their survival curve but now the thought is 1 centimeter because they will do even better and if you can cytoreduce to no visible disease They will do even better than 1 centimeter. But if you leave anything more than 2 centimeters Everything is about the same So I want to show you a recent case Here at Mayo Clinic This is very easy compared to what? You saw Quinn in In Vietnam, this is you will laugh at this cancer because it's so easy This is a 54 year old with a large pelvic mass So on the CT scan, it looks very easy. There's not a lot of peritoneal disease But she has some history She has a history of a large abdominal wall hernia and they repaired it with mesh So this was years ago she also has a history of colon surgery because she has a Perforation and she had a colostomy and then years later after that was treated She had another surgery for reversal of her colostomy That led to the hernia and the repair of hernia with the mesh Otherwise, she's very healthy. She's young and all she has is high blood pressure She saw me in July and her CA 125 was 360 so six days after I saw her I took her to surgery and The reason is that it does not look like she had a lot of cancer and Like you Quinn. I like to do surgery remember GY oncologist. We like to do surgery So I took her but I did laparoscopy and why did I do? laparoscopy because of this history of hernia and mesh There's usually a lot of scar tissue and now we add scar tissue with cancer I will show you next the results of and So here are the pictures that I saw at surgery This is not a show the full Result, but in the middle of her abdomen There was a lot of small bow stuck to the area of mesh with obvious cancer so I Biopsy something like this and it was serious carcinoma Same cancer that you had in your patient in the pelvis. It looks like this so full of tumor Again, she's had previous surgery down here in the diaphragm very little cancer So with this I decided to stop and give her chemotherapy initially So the question is why did I do that? Should we do? Suboptimal surgery then give her chemo. So should I give her the benefit? Should I do that as much surgery as I can because either way I'm gonna give chemotherapy afterwards I based my decision on this very old study from 1995 out of Europe and this study was a study where patients had Suboptimal surgery by a general gynecologist 425 patients they had suboptimal surgery with greater than one centimeter residual and then they entered the study and they were given three cycles of chemotherapy at that time it was before Taxol, so she they received cyclophosphamide and cisplatin and they had a response and Then they were randomized to two arms either surgery Or no surgery and it either way they get three more cycles of chemotherapy and what was the result of that and we'll just go look at survival and In survival, you can see that the arm that had surgery before I'm sorry had surgery instead of more chemotherapy did better. Here's the survival curve With surgery if they had no surgery a lot lower survival So The GOG that the group in America also did a very similar Surgery, I'm sorry a similar study about ten years later and in this Study 550 patients had surgery, but now in America by a gynecologic oncologist and also suboptimal revoking by this time they all receive chemotherapy with Taxol and They were randomized very similarly to after three cycles to get more surgery or no or no surgery and In this study that was done in the United States What did you see and you can see that the two curves are exactly the same Whether you get surgery or no surgery The overall survival is exactly the same So why the difference in outcome in Europe By The trial by the EOR TC Surgery after three cycles after you do Suboptimal debulking is good is better in the United States if you do surgery The curve is exactly the same whether you get surgery or you don't get surgery and just go on with more Chemotherapy and the answer is and This is a little bit You know in the United States were very proud of our abilities through surgery But the difference is we think and how we explain this is who did the first surgery in this case and please chime in for for the other very Experienced GYN oncologist if you have other takes for these classic trials But in Europe the original person who did surgery were not GYN oncologist so if you didn't try very hard to do a debulking you give chemotherapy and you do surgery again, you get an overall survival In the United States a GYN oncologist did the surgery that GYN oncologist tried very hard to get optimal was not able to do it and So when you do chemotherapy and try surgery again, it does not help So if you try hard once it may not help to try again after three cycles of chemotherapy So what happened to my patient Okay, my patient Since there was so much bowel adhesions, I couldn't show you that but there was so much bowel adhesions I decided to give her three cycles of neoadjuvant chemotherapy her CA 125 Went from I think to 300 down to 22. She did very well with three cycles her Cancer got a lot better just in the pelvis. It didn't look a lot better But it is her bowel was still stuck here. But after three cycles, I decided it's time to operate So why neoadjuvant chemotherapy and I'll go very fast through this but this is the classic study about several years ago out of Europe because Chemotherapy prior to surgery in this study of 704 patients in this study. There was no upfront surgery it was diagnosis by some biopsy only and the patients were randomized to surgery versus neoadjuvant Chemotherapy and as you know in this study Progression free survival and overall survival is exactly the same The difference in this study versus the other one is these patients did not get a big surgery up front So just like my patient all I did was laparoscopy and took a biopsy I did not try to operate on her So what happened to our patient to my patient? Last week on October 29. I took her to surgery. I debulked her to no visible disease. I spent about four hours because all the adhesions to the mesh was still there I had to do a small bowel resection and and because of tumor and And where the tumor is stuck to the mesh. I Did a reanastomosis Here we do Hypec and that's heated intraperitoneal chemotherapy That's the new thing that we're doing and we can talk about that another day but the key point here is I did not try to do a surgery the very first time I gave her chemo and Treated her and did surgery and optimally cytoreducer She went home post-op day five and my hope is that in about three weeks after surgery She can get another cycle some more chemotherapy So my take-home points is you only get one chance with surgery Neal-adjuvant chemotherapy works. Well, and This is a rough estimate. I have no data here and Other gynecologists may laugh at me but about 50% of patients at Mayo Will get neoadjuvant chemotherapy unless you are a good candidate We will give you neoadjuvant chemotherapy And this is my opinion only if I were working full-time in Vietnam like you Quinn All of my ovarian cancer patients with stage 3 disease will get neoadjuvant chemotherapy And I think that's all I have. I'll be glad to hear what the other very Knowledgeable and Experienced gynecologists from all over the world think about how they treat advanced ovarian cancer

surgery

ovarian cancer

tumor size

neoadjuvant chemotherapy

stage 3 disease