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How to identify the ldquorightrdquo patient for surgery in recurrent ovarian cancer
Andreas du BoisKliniken Essen Mitte (KEM) Germany
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No COI except that I
spent my whole professional
life to fight ovarian cancer
and I am a dedicated surgeon
hellip and partially make my living out of it
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Surgery in Ovarian Cancer Definitions
Diagnostic surgery (histological diagnosis)
Staging surgery (comprehensive staging after initial diagnosis of presumed early stage OC)
Primary (or upfront) debulking surgery(complete tumor resection or if not possible debulking to less than 1cm residuals)
Completion debulking surgery (2nd attempt upfront after 1st surgery wo max effort)
Interval debulking surgery (complete resection following neoadjuvant chemotherapysometimes also performed for persisting tumor after complete course of chemotherapy)
Second look surgery (currently obsolete verification of complete response optionally with secondary debulking in case of incomplete response)
Cytoreductive surgery for ROC (aka secondary debulking surgery)
Emergency palliative surgery (eg for bowel obstruction or perforation gastric tubes)
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The two faces of surgery in ROC
How to get largely Dr Jekyll and not Mr Hydewhen you invite the same person
OS prolongation
PFS prolongation
Symptom relief
morbidity
hospital stay
costs
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The Way to Dr Jekyll The AGO DESKTOP series
DESKTOP I Retrospective multicentre series1 Identify an appropriate endpoint goal of surgery2 Create a hypothetic model for a predictive score
to select patients who could achieve the endpoint(allowing patient selection for further studies)
DESKTOP II Prospective international non-interventional study1 Validation of the DESKTOP I model (AGO score)2 Descriptive analysis of the selection bias for
offering surgery to patients with ROC3 Description of ROC surgery associated morbidity
DESKTOP III Prospectively randomised controlled phase III trial
1 Evaluation of the impact of ROC surgery on OS
2 acute and delayed morbidity
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0
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0 12 24 36 48
months
surv
ival
pro
babi
lity
0 vs 1-10 mmHR 417 (CI 242 - 716) p lt 00010 vs 10+ mmHR 331 (CI 186 - 588) p lt 0001
no residualsmedian OS 452 mos
residuals gt 10 mmmedian OS 197 mosresiduals 1 - 10 mmmedian OS 196 mos
AGO DESKTOP I
Harter P du Bois A Hahmann M et al Ann Surg Oncol 2006
Dr Jekyll Complete resection is a pre-requisite for a potential OS benefit