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Flashcards in RANZCOG questions Deck (25)
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1

A 25 year old woman is undergoing a caesarean section for an abnormal CTG. After delivery of the baby you find an enlarged ovary that is cystic and solid in nature with a few papillary excrescences on the surface. You suspect this could be a borderline tumour.

a. Describe the intra-operative options available to confirm the diagnosis and assess the disease in this setting? (6 marks)

• Ensure patient stable, haemostasis achieved etc before managing
• Inform patient and anaethetist of findings
• Options: Immediate assessment vs delayed (do nothing now and return later for full staging laparotomy). Preferable to do now if situation allows and patient gives verbal consent.
• Options to confirm diagnosis:
o Biopsy, ovarian cystectomy or unilateral salpingo-oophorectomy – preferable to perform oophorectomy (biopsy may upstage disease, cystectomy alone increases rate of recurrence)
o Frozen section for urgent histology if service available
• Assess the disease:
o Explore (inspect/palpate):
 Other ovary and biopsy/cystectomy if abnormal
 Tubes
 Peritoneal surfaces including diaphragm if tolerated and access allows
 Palpate liver if tolerated and access allows
 Omentum
 Biopsy if any suspicious lesions
o Peritoneal washings – although will be contaminated with blood and amniotic fluid/debris so probably not helpful – document on form manner in which taken
• Issues
o If under GA, inadequate consent
o If under regional analgesia possibly inadequate analgesia to perform above
o Likely have used Pfannensteil incision- limited access to upper abdomen
o Washings likely to be contaminated with blood/amniotic fluid and debris
o Frozen section histology difficult to interpret in pregnancy

2

A 25 year old woman is undergoing a caesarean section for an abnormal CTG. After delivery of the baby you find an enlarged ovary that is cystic and solid in nature with a few papillary excrescences on the surface. You suspect this could be a borderline tumour.

Initial biopsy confirms a serous borderline tumour. How would you counsel the patient about this condition, her treatment and follow up? (9 marks)

• Condition:
o Tumour of low malignant potential. Hasn’t invaded serosa as compared to invasive ovarian cancer
o Tend to be confined to ovary
• Prognosis:
o Good prognosis when staged accurately
o 5 year survival:
 Stage 1 99% (majority -75% are stage 1 at diagnosis)
 Stage 2 98%
 Stage 3 96%
 Stage 4 77%
• Treatment:
o Refer to Gynaeoncology MDM
o Needs to complete staging as this determines future management and identifies occult disease
o Staging: unilateral oophorectomy (if not already done), washings, omentectomy, exploration of peritoneal surfaces
o If other ovary is normal macroscopically and on USS do not need to biopsy
o Given age, TAH/BSO is not necessary however consider if patient adamant would like this, or when childbearing complete as this is definitive treatment
o Ongoing management depends on final staging, rarely need chemotherapy unless stage 3 or 4, and even this is controversial
• Followup:
o Prognosis as above
o Recommend annual longterm followup with history, examination, USS +/- tumour markers
o Pregnancy/fertility treatments not contraindicated
o Consider completion surgery with TAH/BSO once family complete (counsel on surgical menopause)
o Recurrence rates:
 Cystectomy 25%
 Oopherectomy 10%
 TAH/BSO <5%
o Very low risk of malignant transformation <1%

3

You see a 37 year old woman in the Gynaecology Outpatient Clinic. Two months ago she developed acute appendicitis on holiday and had an uncomplicated laparoscopic appendicectomy at a rural hospital. An incidental finding of an 8cm left ovarian cyst was made at the time of surgery and a laparoscopic ovarian cystectomy was performed. Her recovery was uneventful and she attends with a letter from the rural hospital that advised her that she had a borderline ovarian tumour (BOT).

a.
i) After initial history and examination, outline your immediate management plan with regard to her BOT. (4 marks)

ii) Justify each of your management points. (4 marks)
Use a table for your answer in part a.

1. Request notes:
- Ensure cyst was completely excised
- Review images and ensure there was no evidence of intra-peritoneal spread and ensure cyst was on the left ovary
- Review if cyst was ruptured during operation
- Ensure contralateral ovary appeared normal
- The above factors may increase the risk of spread and recurrence
2. Review pathology
- Review pathology of appendix- mucinous tumours of the ovary, especially if associated with pseudomyoxma peritonei, are often of appendiceal origin
- Review DNA aneuploidy status and if micropapillary tumour- higher risk pointing towards needing completion treatment
- Ensure ovary and appendix have been thoroughly sectioned and reviewed by an experienced pathologist as sections of invasion/atypia may be missed
- Higher risk histology may need further surgery and has a higher risk of recurrence
3. Tumour markers
- CA125, CA19-9 and CEA- if levels are high then invasive cancer should be suspected
4. Pelvic USS
- Review current status of both ovaries and if any residual lesions are present
- Consider MRI if lesions are present to review if there are any peritoneal or extra-ovarian lesions
5. Referral to gynae oncology MDM
- Will enable formal case review by qualified gynae-oncologists, radiologists, oncologists, and pathologists to give opinion on treatment options going forward
6. Arrange follow-up
Ensure that above are complete and explain the findings to the woman

4

b. What histological findings are associated with an increased risk of recurrence of a borderline ovarian tumour? (2 marks)

• Higher stage disease
• Invasive implants
• DNA aneuploidy
• Serous tumours with micropapillary features

5

The woman has not yet had a family but intends to in the future. Assuming that she has no high-risk histological findings;

c. Evaluate her current management considerations to reduce her long-term health risks but enable her to have a family and her future management considerations. (5 marks)

• Counselling for the woman to explain the pathology and implications
o Discuss with the woman what her plans are with regards to further fertility and her feelings about surgery
• Conservative management
o No consensus on which women need restaging or completion surgery, which is why review at the gynae onc MDM with the above information will be helpful
o This is often on a case-by-case approach, which takes into account:
 Histological subtype of borderline tumour
 Completeness of the primary surgery
 Fertility desires of the woman
o There is no evidence that pregnancy or fertility treatment increase the risk of recurrence
• Restaging and fertility-sparing conservative surgery
o Restaging surgery should be considered if any of the above histological findings are present and after discussion with the woman
o Should include: peritoneal washings, omentectomy, and examination of the peritoneum in this woman. If there is no evidence of ongoing disease on the left ovary, this could be spared but in most cases a unilateral salpingo-ophorectomy would be performed and the specimens sent for histology
o Surgery should be done in a gynae-oncology unit
• Completion of surgery once family complete or with more advanced disease
o Completion surgery is a total hysterectomy and bilateral salpingo-ophorectomy, washings, omentectomy, appendicectomy, removal of all visible tumour and this should be performed after her family is complete or if necessary
o Should be done in a gynae-oncology unit and be carefully counselled
• HRT
o There is no data regarding the risk of HRT after a borderline tumour
o Women should be counselled about the risks and benefits and consider using HRT up until the average age of menopause
• Ongoing monitoring
o Risk of recurrence is varied- depends on type of tumour and primary surgery
o Clinical examination and ultrasound are of benefit in the detection of recurrent disease in women who have had conservative management or conservative surgery (ie still have one or both ovaries)
 Follow-up every 3 months for the first 2 years, every 6 months for the next 2 years and annually thereafter
o The role of tumour markers in follow-up is uncertain
o She should be advised about the need for earlier review if she develops symptoms
o She should be aware of the risk of peritoneal recurrence, which may not be picked up on routine surveillance and advised to seek medical advice for any symptoms

6

A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.

a. Excluding the ovary, list a pathology in the different anatomical structures you would consider in your differential diagnosis. (5 marks)

Tubal – paratubal cyst, hydrosalpinges, tuboovarian abscess
Peritoneal – peritoneal pseudocysts
Appendix - appendiceal abscess
Bowel – diverticular abscess
Kidney – pelvic kidney
Bladder – bladder cancer
Uterus – fibroid, sarcoma, pregnancy
Cervix – cervical cancer
Ureter – hydroureter

7

A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.

Following a detailed history and examination, what investigations might you order to arrive at a specific diagnosis? (4 marks)

Pregnancy test
Full blood count
Imaging - TV and TA USS abdo/pelvis, CT or MRI
Tumour markers – Ca 125, CEA, Ca-19-9, alpha fetoprotein, LDH, HCG
Depending on results of above – consider biopsy of primary lesion or other mass e.g. omental cake/cytology if ascites, barium enema, IVP, CXR

8

A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.

Your investigations diagnose the pelvic mass as an ovarian cyst with a lesion on the contralateral ovary.

If this woman is postmenopausal with a CA125 measuring 30u/ml calculate the risk of malignancy index (RMI) (2 marks)

RMI = menopausal status (3 points for postmenopausal), x Ca 125 level (30), x USS features (3 points for 2+ suspicious features – bilateral, solid components)
= 270

9

A 42 year old woman is referred with a 7cm “complex pelvic mass” on ultrasound. There are both solid and cystic areas.


ii) Interpret your result and explain how this RMI result would affect your management of this woman (4 marks)

High risk (>200) – 75% of malignancy
Referral to gynaeoncology (improves outcomes)
Staging laparotomy – recommend:
Midline laparotomy
Bilateral cystectomy at least, probable TAH/BSO given menopausal status
Inspection and palpation of all peritoneal surfaces and biopsy of suspicious lesions – can consider frozen section if uncertain
Washings
Select or complete LN dissection
Appendectomy if suspected or known mucinious ca

If ovarian cancer confirmed, adjuvant CTX +/- RTX depending on stage

10

Adnexal mass in pregnancy
A previously well 32 yo nullipara at 8 weeks gestation is incidentally found to have an 7cm right adnexal mass of mixed echogenicity on her dating USS.

What is the differential diagnosis? (4 marks)

- Ovarian, benign
Mature Teratoma
Cystadenoma (serous or mucinous)
Endometrioma
Corpus luteum
Theca lutein cyst (more common if high HCG – GTD, twins)
Luteoma – suspect if maternal virilisation in pregnancy
Functional cysts

- Ovarian, malignant
Germ cell tumour
Epithelial carcinoma
Sex cord tumour

- Secondary malignancy – breast or GI tumour

- Benign non ovarian
Paratubal cyst
Hydrosalpinx
Peritoneal pseudocyst
Pelvic kidney
Subserosal fibroid

11

Adnexal mass in pregnancy
A previously well 32 yo nullipara at 8 weeks gestation is incidentally found to have an 7cm right adnexal mass of mixed echogenicity on her dating USS.

Outline what investigations you would arrange? (4 marks)

Tertiary level transvaginal ultrasound with colour Doppler to look at characteristics of cyst
Unilocular/multilocular
Mixed echogenicity
Solid components, mural nodules, papillary excrescences, ascites increase suspicion and increase suspicion of malignancy
RMI calculated = ultrasound features x menopause status x Ca-125 >200 (sensitivity for malignancy 78%)
Check viability of pregnancy
Ca-125
Not reliable in pregnancy as can be elevated in pregnancy
Appearance of cyst on ultrasound more important
Other tumour markers
LDH for germ cell tumours (not normally raised in pregnancy)
Consider Ca19-9 and CEA for mucinous tumours
MRI could be considered for staging if malignancy suspected or to help plan surgery

12

Adnexal mass in pregnancy
A previously well 32 yo nullipara at 8 weeks gestation is incidentally found to have an 7cm right adnexal mass of mixed echogenicity on her dating USS.


Detail your management strategy for this woman including the pros and cons of surgery (7 marks)

Would need serial scanning during first trimester
If cyst was still present and was similar size or larger at the end of first trimester
Would offer surgical management between 14-20 weeks, by either laparoscopy or laparotomy depending on the surgeon’s expertise and cyst size
Most transient ovarian cysts including corpus luteum cysts would have resolved by 14 weeks gestation
If laparoscopy is being done it is suggested to keep the intraperitoneal pressure to 8-12mmHg to avoid reduction in uteroplacental blood flow

Pros
Cysts >5cm in size are more likely to persist in pregnancy and are less likely to be corpus luteum
Also the larger the cyst, the higher the risk of torsion
If the cyst is resected this would mean the she avoids the risk of emergency surgery if she was to present acutely with torsion
Some recommend expectant management if 5-10cm and simple cystic appearance
However if nodules, solid appearance, septations etc needs to be resected, with likely oophorectomy if suspicious for malignancy
If the cyst was to enlarge during the pregnancy could predispose to obstructed labour or malpresentation
The only way to exclude malignancy is to resect the cyst and send it for histology

Cons
If the cyst turned out to be a corpus luteum, she would need progeseterone support if it was removed before 10 weeks gestation to prevent a miscarriage from inadequate progesterone
The cyst may have regressed spontaneously so surgery may have been unnecessary, but serial scanning would show if cyst was persistent
She is not able to have full staging surgery and continue with her pregnancy if a malignancy is suspected. An oophorectomy can be performed but she would need further surgery to complete after pregnancy.
Surgery carries a risk of miscarriage, tubal adhesions of the fimbria to the incision of the ovarian capsule
Risk of oophorectomy if excessive bleeding from ovary during surgery
Risk of venous thromboembolism increased with surgery in pregnancy
If cyst is still present at term if mother requires caesarean section the cyst could be removed at that time, otherwise a laparotomy or laparoscopy should be booked postpartum after another ultrasound to ensure that the cyst is still present.


Adnexal masses in pregnancy
~75% are simple cysts <5cm
70% resolve by 2nd trimester
>8cm – more likely to have complications
Torsion most likely in late 1st trimester or early 2nd trimester
Simple and cystic <6cm 🡪 RMI <1 🡪 can observe
Surgery if
Persist into 2nd trimester
Rapidly enlarging
>8cm
Appear malignant
Surgery optimally at 16-20/40 because physiological cysts regressed and pregnancy now independent of corpus luteum
If discovered late in 3rd trimester, can defer evaluation, management and surgical exploration until postpartum


Feedback: Thorough evaluation, counselling, surveillance and finally decision on whether to operate

13

a. With respect to the epidemiology of ovarian cancer in Australia and New Zealand:
i) Of 1000 women, approximately how many will develop ovarian cancer in their life? (1 mark)

1.3-1.5/100
13-15/1000

14

ii) Of these women who develop ovarian cancer, approximately how many will develop cancer because of a genetic predisposition? (1 mark)

10%

15

iii) What is the strongest risk factor for developing ovarian cancer? (1 mark)

BRAC1 or BRCA 2 mutation
BRCA1: 20-60% lifetime risk for ovarian cancer
BRCA2: 10-20% lifetime risk for ovarian cancer

16

iv) Describe two epidemiological factors which are most protective against developing ovarian cancer. (2 marks)

Age: premenopausal women are much less likely to develop ovarian cancer

Parity: parous women are less likely to develop ovarian cancer compared to nulliparous women
25% risk reduction for one child, 20% for subsequent births

20% risk reduction for each year breastfeeding

Use of the COC (is this an epidemiological risk factor?): RR decreased by 30% for each 5 years of use and by 15 years a risk reduction of 50%

https://www.cdc.gov/cancer/knowledge/provider-education/ovarian/risk-factors.htm

17

A 36 year old G3P3 with a strong family history of ovarian and breast cancer consults you for advice regarding her risk of developing ovarian cancer. She has tested positive for the BRCA1 gene mutation.
b. Evaluate the use of regular screening in this woman. (3 marks)

Regular screening to detect ovarian cancer is not recommended for the general population

Large US and UK trials have shown that using Ca125 and USS screening for ovarian cancer result in very high false positive rates with subsequent surgical morbidity (5-15% rate of serious complications in women with false positive histology in UKTORCS study)

No additional survival benefit with screening

A recent study using computer algorithms which stratify Ca125 levels into low, medium and high risk based on their trend and comparison to women with ovarian cancer has shown some promise but needs to be further evaluated and has not been used to stratify BRCA positive women

Imaging: can only see tumour once it's developed and will not see ovarian disease, can only detect late stage disease

Ca125: non-specific as can be raised in benign conditions, and is only raised in some epithelial breast cancers

In women with the BRCA mutation, screening has not been shown to improve rates of detection of ovarian cancer

BRCA positive women who have screened negative with USS and Ca125 levels have been shown to have advanced stage ovarian cancer within 6 months of screening

There is no known optimal screening regimen for these women

Women with BRCA mutations should be advised of the symptoms and signs of ovarian and breast cancer and advised to seek medical advice promptly if they have any concerns

Cervical screening should be carried out as per the national screening guidelines- it does not need to be done more regularly in women with BRCA mutations

Breast cancer screening (mammography) can be started early in these women (usually 10 years before population screening starts, 30 years recommended internationally) but also has a high rate of false-positive testing in younger women and lower sensitivity in BRCA carriers

18

c. Describe two proven risk‐reduction strategies for this woman. State two advantages and two disadvantages for each strategy. (7 marks)

- Bilateral salpingo-oophorectomy:
Description: Staging laparotomy/laparoscopy with inspection of pelvis, diaphragm, peritoneum, liver, uterus, tubes and ovaries
Removal of both fallopian tubes and both ovaries
Advantages: • Reduction of ovarian cancer in BRCA positive women by 80-90%
• Reduction in breast cancer in premenopausal women by 50%
Disadvantages: • Surgical menopause: vulvovaginal atrophy, vasomotor symptoms, sexual dysfunction
• Prevents natural conception if pregnancy desired
• Increased cardiovascular risk and lowered bone density
• Increased all-cause mortality
• Does not reduce the risk of peritoneal primary cancer

Bilateral mastectomy
Description: Removal of the fatty tissue of both breasts, extending into both axillae

Advantages: • Reduction in the risk of breast cancer by 90%
• Options can include skin-sparing mastectomy with preservation of the nipple-alveolar complex with immediate breast reconstruction
Disadvantages: • No reduction of risk to ovarian cancer
• Major surgery with possibility for surgical complications eg haematoma, infection
• Cosmetic concerns


Chemoprophylaxis
Description: Use of the combined oral contraceptive pill in women who are BRCA carriers and of reproductive age
Advantages: • Reduction in the risk of ovarian cancer RR 0.5
• No adverse impact on future fertility
Disadvantages: • Uncertainty with regards to increased risk of breast cancer from the progesterone component using the COC
• Requires daily use, can be easily forgotten by some women
• Increased risk VTE/stroke
• Can't use in women with other comorbidities eg focal migraines

19

A 55 year old woman wishes to discuss her concerns after a relative of hers is diagnosed with ovarian cancer. She has no other significant history.

a. Outline your approach in identifying her risk and advising whether she should be tested for familial ovarian cancer

Further family history:
Degree of relation to affected individual
Any other family members with ovarian cancer or other cancers such as breast, colorectal, uterine, stomach, pancreatic, kidney
Draw pedigree for family tree on both sides
Known familial cancer syndrome? BRCA 1, BRCA 2, HNPCC?
Ashkenazi Jewish ancestry?

Own personal risk:
Age of menarche/menopause
Parity
Breastfeeding
COCP use

Advice:
Background risk is 1%
1 1st deg rel is 5%
2 first deg rel 10%

High risk groups identified after history taking should be referred to a geneticist for discussion of individual risk and to consider testing for BRCA 1/2 and/or HNPCC as appropriate. May also recommend risk reduction strategies.
These high risk groups include:
3 or more relatives on 1 side of family with breast/ov ca
3 or more relatives on 1 side of the family with ov/bowel/uterine ca
Ashkenazi Jewish ancestry
Known BRCA 1 or 2, or HNPCC
2 or more relatives on 1 side of family affected, and 1 or more of the following:
Bilateral breast cancer
Breast and ovarian ca in 1 woman
Breast cancer in a male
Breast cancer in a woman under age 45

20

A 55 year old woman wishes to discuss her concerns after a relative of hers is diagnosed with ovarian cancer. She has no other significant history.

What symptoms would you advise her to look out for?

Abdominal pain
Abdominal distension/bloating
New bladder/bowel changes
Unintentional weight loss
Early satiety

21

After assessing her risk you examine her and palpate a 7cm left adnexal mass. Evaluate the advantages and disadvantages or each of the investigations that are available for her pre-op workup

Ca 125: +: Cheap and simple, Can be used to calculate RMI. -: Not always +ve in early EOC, False +ves – endo, fibroids, PID


CEA/ CA199: +: Assess possibility of mucinous Ca, bowel Ca, pancreatic Ca. -: Non-specific to ovary


Pelvic USS: +: Features relevant to RMI score
Readily available and cheap -:Not as useful for assessing peritoneal/abdominal disease, Operator dependent


CT abdo/pelvis: +:Best for peritoneal/solid organ/LN mets, ‘stage’ pre-op -:Radiation exposure


MRI pelvis: +: More detailed images of soft tissues to further characterize nature of lesion
-: Expensive and not always readily available. Unlikely to change management


Tissue biopsy: +:Can assist to tailor Rx e.g. chemotherapy. -:Potential to seed tumour/upstage

22

a. What is the lifetime incidence of ovarian cancer? (1 mark)

Lifetime risk of developing ovarian cancer is 1 - 1.5%
Peak incidence is 56-60 years (borderline tumours 46 years)
Approx 30% of ovarian neoplasms in postmenopausal women are malignant vs only 7% in premenopausal women

23

b. Describe features of Stage 3 epithelial ovarian cancer. (5 marks)

FIGO Staging
Stage 1 (confined to ovaries)
• 1a - one ovary, negative cytology
• 1b - both ovaries, negative cytology
• 1c - stage 1a / 1b with surface tumour, capsular rupture, and/or positive cytology

Stage 2 (involving one or both ovaries with pelvic extension)
• 2a - extension to uterus / fallopian tubes, negative cytology
• 2b - extension to other pelvic tissues, negative cytology
• 2c - stage 2a / 2b with surface tumour or capsule rupture and/or positive cytology

Stage 3 (tumour involving one or both ovaries with peritoneal implants outside the pelvis and/or nodes)
• 3a
o tumour limited to true pelvis
o microscopic seeding of abdominal/peritoneal surfaces
o negative nodes
• 3b
o tumour to one or both ovaries
o histologically confirmed implants of abdominal peritoneal surfaces <2cm
o negative nodes
• 3c
o tumour to one or both ovaries
o histologically confirmed implants of abdominal peritoneal surfaces >2cm AND/OR
o Positive retroperitoneal or inguinal LN

Stage 4 (tumour involving one or both ovaries with distant metastasis)
• +ve pleural effusion
• +ve liver parenchymal metastasis

24

. List the major histological types of primary epithelial ovarian cancer. (3 marks)

Ovarian Cancer
• Epithelial ~90%
o Serous
o Mucinous
o Endometrioid
o Clear cell
o Transitional cell (Brenner)
o Mixed
o Small cell
o Primary peritoneal
• Non Epithelial ~10%
o Stromal tumours
 Granulose cell
 Thecoma
 Fibroma
 Sertoli
 Sertoli-Leydig
 Steroid
o Germ Cell tumours
 Dysgerminoma
 Yolk sac tumour
 Embryonal Cariconma
 Choriocarcinomal
 Teratoma

25

d. What is the primary management of Stage 3 epithelial ovarian cancer in a 55 year old woman who is otherwise well? (6 marks)

Treatment Options
• Primary surgical cytoreduction followed by systemic chemotherapy is the preferred initial management for women with stage 3 or 4 EOC
• Patients who are not good candidates for surgery at time of diagnosis can be considered for a regime of primary chemotherapy with the view for interval debulking surgery (3 cycles - cytoreduction - 3 cycles)
o Location and volume of disease involvement preventing optimal cytoreduction (liver or pulmonary mets, disease in porta hepatis, massive ascites)
o Medical comorbidities precluding surgery

Aims of Surgery
• Obtain histological confirmation of diagnosis
• Assess the extent of disease and assign surgical staging
• Attempt optimal cytoreduction of all tumour bulk with residual deposits <1cm

Pre operative Work up
• Tumour markers
• Pelvic USS
• Staging CT (chest / abdo / pelvis) or CT (abdo/pelvis) + CXR
• Cytology or image guided biopsy
• Pre operative medical optimisation
• Anaesthetic review
• Nutritional assessment
• Antimicrobial and venous thromboprophylaxis considerations
• Bowel prep may be indicated if likely need to resect bowel as part of cytoreduction
• Patient counseling regarding aims of surgery and likely outcomes

Surgical Technique
• Midline Laparotomy
• Free fluid sent for cytology - if no free fluid then washings taken
• Removal of primary tumour mass
• TAH + BSO
• Infracolic omentectomy
• Systemic exploration of all intra, abdominal, pelvic, visceral surfaces
o Removal of any suspicious lesions
o Systematic biopsy to sample POD / Paracolic gutters / uterovesical pouch / intestinal mesenteries / diaphragmatic surface if no obvious disease
• Exploration of the retroperitoneal space and evaluation of pelvic and paraaortic lymph nodes
• Cytoreduction
o Aim to optimally cytoreduce any tumour bulk so that residual tumour burden is <1cm
o Should include
 Peritonectomy of all involved peritoneal surfaces
 Consideration of resection of other organs to achieve optimal cytoreduction
­ Diaphragmatic deposits
­ Liver deposits
­ Spleen
­ Bladder
­ Bowel
NB: These extensive resections only indicated if they will allow optimal cytoreduction to be achieved as carry significant added surgical morbidity and mortality AND to relieve symptomatic obstructions.

Post operative Chemotherapy
• Systemic combination therapy for Carboplatin and Paclitaxel is treatment of choice
o Given every 3 weeks for 6-8 cycles
• Routinely given as IV but IP administration is possible
o IP may confer increased benefit but higher discontinuation rates, catheter related complications , and higher morbidity than IV therapy

NOTE:
Neoadjuvant Chemotherapy
• Considered in patients with stage 3 and 4 disease that have
o Significant medical co morbidities (including large volume ascites)
o Tumour bulk and volume that would preclude optimal debulking
• Involves primary chemotherapy for 3 cycles with interval cytoreductive surgery, followed by further chemotherapy for 3 cycles
• Associated with
o Identical progression free survival
o Significantly reduced morbidity associated with surgery
o Greater likelihood of achieving optimal cytoreduction