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Surgery in Early-Stage Ovarian Cancer

Panelists: Bradley J. Monk, MD, FACS, FACOG, Arizona Oncology Practice of US Oncology; Oliver Dorigo, MD, PhD, Stanford University Medical Center; Thomas Herzog, MD, University of Cincinnati Cancer Institute; Kathleen Moore, MD, Stephenson Cancer Center; Leslie M. Randall, MD, MAS, University of California, Irvine
Published: Thursday, Jul 26, 2018



Transcript: 

Bradley J. Monk, MD, FACS, FACOG: Hello, and thank you for joining this OncLive® Peer Exchange®, titled “Therapeutic Strategies in Advanced Ovarian Cancer.” Despite recent progress in developing novel therapies for advanced malignancies, particularly ovarian, fallopian tube, and peritoneal cancer, which we’ll collectively call ovarian cancer, this is a heterogeneous group of diseases. Unfortunately, most of our patients recur and die. A continued understanding of the underlying biology of these clinically challenging diseases will facilitate the development of personalized approaches to surgery and systemic therapy. In addition, we are challenged to delay recurrence—not only delaying recurrence but improving outcomes, improving survivorship, and optimizing the use of agents that we have available in the clinic today. In this OncLive® Peer Exchange®, my colleagues and I will discuss the latest research and the results of those research findings surrounding systemic therapy and the surgical management for what we collectively call ovarian cancer and will discuss how those implications can be used in the clinic on a daily basis.

I’m Brad Monk. I’m a professor of gynecologic oncology at the University of Arizona College of Medicine in Phoenix, as well as at the Creighton University School of Medicine, also in Phoenix. I’m also a member of Arizona Oncology, which is part of the US Oncology Network, and I chair gynecologic oncology research within the US Oncology Network. Participating today are my distinguished friends. No. 1, Dr Oliver Dorigo. Dr Dorigo is the director of the division of gynecologic oncology and director of clinical research at Stanford University Medical Center. Oliver, thank you for being here.

Oliver Dorigo, MD, PhD: My pleasure, Brad.

Bradley J. Monk, MD, FACS, FACOG: Thank you. And then, to my right, Dr Thomas Herzog, the Paul & Carolyn Flory endowed professor of obstetrics and gynecology at the University of Cincinnati College of Medicine and deputy director of the Cancer Institute in Cincinnati, Ohio. Thank you, Tom.

Thomas Herzog, MD: Thanks for having me, Brad.

Bradley J. Monk, MD, FACS, FACOG: My pleasure. And Dr Katie Moore, the Jim and Christy Everest endowed chair in cancer research, the associate director of clinical research and the director of the Oklahoma TSET Phase I Program at the Stephenson Cancer Center at the University of Oklahoma Health Sciences Center, in Oklahoma City. Katie, thank you.

Kathleen Moore, MD: Thank you for having me.

Bradley J. Monk, MD, FACS, FACOG: And last but not least, Dr Leslie Randall, an associate professor of obstetrics and gynecology and the director of medical education and the gynecologic oncology Fellowship at the University of California, Irvine. Thank you, Leslie.

Leslie M. Randall, MD, MAS: Thanks for having me.

Bradley J. Monk, MD, FACS, FACOG: Thank you for joining us today. Let’s get right into it. Let’s begin with early-stage ovarian cancer. Oliver, let’s begin with you. How do you approach the treatment of early-stage epithelial ovarian cancer?

Oliver Dorigo, MD, PhD: Thank you, Brad. I think this is a very important group of patients that, as we know, have a disease with a biology that is very different from later-stage diseases. We see more clear cell carcinomas, endometrioid cancers. As we know, those cancers, in general, have a better prognosis. Nevertheless, I think it’s very important to start the treatment with complete surgical staging. I personally might start with a laparoscopy, to evaluate the pelvic and peritoneal cavity. I think it’s important to remove both the fallopian tubes and ovaries, do a hysterectomy, do a lymphadenectomy in the pelvis around the aorta, and do an omentectomy. So I think we need to do standard staging, as we are accustomed to in ovarian cancer.

Bradley J. Monk, MD, FACS, FACOG: Leslie, he says both ovaries have to be removed. What happens if the woman wants to have more children? Is fertility-sparing, meaning preservation of an ovary, a tube, or of the uterus, possible?

Leslie M. Randall, MD, MAS: I think it’s possible. It’s just for select patients. One tumor type that we didn’t talk about is our germ cell tumors, or our sex cord-stromal tumors, in addition to those other disease biologies. I think if you have the lower-grade tumors, early-stage tumors that require a full surgical staging procedure to decide that, those patients might be eligible for a fertility-sparing operation.

Bradley J. Monk, MD, FACS, FACOG: Katie, are borderline tumors cancer? Is everything that they just said related to a borderline tumor, or is a borderline tumor basically more of a benign disease?

Kathleen Moore, MD: Borderline tumors exist in a continuum between benign disease and malignancy. We don’t consider them malignancy. They’re not invasive. They do require follow up. They can sometimes be confusing at the time of initial surgery. Depending on the specimen and your pathologists, they may not recognize whether or not it’s a borderline or invasive cancer. And so, you sometimes have to make decisions about staging a patient in the operating room. This is where fertility preservation conversations, preoperatively, are critical. If the patient is someone who wants to maintain fertility and meets other criteria, it’s not someone in whom you want to remove the tubes and ovaries in the uterus until you absolutely know what their pathology is. If it’s a borderline tumor, they don’t require any additional treatment, in terms of chemotherapy, but they do need to be followed over time because there is a low but present risk for recurrence. The risk for recurrence is tied to the completeness of the surgery.

Bradley J. Monk, MD, FACS, FACOG: Right.

Transcript Edited for Clarity 

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Transcript: 

Bradley J. Monk, MD, FACS, FACOG: Hello, and thank you for joining this OncLive® Peer Exchange®, titled “Therapeutic Strategies in Advanced Ovarian Cancer.” Despite recent progress in developing novel therapies for advanced malignancies, particularly ovarian, fallopian tube, and peritoneal cancer, which we’ll collectively call ovarian cancer, this is a heterogeneous group of diseases. Unfortunately, most of our patients recur and die. A continued understanding of the underlying biology of these clinically challenging diseases will facilitate the development of personalized approaches to surgery and systemic therapy. In addition, we are challenged to delay recurrence—not only delaying recurrence but improving outcomes, improving survivorship, and optimizing the use of agents that we have available in the clinic today. In this OncLive® Peer Exchange®, my colleagues and I will discuss the latest research and the results of those research findings surrounding systemic therapy and the surgical management for what we collectively call ovarian cancer and will discuss how those implications can be used in the clinic on a daily basis.

I’m Brad Monk. I’m a professor of gynecologic oncology at the University of Arizona College of Medicine in Phoenix, as well as at the Creighton University School of Medicine, also in Phoenix. I’m also a member of Arizona Oncology, which is part of the US Oncology Network, and I chair gynecologic oncology research within the US Oncology Network. Participating today are my distinguished friends. No. 1, Dr Oliver Dorigo. Dr Dorigo is the director of the division of gynecologic oncology and director of clinical research at Stanford University Medical Center. Oliver, thank you for being here.

Oliver Dorigo, MD, PhD: My pleasure, Brad.

Bradley J. Monk, MD, FACS, FACOG: Thank you. And then, to my right, Dr Thomas Herzog, the Paul & Carolyn Flory endowed professor of obstetrics and gynecology at the University of Cincinnati College of Medicine and deputy director of the Cancer Institute in Cincinnati, Ohio. Thank you, Tom.

Thomas Herzog, MD: Thanks for having me, Brad.

Bradley J. Monk, MD, FACS, FACOG: My pleasure. And Dr Katie Moore, the Jim and Christy Everest endowed chair in cancer research, the associate director of clinical research and the director of the Oklahoma TSET Phase I Program at the Stephenson Cancer Center at the University of Oklahoma Health Sciences Center, in Oklahoma City. Katie, thank you.

Kathleen Moore, MD: Thank you for having me.

Bradley J. Monk, MD, FACS, FACOG: And last but not least, Dr Leslie Randall, an associate professor of obstetrics and gynecology and the director of medical education and the gynecologic oncology Fellowship at the University of California, Irvine. Thank you, Leslie.

Leslie M. Randall, MD, MAS: Thanks for having me.

Bradley J. Monk, MD, FACS, FACOG: Thank you for joining us today. Let’s get right into it. Let’s begin with early-stage ovarian cancer. Oliver, let’s begin with you. How do you approach the treatment of early-stage epithelial ovarian cancer?

Oliver Dorigo, MD, PhD: Thank you, Brad. I think this is a very important group of patients that, as we know, have a disease with a biology that is very different from later-stage diseases. We see more clear cell carcinomas, endometrioid cancers. As we know, those cancers, in general, have a better prognosis. Nevertheless, I think it’s very important to start the treatment with complete surgical staging. I personally might start with a laparoscopy, to evaluate the pelvic and peritoneal cavity. I think it’s important to remove both the fallopian tubes and ovaries, do a hysterectomy, do a lymphadenectomy in the pelvis around the aorta, and do an omentectomy. So I think we need to do standard staging, as we are accustomed to in ovarian cancer.

Bradley J. Monk, MD, FACS, FACOG: Leslie, he says both ovaries have to be removed. What happens if the woman wants to have more children? Is fertility-sparing, meaning preservation of an ovary, a tube, or of the uterus, possible?

Leslie M. Randall, MD, MAS: I think it’s possible. It’s just for select patients. One tumor type that we didn’t talk about is our germ cell tumors, or our sex cord-stromal tumors, in addition to those other disease biologies. I think if you have the lower-grade tumors, early-stage tumors that require a full surgical staging procedure to decide that, those patients might be eligible for a fertility-sparing operation.

Bradley J. Monk, MD, FACS, FACOG: Katie, are borderline tumors cancer? Is everything that they just said related to a borderline tumor, or is a borderline tumor basically more of a benign disease?

Kathleen Moore, MD: Borderline tumors exist in a continuum between benign disease and malignancy. We don’t consider them malignancy. They’re not invasive. They do require follow up. They can sometimes be confusing at the time of initial surgery. Depending on the specimen and your pathologists, they may not recognize whether or not it’s a borderline or invasive cancer. And so, you sometimes have to make decisions about staging a patient in the operating room. This is where fertility preservation conversations, preoperatively, are critical. If the patient is someone who wants to maintain fertility and meets other criteria, it’s not someone in whom you want to remove the tubes and ovaries in the uterus until you absolutely know what their pathology is. If it’s a borderline tumor, they don’t require any additional treatment, in terms of chemotherapy, but they do need to be followed over time because there is a low but present risk for recurrence. The risk for recurrence is tied to the completeness of the surgery.

Bradley J. Monk, MD, FACS, FACOG: Right.

Transcript Edited for Clarity 
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