Ovarian Cancer III

Ovarian Cancer IIIOvarian Cancer III

The PatientThe Patient

病歷號碼：病歷號碼： 00048421340004842134姓名：張林素真姓名：張林素真身分證號：身分證號： G201044041G201044041床號：床號： 5360353603出生日期：出生日期： 043/01/02043/01/02性別：女性別：女入院日期：入院日期： 094/05/06094/05/06年齡：年齡： 5151

Chief ComplaintChief Complaint

Fullness of abdomen sensationFullness of abdomen sensation

History or Present IllnessHistory or Present Illness

Noted abdominal distention for about one Noted abdominal distention for about one month. month. She also noted frequency of urinationShe also noted frequency of urinationAssuming that the feeling of fullness of abAssuming that the feeling of fullness of abdomen was due to IUD (since 1997), she vdomen was due to IUD (since 1997), she visited Dr. Chang's OPD and requested reisited Dr. Chang's OPD and requested removal of the IUDmoval of the IUDShe underwent an abdominal ultrasound wShe underwent an abdominal ultrasound which revealed hich revealed bilateral ovarian tumor and abilateral ovarian tumor and ascitesscites

UltrasoundUltrasound

Continued HPIContinued HPI

CT scan and was arranged to evaluate thCT scan and was arranged to evaluate the extent of the disease.e extent of the disease. CT, done on 5/4, showed a CT, done on 5/4, showed a 6.7x3.4 cm solid mass over right adnexa6.7x3.4 cm solid mass over right adnexa4cm soft tissue shadow over left adnexa4cm soft tissue shadow over left adnexaMassive ascitesMassive ascitesPeritoneal seedingPeritoneal seeding2 cm liver tumor2 cm liver tumor

CTCT

Continued HPIContinued HPI

Tumor markers were also determined.Tumor markers were also determined.

Serum CA125 = 2288 U/ml Serum CA125 = 2288 U/ml

Serum CEA = 0.5 ng/ml Serum CEA = 0.5 ng/ml

Diagnosis: Ovarian malignancyDiagnosis: Ovarian malignancy

She was advised surgery. Patient consentShe was advised surgery. Patient consented. ed.

Therefore, she was admitted for further maTherefore, she was admitted for further management.nagement.

Past HistoryPast History

1.Asthma for 10+ years1.Asthma for 10+ years

2.Cigarette smoking: Nil; Alcoholic 2.Cigarette smoking: Nil; Alcoholic

drinking: Nildrinking: Nil

3.Previous op. history: Nil3.Previous op. history: Nil

4.allergy: nil4.allergy: nil

Gynecology HistoryGynecology History

G3P3, menopause at 48 y/oG3P3, menopause at 48 y/o

IUD was inserted in 1997 and removed IUD was inserted in 1997 and removed on 2005/5/on 2005/5/

Physical ExamPhysical Exam

Vital sign: stableVital sign: stableHEENT: pink conjunctiva, anicteric sclera, no lyHEENT: pink conjunctiva, anicteric sclera, no lymphadenopathymphadenopathyChest: clear breath soundsChest: clear breath soundsHeart:RHBHeart:RHBAbd: soft, distended, AC 85 cmAbd: soft, distended, AC 85 cm normoactive bowel soundnormoactive bowel sound shifting dullness: (+)shifting dullness: (+) (+) direct tenderness(+) direct tendernessExtremities: no pitting edemaExtremities: no pitting edema

Pelvic ExamPelvic Exam

Uterus non-palpableUterus non-palpable

Bilateral adnexa palpable , enlarged, solidBilateral adnexa palpable , enlarged, solid

Vaginal discharge minimalVaginal discharge minimal

Cervix (-) erosionsCervix (-) erosions

LaboratoryLaboratory

94-05-0694-05-06Hb12.6 Ht38.6 RBC4.20 WBC6.57 NeHb12.6 Ht38.6 RBC4.20 WBC6.57 Neut. Seg53.9 Lympho S.32.9 Mono.10.8 Eut. Seg53.9 Lympho S.32.9 Mono.10.8 Eos.2.1 Baso.0.3 MCV91.9 MCH30.0 Mos.2.1 Baso.0.3 MCV91.9 MCH30.0 MCHC32.6 PLT.283 PT.11.8 PT. control11.CHC32.6 PLT.283 PT.11.8 PT. control11.4 INR1.08 P.T.T.26.8 P.T.T. control30.6 4 INR1.08 P.T.T.26.8 P.T.T. control30.6 94-05-0694-05-06Na140meq/L Na140meq/L K2.9meq/L(L) Ca8.1mg/dl(L)K2.9meq/L(L) Ca8.1mg/dl(L) Cl107meq/L Cl107meq/L Glu.149mg/dl(H)Glu.149mg/dl(H) B.U.N14mg/ B.U.N14mg/dl G.O.T.24I.U./L G.P.T.17I.U./L Cr.1.1mdl G.O.T.24I.U./L G.P.T.17I.U./L Cr.1.1mg/dl g/dl

Course in the WardCourse in the Ward

94.5.6: She was admitted and prepared for 94.5.6: She was admitted and prepared for surgerysurgery

94.5.7: Underwent surgery: laparotomy94.5.7: Underwent surgery: laparotomy

OP FindingsOP FindingsBilateral ovarian tumor with papillary Bilateral ovarian tumor with papillary lesionslesions(+) tumor seeding on the rectum, uterus (+) tumor seeding on the rectum, uterus and bilateral infundibulopelvic ligamentand bilateral infundibulopelvic ligamentAscites of 1300 cc (20 cc sent for cytology Ascites of 1300 cc (20 cc sent for cytology exam)exam)(+) Omental cake(+) Omental cake(+) Tumor on omentum invade the (+) Tumor on omentum invade the superficial lining of the transverse colonsuperficial lining of the transverse colonEstimated blood loss 300 ccEstimated blood loss 300 cc

Surgical procedureSurgical procedure

Optimal Debulking Surgery:Optimal Debulking Surgery:

ATH + BSOATH + BSO

OmentectomyOmentectomy

Bilateral Pelvic Lymph Node DissectionBilateral Pelvic Lymph Node Dissection

Final DiagnosisFinal Diagnosis

Ovarian Cancer IIIcOvarian Cancer IIIc

REVIEWREVIEW

Ovarian Cancer StagingOvarian Cancer StagingStage IStage I - Growth of tumor limited to the ovaries - Growth of tumor limited to the ovaries Stage IIStage II - Growth of tumor in one or both ovaries - Growth of tumor in one or both ovaries Stage IIIStage III - Tumor involving one or both ovaries with - Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal lymph nodes. Superficial liver retroperitoneal or inguinal lymph nodes. Superficial liver metastasis equals stage III. metastasis equals stage III. Stage IVStage IV - Growth involving one or both ovaries with - Growth involving one or both ovaries with distant metastases. If pleural effusion is present there distant metastases. If pleural effusion is present there must be positive cytology to allot a case to stage IV. must be positive cytology to allot a case to stage IV. Tumor spread inside the liver, equals stage IV. Tumor spread inside the liver, equals stage IV. Recurrent/RefractoryRecurrent/Refractory - Recurrence means that the - Recurrence means that the tumor has returned after initial therapy. Refractory tumor has returned after initial therapy. Refractory means that the tumor fails to respond to initial treatment.means that the tumor fails to respond to initial treatment.

Ovarian Cancer StagingOvarian Cancer Staging

Stage IIIStage III Tumor involving one or both ovaries with peritoneal implant Tumor involving one or both ovaries with peritoneal implants outside the pelvis and/or positive retroperitoneal or inguinal nodes. s outside the pelvis and/or positive retroperitoneal or inguinal nodes. Superficial liver metastasis equals Stage III. Tumor is limited to the Superficial liver metastasis equals Stage III. Tumor is limited to the true pelvis but with histologically proven malignant extension to smaltrue pelvis but with histologically proven malignant extension to small bowel or omentrum.l bowel or omentrum.

IIIAIIIA Tumor grossly limited to the true pelvis with negative node Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abds but with histologically confirmed microscopic seeding of abdominal peritoneal surfacesominal peritoneal surfaces

IIIBIIIB Tumor of one or both ovaries with histologically confirmed Tumor of one or both ovaries with histologically confirmed implants of abdominal peritoneal surfaces, none exceeding 2 cimplants of abdominal peritoneal surfaces, none exceeding 2 cm in diameter; nodes are negativem in diameter; nodes are negative

IIIC IIIC Abdominal implants greater than 2 cm in diameter and/or p Abdominal implants greater than 2 cm in diameter and/or positive retroperitoneal or inguinal nodes.ositive retroperitoneal or inguinal nodes.

Treatment of Stage IIITreatment of Stage III

SurgerySurgery has been used as a has been used as a therapeutictherapeutic modalitmodality and also to adequately y and also to adequately stage the disease.stage the disease. Surgery should include Surgery should include total abdominal hysterectotal abdominal hysterectomy and bilateral salpingo-oophorectomy with otomy and bilateral salpingo-oophorectomy with omentectomy and debulkingmentectomy and debulking of as much gross tu of as much gross tumor as can safely be performed. mor as can safely be performed. The The volume of disease leftvolume of disease left at the completion of t at the completion of the primary surgical procedure is related to he primary surgical procedure is related to patiepatient survivalnt survival

Optimal vs. Suboptimal CytoreductiOptimal vs. Suboptimal Cytoreductionon

A literature review showed that patients with A literature review showed that patients with optioptimal cytoreduction had median survival of 39 momal cytoreduction had median survival of 39 monthsnths compared with survival of only compared with survival of only 17 months in 17 months in patients with suboptimal residual diseasepatients with suboptimal residual disease

Hoskins WJ: Surgical staging and cytoreductive Hoskins WJ: Surgical staging and cytoreductive surgery of epithelial ovarian cancer. surgery of epithelial ovarian cancer. CancerCancer 71 71 (4 Suppl): 1534-40, 1993. (4 Suppl): 1534-40, 1993.

INTRAPERITONEAL REGIMENS INTRAPERITONEAL REGIMENS The use of The use of IP cisplatinIP cisplatin as part of the initial up-front a as part of the initial up-front approach in stage III optimally-debulked ovarian cancpproach in stage III optimally-debulked ovarian cancer is supported by the results of 3 randomized clinicer is supported by the results of 3 randomized clinical trials. al trials.

In all 3 studies In all 3 studies superior progression-free survivalsuperior progression-free survival wa was documented favoring IP, and in the 2 fully reported s documented favoring IP, and in the 2 fully reported to date, the to date, the overall survival was also significantly betoverall survival was also significantly betterter in the IP. in the IP.

Alberts DS, Markman M, Armstrong D, et al.: IntraperAlberts DS, Markman M, Armstrong D, et al.: Intraperitoneal therapy for stage III ovarian cancer: a therapy itoneal therapy for stage III ovarian cancer: a therapy whose time has come! whose time has come! J Clin OncolJ Clin Oncol 20 (19): 3944-6, 2 20 (19): 3944-6, 2002 002

IP therapy has not been routinely adopted, in part beIP therapy has not been routinely adopted, in part because of issues relating to cause of issues relating to greater toxicity and incongreater toxicity and inconvenience venience

IP ChemotherapyIP Chemotherapy

This study has demonstrated the feasibility, modThis study has demonstrated the feasibility, moderate toxicity and efficacy of first-line intraperitonerate toxicity and efficacy of first-line intraperitoneal eal paclitaxel-cisplatin chemotherapy.paclitaxel-cisplatin chemotherapy.

Zylberberg B, Dormont D, Madelenat P, Darai E.Zylberberg B, Dormont D, Madelenat P, Darai E.First-line intraperitoneal cisplatin-paclitaxel and iFirst-line intraperitoneal cisplatin-paclitaxel and intravenous ifosfamide in Stage IIIc ovarian epithntravenous ifosfamide in Stage IIIc ovarian epithelial cancer. elial cancer. Eur J Gynaecol OncolEur J Gynaecol Oncol. 2004;25(3):3. 2004;25(3):327-3227-32. .

CHEMOTHERAPY CHEMOTHERAPY

First-line chemotherapy has been built on 2 First-line chemotherapy has been built on 2 premises supported by retrospective analyses premises supported by retrospective analyses and consecutive clinical trials by cooperative and consecutive clinical trials by cooperative groups: groups:

1. 1. PLATINUMPLATINUM COMPOUNDS, UP TO AN COMPOUNDS, UP TO AN “OPTIMAL DOSE-INTENSITY,” REPRESENT “OPTIMAL DOSE-INTENSITY,” REPRESENT THE CORE OF THE TREATMENT (E.G., THE CORE OF THE TREATMENT (E.G., PLATINUM-BASED CHEMOTHERAPY). PLATINUM-BASED CHEMOTHERAPY).

2. 2. CISPLATIN AND CARBOPLATINCISPLATIN AND CARBOPLATIN YIELD YIELD EQUIVALENT RESULTS EQUIVALENT RESULTS

RadiotherapyRadiotherapy

Consolidation with radiation therapy did Consolidation with radiation therapy did not yield not yield improved resultsimproved results in randomized trials following pl in randomized trials following platinum-based chemotherapy.atinum-based chemotherapy.

Fuks Z, Rizel S, Biran S: Chemotherapeutic and Fuks Z, Rizel S, Biran S: Chemotherapeutic and surgical induction of pathological complete remissurgical induction of pathological complete remission and whole abdominal irradiation for consolidsion and whole abdominal irradiation for consolidation does not enhance the cure of stage III ovaration does not enhance the cure of stage III ovarian carcinoma. ian carcinoma. J Clin OncolJ Clin Oncol 6 (3): 509-16, 1988 6 (3): 509-16, 1988