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Ovarian Cancer III Ovarian Cancer III

Ovarian Cancer III

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Ovarian Cancer III. The Patient. 病歷號碼: 0004842134 姓名:張林素真 身分證號: G201044041 床號: 53603 出生日期: 043/01/02 性別:女 入院日期: 094/05/06 年齡: 51. Chief Complaint. Fullness of abdomen sensation. History or Present Illness. Noted abdominal distention for about one month. - PowerPoint PPT Presentation

Text of Ovarian Cancer III

  • Ovarian Cancer III

  • The Patient0004842134G20104404153603043/01/02094/05/0651

  • Chief ComplaintFullness of abdomen sensation

  • History or Present IllnessNoted abdominal distention for about one month. She also noted frequency of urinationAssuming that the feeling of fullness of abdomen was due to IUD (since 1997), she visited Dr. Chang's OPD and requested removal of the IUDShe underwent an abdominal ultrasound which revealed bilateral ovarian tumor and ascites

  • Ultrasound

  • Continued HPI CT scan and was arranged to evaluate the extent of the disease. CT, done on 5/4, showed a 6.7x3.4 cm solid mass over right adnexa4cm soft tissue shadow over left adnexaMassive ascitesPeritoneal seeding2 cm liver tumor

  • CT

  • Continued HPITumor markers were also determined.Serum CA125 = 2288 U/ml Serum CEA = 0.5 ng/ml Diagnosis: Ovarian malignancyShe was advised surgery. Patient consented. Therefore, she was admitted for further management.

  • Past History1.Asthma for 10+ years2.Cigarette smoking: Nil; Alcoholic drinking: Nil3.Previous op. history: Nil4.allergy: nil

  • Gynecology History G3P3, menopause at 48 y/o IUD was inserted in 1997 and removed on 2005/5/

  • Physical ExamVital sign: stableHEENT: pink conjunctiva, anicteric sclera, no lymphadenopathyChest: clear breath soundsHeart:RHBAbd: soft, distended, AC 85 cm normoactive bowel sound shifting dullness: (+) (+) direct tendernessExtremities: no pitting edema

  • Pelvic ExamUterus non-palpableBilateral adnexa palpable , enlarged, solidVaginal discharge minimalCervix (-) erosions

  • Laboratory94-05-06Hb12.6 Ht38.6 RBC4.20 WBC6.57 Neut. Seg53.9 Lympho S.32.9 Mono.10.8 Eos.2.1 Baso.0.3 MCV91.9 MCH30.0 MCHC32.6 PLT.283 PT.11.8 PT. control11.4 INR1.08 P.T.T.26.8 P.T.T. control30.6 94-05-06Na140meq/L K2.9meq/L(L) Ca8.1mg/dl(L) Cl107meq/L Glu.149mg/dl(H) B.U.N14mg/dl G.O.T.24I.U./L G.P.T.17I.U./L Cr.1.1mg/dl

  • Course in the Ward94.5.6: She was admitted and prepared for surgery94.5.7: Underwent surgery: laparotomy

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

  • Surgical procedureOptimal Debulking Surgery:ATH + BSOOmentectomyBilateral Pelvic Lymph Node Dissection

  • Final DiagnosisOvarian Cancer IIIc

  • REVIEW

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

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

    IIIA Tumor grossly limited to the true pelvis with negative nodes but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces

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

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

  • Treatment of Stage IIISurgery has been used as a therapeutic modality and also to adequately stage the disease. Surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy with omentectomy and debulking of as much gross tumor as can safely be performed. The volume of disease left at the completion of the primary surgical procedure is related to patient survival

  • Optimal vs. Suboptimal CytoreductionA literature review showed that patients with optimal cytoreduction had median survival of 39 months compared with survival of only 17 months in patients with suboptimal residual disease

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

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

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

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

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

  • IP ChemotherapyThis study has demonstrated the feasibility, moderate toxicity and efficacy of first-line intraperitoneal paclitaxel-cisplatin chemotherapy. Zylberberg B, Dormont D, Madelenat P, Darai E. First-line intraperitoneal cisplatin-paclitaxel and intravenous ifosfamide in Stage IIIc ovarian epithelial cancer. Eur J Gynaecol Oncol. 2004;25(3):327-32.

  • CHEMOTHERAPY First-line chemotherapy has been built on 2 premises supported by retrospective analyses and consecutive clinical trials by cooperative groups: 1. PLATINUM COMPOUNDS, UP TO AN OPTIMAL DOSE-INTENSITY, REPRESENT THE CORE OF THE TREATMENT (E.G., PLATINUM-BASED CHEMOTHERAPY).

    2. CISPLATIN AND CARBOPLATIN YIELD EQUIVALENT RESULTS

  • RadiotherapyConsolidation with radiation therapy did not yield improved results in randomized trials following platinum-based chemotherapy.

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