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.
She also noted frequency of urination
Assuming that the feeling of fullness of
abdomen was due to IUD (since 1997),
she visited Dr. Chang's OPD and
requested removal of the IUD
She 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 adnexa
4cm soft tissue shadow over left adnexa
Massive ascites
Peritoneal seeding
2 cm liver tumor
CT
Continued HPI
Tumor markers were also determined.
Serum CA125 = 2288 U/ml
Serum CEA = 0.5 ng/ml
Diagnosis: Ovarian malignancy
She was advised surgery. Patient
consented.
Therefore, she was admitted for further
management.
Past History
1.Asthma for 10+ years
2.Cigarette smoking: Nil; Alcoholic
drinking: Nil
3.Previous op. history: Nil
4.allergy: nil
Gynecology History
G3P3, menopause at 48 y/o
IUD was inserted in 1997 and removed
on 2005/5/
Physical Exam
Vital sign: stable
HEENT: pink conjunctiva, anicteric sclera, no
lymphadenopathy
Chest: clear breath sounds
Heart:RHB
Abd: soft, distended, AC 85 cm
normoactive bowel sound
shifting dullness: (+)
(+) direct tenderness
Extremities: no pitting edema
Pelvic Exam
Uterus non-palpable
Bilateral adnexa palpable , enlarged, solid
Vaginal discharge minimal
Cervix (-) erosions
Laboratory
94-05-06
Hb12.6 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
94-05-06
Na140meq/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 Ward
94.5.6: She was admitted and prepared for
surgery
94.5.7: Underwent surgery: laparotomy
OP Findings
Bilateral ovarian tumor with papillary
lesions
(+) tumor seeding on the rectum, uterus
and bilateral infundibulopelvic ligament
Ascites of 1300 cc (20 cc sent for cytology
exam)
(+) Omental cake
(+) Tumor on omentum invade the
superficial lining of the transverse colon
Estimated blood loss 300 cc
Surgical procedure
Optimal Debulking Surgery:
ATH + BSO
Omentectomy
Bilateral Pelvic Lymph Node Dissection
Final Diagnosis
Ovarian Cancer IIIc
REVIEW
Ovarian Cancer Staging
Stage 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 Staging
Stage 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 III
Surgery has been used as a therapeutic
modality and also to adequately stage the
disease.
Surgery should include total abdominal
hysterectomy and bilateral salpingooophorectomy 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
Cytoreduction
A 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 Chemotherapy
This 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
Radiotherapy
Consolidation 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