Optimal debulking targets in women with advanced stage ovarian cancer: a retrospective study of immediate versus interval debulking surgery

ObjectiveThe objective of this study was to examine both overall and disease-free survival of patients with advanced stage ovarian cancer after immediate or interval debulking surgery based on residual disease.MethodsWe performed a retrospective chart review at the Tom Baker Cancer Centre in Calgary, Alberta of patients with pathologically confirmed stage III or IV ovarian cancer, fallopian tube cancer, or primary peritoneal cancer between 2003 and 2007. We collected data on the dates of diagnosis, recurrence, and death; cancer stage and grade, patients’ age, surgery performed, and residual disease.ResultsOne hundred ninety-two patients were included in the final analysis. The optimal debulking rate with immediate surgery was 64.8%, and with interval surgery it was 85.9%. There were improved overall and disease-free survival rates for optimally debulked disease (< 1 cm) with both immediate and interval surgery (P < 0.001) compared to suboptimally debulked disease. Overall survival rates for optimally debulked disease were not significantly different in patients having immediate and interval surgery (P = 0.25). In the immediate surgery group, patients with microscopic residual disease had better disease-free survival (P = 0.015) and overall survival (P = 0.005) than patients with < 1 cm residual disease. In patients who had interval surgery, those who had microscopic residual disease had more improved disease-free survival than those with < 1 cm disease (P = 0.05), but they did not have more improved overall survival (P = 0.42). Patients with microscopic residual disease who had immediate surgery had a significantly better overall survival rate than those who had interval surgery (P = 0.034).ConclusionIn women with advanced stage ovarian cancer, the goal of surgery should be resection of disease to microscopic residual at the initial procedure. This results in improved overall survival than lesser degrees of resection. Further studies are required to determine optimal surgical management.     

Major hepatectomy and right hemicolectomy at the time of primary cytoreductive surgery for advanced ovarian cancer: report of a case

Major liver involvement at the time of diagnosis is a rare event in patients with ovarian cancer, and the issue of major hepatectomy at the time of primary cytoreductive surgery is controversial. A 61-year-old woman was admitted to our hospital with nonspecific abdominal pain of 2-month duration and weight loss of 5 kg during the last semester. A computed tomography scan demonstrated bilateral ovarian masses, extending to the right iliac fossa, pressing the cecum-ascending colon. In the liver parenchyma, three cystic lesions were found of about 6-cm maximum diameter each, along with pelvic lymphadenopathy. There was no ascites. The diagnosis of advanced ovarian cancer was clinically suspected; the patient underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, right hemicolectomy, omentectomy, left lobectomy, deroofing, and draining of the cystic formation of the right liver lobe along with systematic pelvic and para-aortic lymphadenectomy. Systemic chemotherapy (six cycles of paclitaxel/carboplatin) was subsequently administered, and after 15 months of follow-up period, the patient is still in first remission and alive. Ovarian cancer with concomitant extensive right colon infiltration and hematogenous liver metastases can be successfully managed with aggressive surgical resection and postoperative chemotherapy in carefully selected patients.     

Polymyositis and ovarian carcinoma: a case report

We are reporting a case of ovarian carcinoma, who presented with polymyositis. Polymyositis, without any evidence of dermatomyositis, as the presentation of ovarian carcinoma has never been reported. In fact, for patients with polymyositis, there does not appear to be a great increase in the risk of malignancy. The purpose of this report is to make the gynaecologists aware that polymyositis alone can also be the presenting symptom for ovarian carcinoma.     

Neoadjuvant chemotherapy and interval debulking for advanced epithelial ovarian cancer

A retrospective matched-control study was conducted to review our experience with FIGO stage III and IV epithelial ovarian cancer in patients referred after initial laparotomy and biopsy only. The study group comprised 22 patients; planned treatment was two to four cycles of chemotherapy, interval debulking surgery, six more chemotherapy cycles, and second-look laparotomy. Two control groups were matched with the study group according to FIGO stage, histologic type, and grade (2 or 3) and patient age +/- 5 years. The first control group (22 patients) had greater than 2 cm residual disease after initial surgery; their planned treatment was a minimum of six cycles of chemotherapy plus second-look laparotomy. The second control group (18 patients) was referred after initial laparotomy and biopsy only; their disease was immediately reexplored and debulked. Subsequent planned treatment was a minimum of six cycles of chemotherapy plus second-look laparotomy. All patients received cisplatin-based chemotherapy. Optimal cytoreduction to less than or equal to 2 cm was achieved for 77% of the study group vs 39% of the immediate-reexploration group (P = 0.02). Median survival times for the three groups were not different (16 vs 19.3 vs 18 months, respectively) (P = 0.58). Within the study group, patients who were optimally debulked survived significantly longer than those who were not (18.1 vs 7.5 months) (P = 0.02). Morbidity of the interval debulking procedure was acceptable. Study findings suggest that patients with bulky residual disease have a uniformly poor prognosis regardless of the timing of further surgery.     

Normal-sized ovarian papillary serous carcinoma: a case report

A normal-sized ovarian papillary serous carcinoma is rare. We present the case of a 46-year-old woman with progressive abdominal fullness of one week's duration. The medical evaluation revealed abdominal carcinomatosis with normal-sized ovaries and an elevated serum CA-125 level of 147,365.8 U/ml. Cytoreductive surgery (hysterectomy, bilateral salpingo-oophorectomy, omentectomy, lymphadenectomy, infracolic omentectomy, peritoneal biopsy, washing cytology, and appendectomy) was performed. The histologic examination revealed an ovarian serous papillary carcinoma. Adjuvant chemotherapy was administered. The serum CA-125 level decreased after completion of treatment. Normal-sized ovarian serous surface papillary carcinomas should be kept in mind as an origin of disease in patients who have peritoneal carcinomatosis, which sometimes is a diagnostic dilemma of the disease source. We report this case to emphasize the clinical symptoms and importance of the early and accurate diagnosis of a normal-sized ovarian papillary serous carcinoma.     

Treatment of FIGO stage IV ovarian carcinoma: results of primary surgery or interval surgery after neoadjuvant chemotherapy: a retrospective study

The objective of the study is to determine whether surgery influences the outcome of stage IV ovarian cancer. The study design is as follows: From May 1995 to December 2000, 129 patients with FIGO stage IV ovarian cancer, recruited in 42 centers, were prospectively included in GINECO first-line randomized studies of platinum-based regimens with paclitaxel administered simultaneously or sequentially. In all, 109 were eligible for this study. Standard peritoneal cytoreductive surgery was defined as a procedure including at least total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and peritoneal debulking. Surgery was considered optimal if residual lesions were smaller than 1 cm. The Kaplan-Meier method was used to compare survival. Initial abdominopelvic cytoreductive surgery was considered standard in 55 (54%) patients. Abdominopelvic surgery was optimal in 29 patients and nonoptimal in 26. Twenty-two (22%) patients had a simple biopsy, and 25 (24%) patients underwent substandard surgery. Twenty-two of these 47 patients without initial standard surgery underwent a second surgical procedure, and 17 of the 22 patients completed standard surgery. The median overall survival time in the entire population was 24.3 months (95% confidence interval [CI], 19.5-29.1 months). Patients treated without a cytoreductive surgical procedure had significantly worse median survival (15.1 months; 95% CI, 5.4-24.9 months) than patients who had optimal primary surgery (22.9 months; 95% CI, 15.6-30.1 months), nonoptimal primary surgery (27.1 months; 95% CI, 21.2-32.9 months), or neoadjuvant chemotherapy followed by surgery (45.5 months; 95% CI, 23.5-67.5 months) (P= .001). In conclusion, this study shows a significant benefit of debulking surgery in stage IV ovarian cancer patients who responded to neoadjuvant chemotherapy. Neoadjuvant chemotherapy can help to select patients for surgery.     

Complete response to docetaxel and carboplatin combination chemotherapy for a stage IV uterine papillary serous carcinoma: a case report

We report a case of a stage IV uterine papillary serous carcinoma (UPSC) with multiple organ metastases. The patient was treated with docetaxel and carboplatin combination chemotherapy. After five courses, uterine tumor, Douglas tumor, lymphadenopathy, and distant metastases on magnetic resonance imaging or computed tomography scan were completely resoluted. Moreover, endometrial biopsy showed no carcinoma tissues after six courses. We suggest that this regimen may be effective for treatment of advanced-stage UPSC.     

Massive ovarian edema revealing gastric carcinoma: a case report

Tumor-like enlargement of the ovaries due to accumulation of edema fluid within the ovarian stroma is referred to as massive ovarian edema (MOE). The pathogenesis of MOE is thought to be intermittent torsion of the ovary on its pedicle, causing partial obstruction of venous and lymphatic drainage. The diagnosis of MOE is based on imaging techniques. The case described here due to ovarian lymphatic vessel obstruction by carcinoma cells shows that metastatic disease may be a cause of MOE.     

Peritoneal tuberculosis simulating advanced ovarian carcinoma: a case report

Disseminated peritoneal tuberculosis accounts for 1-3% of tuberculosis disease, represented by high frequency of lung defects in endemic countries. The authors report one case in a 43-year-old woman, the initial interpretation of which, based on pleural and peritoneal exudate, showed suspected latero-uterine mass and significant elevated serum CA 125 level, mimicking disseminated ovarian carcinoma. Only after exploring laparotomy with biopsy was disseminated peritoneal tuberculosis identified, thus correcting the diagnosis. Symptomatology, X-ray defect, and cynetic of serum CA 125 level were left in totality after 3 months of antituberculosis multidrugs. This is a diagnostic trap, which presents a new interest for such pathology as tuberculosis, which is on the increase again in the West.     

Optimizing the treatment of ovarian cancer: Neoadjuvant chemotherapy and interval debulking versus primary debulking surgery for epithelial ovarian cancers likely to have suboptimal resection

Objective

To: a) identify prognostic factors in patients with epithelial ovarian cancer treated with neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS), and b) compare post-surgical survival between patients treated with NACT/IDS for presumed unresectable disease and stage IIIC/IV patients who underwent suboptimal primary debulking surgery (PDS).

Stage IV micropapillary serous ovarian carcinoma: a report of three cases.

Micropapillary serous carcinomas (MPSCs) have been distinguished from typical ovarian serous borderline tumors. Although the clinical features of MPSCs have been described in several studies, there is almost no clinicopathologic information regarding stage IV MPSC patients. We describe three cases of stage IV invasive MPSC with clinical and pathologic findings. One case had an umbilical metastasis (Sister Mary Joseph's nodule), and the other two cases had cytologically positive pleural effusions. These cases demonstrate the potential of MPSCs for aggressive clinical behavior and distant metastases.     

Stage IV ovarian carcinoma following ovulation induction: a report of three cases

Recent attention, in both the medical and lay communities, has been focused on a possible causal relationship between ovulation induction and ovarian carcinoma. The three cases reported here display marked heterogeneity in their risk factor profiles for ovarian cancer, illustrating several of the inconsistencies that have hampered epidemiological studies examining the proposed mutagenic effect of fertility drugs on ovarian epithelium. Three cases of stage IV invasive ovarian carcinoma, developing in infertility patients following from one to seven cycles of ovulation induction, are presented. The biological plausibility of a causal effect of fertility drugs on ovarian carcinogenesis has not been corroborated by consistent dose-dependent or lag-time effects. Fertility drug use may be an incidental finding associated with the known ovarian cancer risk factor of infertility. Nevertheless, until the precise effects of fertility drugs on ovarian epithelium are elucidated, a high index of suspicion for malignant ovarian neoplasms in women using these medications is indicated.     

Full-thickness diaphragmatic resection for stage IV ovarian carcinoma using the EndoGIA stapling device followed by diaphragmatic reconstruction using a Gore-tex graft: a case report and review of the literature

BACKGROUND: Previous studies have reported the results of full-thickness diaphragmatic resection for ovarian cancer metastatic to the diaphragm. CASE.: We present the first case of an extensive full-thickness diaphragmatic resection performed using the EndoGIA [US Surgical Corp., Norwalk, CT] staple device followed by successful reconstruction using a Gore-tex (W.L. Gore and Associates, Inc., Newark, DE) graft. CONCLUSION: Full-thickness diaphragmatic resection using the EndoGIA stapling device is a safe and effective method to completely remove extensive tumor during cytoreductive surgery. Use of the stapler expeditiously assists in removal of the specimen with minimal blood loss. In cases where large defects cannot be repaired primarily, a Gore-tex patch should be used.     

Early-stage ovarian carcinoma combined with pulmonary tuberculosis mimicking advanced ovarian cancer: a case report

In patients of ovarian cancer combined with multiple pulmonary nodules, the diagnosis of metastatic ovarian cancer is always considered. However, benign pulmonary conditions can be discovered instead. An 80-year-old female presented with a rapidly growing ovarian mass, elevated serum CA-125, and multiple pulmonary varying-sized nodular lesions. The pretreatment workup of her lung lesions failed to show a malignant cell, and it also failed to show any evidence of tuberculosis or other infectious diseases. After surgery, her disease was allotted to 'stage IV' epithelial ovarian cancer and adjuvant cytotoxic chemotherapy was then used. However, her sputum culture showed positive growth of Mycobacterium tuberculosis 4 weeks later. For fear of reactivation of pulmonary tuberculosis, the anticancer cytotoxic chemotherapy was postponed and the antituberculous treatment was given instead. After 6-month course of antituberculous therapy, no active lung lesion was detectable. In conclusion, infectious or inflammatory conditions can mimic metastatic disease and therefore add to the difficulty of stage determination. We recommend that there must be positive cytologic or pathologic results of lung lesions to allot a case of ovarian cancer to stage IV. Furthermore, whenever pulmonary lesions are seen on imaging, the possibility of diagnoses other than metastatic ovarian cancer should always be considered.     

The role of partial sigmoid colectomy for debulking epithelial ovarian carcinoma

Forty women underwent partial sigmoid colectomy during cytoreductive surgery for advanced epithelial ovarian carcinoma. Twenty-one (53%) and nineteen (47%) received this as part of primary or secondary debulking procedures, respectively. Fifty-four percent had postoperative residual disease less than 1 cm in largest diameter. Even though multiple surgical procedures were performed in conjunction with sigmoid colectomy, 75% of the patients had no significant postoperative morbidity. Postoperative mortality was 2.5%. Seventy-eight percent avoided permanent colostomy. Despite the above morbidity rate and aggressive postoperative therapy, the median survival for the entire group was only 14.5 months, with no significant differences between groups of patients who were categorized by primary or secondary debulking, histologic grade, amount of preoperative disease, ascites, or extent of postoperative residual disease. Although a partial sigmoid colectomy can be performed with a reasonable morbidity rate as part of debulking for ovarian cancer, and probably provides significant palliation of symptoms from large pelvic tumors, it must be used judiciously in selected patients.     

Colposcopic diagnosis of ovarian carcinoma spreading to cervix: a case report

Secondary carcinoma of the cervix is uncommon. A patient with a history of ovarian carcinoma had an abnormal cervical smear and colposcopy was performed. Colposcopy and directed biopsy led to the diagnosis of ovarian cancer which had spread to the cervix. The unusual colposcopic features which allowed a clinical diagnosis are correlated with histopathology and the findings discussed.     

Exceptional widespread,life threatening lung metastasis in stage IA ovarian endometrioid carcinoma: A case report

ObjectiveLow-risk, early stage, ovarian endometrioid carcinoma seems to have little chance to recur in clinical practice. Such a patient developed widespread, life-threatening pulmonary metastases is also extreme rare and is worthy to be reported.Case reportA 53-year-old female, who was diagnosed to have stage IA, grade 2, ovarian endometrioid carcinoma, developed a life threatening widespread lung metastasis in 2 years after primary surgery. She received salvage systemic chemotherapy with paclitaxel plus carboplatin. Bevacizumab was added after occurrence of paroxysmal supraventricular tachycardia during chemotherapy. The patient had clinical improvement and radiological stable after systemic therapy.ConclusionOur case report enhances the aggressive post-operative surveillance including chest field would still be recommended even in the low-risk patients. To detect distant metastases earlier probably has higher chance of cure by systemic therapy.