Abstract
Dear Editor:
Recent improvement in ovarian cancer survival is probably due to progress in treatment, especially regimens including the combination of chemotherapy and surgery.1–3 Here I present an explicative case of a long-term bilateral ovarian cancer in a 47-year-old-woman, heavily pretreated, who underwent cytoreductive and palliative surgery because of bowel obstruction with relapse in epithelial ovarian cancer. In March 2002 she underwent bilateral salpingo-oophorectomy and omentectomy for bilateral ovarian papillary serous adenocarcinoma with lymph node and omentum metastases (Stage IIIC). Subsequently she was treated with monochemotherapy with carboplatin (AUC5) for suspected reaction to first administration of taxol. After six cycles she underwent a surgical second look: her histological exam was negative. In June 2005, for a rapid growth of CA125 serum level (145 U/ml), a choline PET was performed, with evidence of multiple abdominal metastases. The patient was treated with docetaxel (75 mg/m2) and carboplatin (AUC5) for eight cycles, with complete negative choline PET-TB and CA125; subsequentely, in June 2006, she underwent a surgical third look, with a second negative histological exam. In September 2006 a CT scan revealed a peritoneal relapse of disease. Different lines of chemotherapy respectively with PLD (40 mg/m2), carboplatin (AUC5) and gemcitabine (1200 mg/m2), and topotecan (3.75 mg/m2) were carried out. In March 2009 a fourth look was performed, with removal of the relapse metastases from ovarian serous papillary adenocarcinoma—transverse colon, jejunum, and small pancreas— along with splenectomy and lymphadenectomy. Two other lines of chemotherapy were administered. Subsequently, the patient underwent surgery again for occlusive status (end-to-end anastomosis and ileostomy). Eastern Cooperative Oncology Group (ECOG) performance status (PS) was 2. Another line of chemotherapy was performed without any results in PFS or clinical benefit. We assisted with a progressive worsening of PS; in May 2011 unfortunately the patient died as a result of disease progression.
This case is explicative concerning the importance of surgery in the management of ovarian cancer, with different and consecutive-look laparotomies (four in our case). A negative second-look laparotomy does not preclude recurrence, and subsequent-look laparotomies could be necessary for management of this complex disease. The literature indicates that complete resection of recurrent tumor formations should be aimed for (since survival prolongation is mainly seen in patients with no residual disease) in order to offer the best therapeutic chances to patients and to protect patients with limited life expectancy from additional surgical burden. 4 Moreover, advanced ovarian cancer patients who have undergone multiple surgeries and multiple chemotherapy regimes often present with acute or subacute intestinal obstruction as a preterminal debilitating event. Usually these are multilevel obstructions where surgical effort may not be possible or may not be useful. In a select few patients the entire proximal bowel up to the mid or distal ileum may be unobstructed, with a multilevel obstruction below this point. Such a patient may benefit from an ileostomy. This may have been the situation with this case. This experience shows that the multidisciplinary treatment modality in these complex cases, combining both medical and surgical modalities, should ensure a consistent and equitable approach to planning and managing care for advanced ovarian cancer in order to offer each patient the best strategy for improving survival and quality of life.