Dr. Sanjay Dudhat
Head of Department -
Oncosurgery
Nanavati Super Speciality
Hospital, Mumbai
Unlocking its mysteries and a survivor’s tale
Ovarian Cancer has emerged as one of the common malignancies
affecting women in India, with nearly 30,000 new patients being
diagnosed every year. Because of vague symptoms, lack of good
screening methods, majority of the patients are diagnosed in stage III
or IV. During the past decades, there were a lot of advances in surgical
techniques (radical and debulking surgeries), newer and effective
chemotherapeutic drugs and targeted therapies which resulted in
improving survival rate and more effective treatment of relapsed
disease.
THE CASES
A 58 year old female patient visited Nanavati Super Speciality
Hospital with complaint of pain and heaviness in lower abdomen for
about a month. She was investigated for the same after undergoing
primary treatment. Sonography abdomen and pelvis showed cystic
mass probably arising from right ovary. Further CT scan of abdomen
and pelvis showed large solid cystic mass arising from right ovary
without involving surrounding structures, omental thickening without
any significant lymphadenopathy or peritoneal nodules. CA-125 level
was 146 u/ml. After ascertaining her basic biochemical parameters,
decision was taken to perform Exploratory Laparotomy with frozen
section.
THE PROCEDURE
On exploration, large solid cystic mass replacing the right ovary,
adherent to bladder peritoneum was visible. There was minimal free
fluid in the pelvis and no significant lymphadenopathy or peritoneal
nodules. Omentum did show significant nodularity. The right ovarian
mass was dissected properly and was sent for frozen section. Frozen
section reported high grade carcinoma arising from the ovary.
Complete Radical Hysterectomy with Bilateral Pelvic Node Dissection,
Para-aortic Lymphnode Sampling and Omentectomy were performed.
Peritoneal biopsy and washings were also taken as surgical staging
purpose.
THE RESULT
The patient’s post operative recovery was uneventful. Final
histopathology report showed high grade seromucinous carcinoma of
the right ovary with clear cell component with metastatic omental
tumour deposits, positive peritoneal fluid cytology and regional reactive
lymphnodes. Post operative, Chemotherapy sessions were initiated.
DISCUSSION
Surgery plays an important role throughout the spectrum of Ovarian
Cancer management. The surgery in early stage Ovarian Cancer entails
total Abdominal Hysterectomy Bilateral Salpingo-oophorectomy,
Omentectomy, Pelvic and Para-aortic Lymphadenectomy and
comprehensive surgical staging. After adequate surgical staging
nearly 30% patients are upstaged from stage I to stage III. Removal of
the tumour should be completed without rupturing the capsule of the
ovary because any spillage will upstage the disease. Spillage during
surgery is an important prognostic parameter affecting the survival in
major studies.
Cytoreductive surgery is removal of primary tumour and metastatic
disease as much as possible so as to leave behind minimal or no
residual disease. Chemotherapy will have much better effect when this
hypoperfused masses are removed. Surgeons’ clinical judgement on
whether to do Cytoreductive surgery or Neoadjuvant Chemotherapy to
downstage the disease is quite critical in such cases.
Interval debulking surgery is performed by downstaging tumour
after Neo-adjuvant Chemotherapy. In this type of treatment, first 3
cycles of Chemotherapy are given and the response is monitored. After
assessing the response, the patient is operated upon. Post surgery,
remaining 3 cycles of Chemotherapy are given. Conservative / fertility
preserving surgery for early stage disease can be indicated in young
women with low malignant potential tumours / well differentiated
tumours confined to the ovary. These patients can be offered unilateral
Salpingo-oophorectomy with comprehensive staging including
Peritoneal Biopsies and Bilateral Pelvic and Para-aortic Lymphnode
Sampling. Frozen section is essential for this procedure. Stage 1A
disease has to be clearly defined. Careful monitoring is required since
recurrence rates in such cases are around 7%. Uterus and remaining
ovary should be removed after chances of pregnancy has been ruled
out.