Dr. Sanjay Dudhat
Head of Department -
Oncosurgery
Nanavati Super Speciality
Hospital, Mumbai

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.