Case Conference September 20th 2017

20-Sep-2017, Divisi Ginekologi Onkologi RSCM

Mrs. M

Incompletely Operated Ovarian cancer stage IA

 

February 2017

Patient realized her abdomen was enlarged. Patient went to Hermina Hospital to seek medical attention. Examination in Hermina hospital revealed she had ovarian cyst diameter 5 cm, and no further treatment was performed.

 

April 2017

Patient complained the abdomen was more distended and she experienced short of breath. She controlled to Hermina hospital, and was told mioma uteri 21 cm with right pleural effusion. Patient was referred to RSCM

 

April 17^th 2017

Patient’s first visit at RSCM with chief complain enlarged abdomen since 2 months ago. From gynecological examination revealed enlarged uterus until half of navel-symphysis push to the left, at right adnexal, palpated cystic mass with irregular surface, enlarged until 2 finger breadth below navel, immobile. No mass at left adnexa.

 

FM ultrasound revealed ntramural and submucous myom, bilateral ovarian cyst mass with solid part suspected malignant. Plerual effusion.

 

USG by oncologist :

Bilateral ovarian cyst with solid part, RI 0.2, IOTA index risk of malignancy 63%

 

RMI 1x3x492.5 = 1477.5

 

Mei 12^th 2017

Abdominal CT-scan revealed cyst ovarian mass with septum and vivid calcification post contrast at right adnexa, diameter 11,5x13,8x14,3 cm, suspected malignant

No parailiaka and paraaorta lymphadenopathy.

 

June 19^th 2017

Patient was operated, during operation was found ovarian cyst on right and left ovarian. Left ovarian cyst was sent to VC, the result was endometriosis cyst with severe inflammation, necrotic area, and atypic cells in stroma. The operation was continued with total hysterectomy and right salphyngoovorectomy.

 

 

 

June 26^th 2017

Parrafin block revealed clear cell carcinoma, moderate differentiation, with endometriosis cyst, uterine adenomyosis, right salphynx simple cyst, no spreading to uterine and left adnexa

 

Cytology : inconclusive atypic cells

 

Problems to be discussed

1.      What is the best next step in managing patient with incompletely operated early stage ovarian cancer?

2.      Is the treatment feasible in this case?

3.      Will the potential benefits of treatment outweigh the potential harms of treatment for my patient?

 

METHODS

Search strategy

The search was conducted on Pubmed, Science Direct  on September 16^th  2017, using the search tool containing the keyword “incompletly operated or incompletely staging”, “early stage ovarian cancer”, (Table 1). Search results were filtered by the engine according to the following criteria : articles published in the past 5 year, human species, and English language. Search strategy, result, and the inclusion and exclusion criteria are shown in the flowchart (Figure 1).

 

Table 1. Search strategy used in Pubmed, Science Direct , conducted on 16^th September 2017

Engine	Search Terms	Results
Pubmed     Science Direct	“management”, “incompletely operated”, “early ovarian cancer”   “management”, “incompletely operated”, “early ovarian cancer”	38     107

 

Figure 1. Flow chart of search strategy

 

	Incompletely operated early stage ovarian cancer

 

 

 

		Pubmed 38       advanced stage endometrial cancer”, “chemotherapy”, “radiotherapy”			Science Direct 107   advanced stage endometrial cancer”, “chemotherapy”, “radiotherapy”
	Screening files       advanced stage endometrial cancer”, “chemotherapy”, “radiotherapy”
			Useful articles: 2    $

 

 

 

 

 

 

 

 

 

 

 

 

Table 1. Related Journal to Clinical Question

Author	Year	Title
Trimbos B, et al	2003	Impact of Adjuvant Chemotherapy and Surgical Staging in Early-Stage Ovarian Carcinoma: European Organisation for Research and Treatment of Cancer–Adjuvant ChemoTherapy in Ovarian Neoplasm Trial
Hua Tu, et al	2015	Individualized Treatment of Patients With Early-Stage Epithelial Ovarian Cancer After Incomplete Initial Surgery

 

Table 2. PICO of journal

 

What question did the study ask?	PICO Analysis
Patients	Incompletely operated early stage ovarian cancer
Intervention	Chemotherapy
Comparison	Re-staging
Outcome	Overall survival and Recurrence free survival

 

Result

Trimbos B et al, conducted large randomized control trial (ACTION-1 trial) to evaluate the effect of adjuvant chemotherapy in ovarian cancer patient in survival and progression of disease. This randomized control trial include 448 patients. In subgroup of analysis patient who underwent non-optimal surgery who received chemotherapy has better overall survival with HR 1.75 (95% CI 1.04 to 2.95, p=0.03), and recurrence free survival with HR 1.78 (95% CI 1.51-2.77, p=0.009).

 

Hua tu e al, conducted retrospective study to evaluate outcome of patient who received adjuvant chemotherapy or re-staging in incompletely operated ovarian cancer. This study included 246 patients. The author found overall survival 5 year for re-staging vs chemotherapy was  87.5% vs 74.7% p=0.038, recurrence free survival 5 years for re-staging vs chemotherapy 68.9% vs 57.5% p=0.035.

 

 

Discussion

There are six different types of surgical approaches in epithelial ovarian carcinomas.

1.     Primary Maximal Debulking Surgery: (MDS)

Defined as the standard treatment. The goal of the maximal debulking surgery is removing all gross tumoral tissue with no visible disease left.

2.     Interval Debulking Surgery: (IDS)

Defined for advanced stage ovarian carcinoma if debulking surgery cannot achieve an optimal cytoreductive success, patients undergone a 3–6 cycles of postoperative chemotherapy, then second operation is performed for maximal debulking.

3.     Neoadjuvant Chemotherapy: (NAC)

Describes administration of 3–6 cycles of chemotherapy to the patients with the tissue diagnosis of ovarian cancer either with biopsy or cytology prior to the surgery. Patients, who have a partial or complete response, undergo a primary debulking surgery.

4.     Palliative surgery:

Palliative surgery aims at the improvement of cancer-related symptoms, especially bowel obstruction and quality of life rather than curative intent

5.      Direct chemotherapy for incompletely operated patients:

Administration of chemotherapy instead of secondary surgery, especially for non-epithelial ovarian carcinoma patients.

6.     Secondary Cytoreductive Surgery:

Refers to the reoperation and re-debulking surgery for recurrent ovarian carcinoma.

 

Staging is crucial for ovarian carcinoma because the accurate stage is important to determine the need for adjuvant therapy. In one study, almost 24.6% patients with preoperatively CT-scan and MRI revealed no pelvic lymph node metastasis has positive metastasis in final pathologic examination. This condition related to aggressive spread pattern of ovarian cancer.¹ Other study also reported almost 30% apparently early-stage ovarian cancer are found to have extra-pelvic metastasis after surgical staging was performed.²

 

Patient with incompletely operated ovarian cancer account for 33-67% cases of overall ovarian cancer. This condition is related to unpredicted malignancy or unsuccessful attempt for debulking.³ Unsuccessful attempt is related to the first operator, whether performed by gynaecologist or gynaecological oncologists.^{4, 5} Incomplete surgical staging in early ovarian cancer related to outcome of patient, such as reoperation with the complication, and relapse of tumor.^{2, 6}

 

 

Patient with incompletely operated early ovarian cancer, the next management is debateable. One RCT reported patient with non-optimal debulking favour the adjuvant chemotherapy for overall survival and recurrence free survival.⁷ Only 1 study compared the benefit of re-staging in incompletely operated ovarian cancer, which is related to quality of first operation and histological type of ovarian cancer.

,