CASE CONFERENCE

October 7th, 2015

Mrs. Elly Marlina Siahaan, P3, 55 years old, 367 44 89
Localized Recurrent Ovarian Cancer
CASE DESCRIPTION
Chief complaint: abdominal enlargement since 4 months before coming to
oncology gynecology outpatient clinic department Cipto Mangunkusumo Hospital
on February 21st 2012. At the beginning, she was admitted to Budhi Asih General
Hospital, told to have suspected ovarian cancer and pulmonary tuberculosis,
then reffered to Cipto Mangunkusumo Hospital. She lost 5 kg weight in 4 months.
She also complained about bloating, loss of appetite, disturbance in micturition
and defecation. No history of malignancy on the genital tract, breast or colon in
the family. She was already menopause for 4 years when admitted to hospital.
Pre operative examination: cystic mass with solid part diameter 7 cm, Ca 125:
112,6 U/mL, RMI: 675,6. She underwent laparotomy suboptimal debulking on
March 19th 2012 with residu on rectum. Histopathology result: adenocarcinoma
with moderate differentiation. She was given chemotherapy with carboplatin and
paclitaxel for 6 cycles following the surgery, ended on September 2012 and also
treatment for the pulmonary tuberculosis. No mass was found and Ca125 level
was normal after the chemotherapy. Follow up period was uneventful until about
a month ago when she started to complain about abdominal discomfort.
Physical examination:
General status: no enlargement of the lymph nodes, there were umbilical hernia,
no mass palpable in the abdomen.
Gynecological status: solid mass was palpated on the left side of the vaginal
vault, diameter 4 cm, fixed.
Ca125 (September 3rd 2015): 12 U/mL
Ultrasound (September 16th 2015):
Conclusion: ovarian carcinoma post TAH BSO. Cystic mass with solid part on
cranial of the vaginal vault possibly recurrent tumor.
CT Scan (September 22nd 2015):
Conclusion: soft tissue mass predominant of cystic part in the left pelvic cavity,
suspected recurrent, umbilical hernia, contracted left kidney with nephrolithiasis
and pelviokaliectasis and suspected pneumonia.
CLINICAL QUESTION
What is the next best management for this patient?
P
55 years old women, P3 with localized recurrent ovarian
cancer
I
Secondary cytoreductive surgery
C
Chemotherapy
O
Survival

THE SEARCH
Database
PubMed

ScienceDirect

Cochrane

Search strategy
(recurrent ovarian
cancer)
AND
(management)
(recurrent ovarian
cancer) AND
(management)
(recurrent ovarian
cancer)
AND
(management)

BEST EVIDENCE PAPERS

Author
Patients
group
Chi DS,
157patients
McCaughty
underwent
K, Diaz JP,
secondary
et al., 2006, cytoreduction
Cancer
(153were
evaluable)

Salani R,
Santillan A,
Zahurak
ML, et al.,
2007,
Cancer

Fiftyfive
patientsmetthe
studyinclusion
criteria(complete
clinicalresponse
toprimary
therapy,>12
monthsbetween
initialdiagnosis
andrecurrence,
and<5
recurrencesites
onpreoperative
imagingstudies)

Hits
146

Selected articles
3

162

88

Outcome

Result

Comments

Median
survival

41.7months(95%
confidenceinterval,
36.047.2months).

Significantsurvival
benefitwas
demonstratedforre
sidualdiseasethat
measured<0.5cm.
Thediseasefree
intervalandthenumber
ofrecurrencesites
shouldbeusedas
selectioncriteriafor
offeringsecondary
cytoreduction.

Statistically
significantand
independent
predictorsof
overall
survival

Diagnosisto
recurrenceinterval
>18months(median
survival,49months
vs3months;P<.01)

Age,tumorgrade,
histology,CA125
level,ascites,and
tumorsizewerenot
associatedsignifi
cantlywithsurvival.

Numberof
radiographic
recurrencesites
(mediansurvival,50
monthsforpatients
with1or2sitesvs
12monthsfor
patientswith3to5
sites;P<.03)

Localizedrecurrent
ovariancancer:patients
with1or2
radiographicrecurrence
sitesadiagnosisto
recurrenceinterval>18
monthsandcomplete
secondarysurgical
cytoreductiona
medianpostrecurrence
survivalof
approximately50
months.

Residualdisease
(mediansurvival,50
monthsforpatients

withnomacroscopic
residualdiseasevs
7.2monthsfor
patientswith
macroscopicresidual
disease;P<.01)
GalaalK,
NaikR,
BristowRE,
et al., 2014,
Cocharane
Database
Syst Rev.

1431possible
articles
(comparing
secondary
cytoreductive
surgeryand
chemotherapy
with
chemotherapy
aloneinwomen
withrecurrent
epithelialovarian
cancer)

Prolonginglife

Norelevantstudies

Noevidenceto
determineifsecondary
cytoreductivesurgery
isbetterorworsethan
chemotherapyalonein
termsofprolonging
life.

DISCUSSION
Most women with advanced epithelial ovarian cancer will ultimately
develop recurrent disease after completion of initial treatment with primary
surgery and adjuvant chemotherapy. Secondary cytoreductive surgery may have
survival benefits in selected patients. However, a number of chemotherapeutic
agents are active in recurrent ovarian cancer and the standard treatment of
patients with recurrent ovarian cancer remains poorly defined.
There is no evidence from RCTs to inform decisions about secondary
surgical cytoreduction and chemotherapy compared to chemotherapy alone for
women with recurrent epithelial ovarian cancer. Ideally, a large randomised
controlled trial or, at the very least, well designed non-randomised studies that
use multivariate analysis to adjust for baseline imbalances are needed to
compare these treatment modalities.
Secondary cytoreduction is defined as an attempt to resect or optimally
debulk selected patients with recurrent disease following first-line chemotherapy.
Patients with platinum-refractory or platinum-resistant disease are not suitable
candidates for secondary cytoreduction, but selected patients with platinumsensitive recurrent ovarian cancer may benefit if all macroscopic residual disease
can be resected.

In conclusion, because this patient has disease free interval for about 18
months, single site and also platinum sensitive, she should be offered for
secondary cytoreduction.

REFERENCES
1. Chi DS, McCaughty K, Diaz JP, et al. Guidelines and selection criteria for
secondary cytoreductive surgery in patients with recurrent, platinumsensitive epithelial ovarian carcinoma. Cancer. 2006; 106:19331939.

2. Salani R, Santillan A, Zahurak ML, et al. Secondary cytoreductive surgery

for localized recurrent epithelial ovarian cancer: Analysis of prognostic
factors and survival outcome. Cancer. 2007;109:685691.
3. Galaal K, Naik R, Bristow RE, et al. Cytoreductive surgery plus
chemotherapy versus chemotherapy alone for recurrent epithelial ovarian
cancer. Cochrane Database Syst Rev.2014;2:123.
4. Hacker, Neville F. Berek & Hackers Gynecologic Oncology. Six eds 2015.
Chapter 11.