In a trial of carboplatin AUC 6 vs. AUC 12 there was no difference in survival although the delivered dose in the higher dose arm was significantly lower than planned.
The possibility that the disease is metastatic to the ovary must be borne in mind. It is a disease of middle and upper socioeconomic classes, more common in highly industrialized countries. Rarely does the disease present as a surgical emergency.
We're not around right now. Cytoreductive or debulking surgery has been shown to (i) enhance immunologic competence of the patient, (ii) improve tumour perfusion and increased growth fraction, (iii) provide a physiological benefit for the patient by removing a large tumour mass and (iv) increase survival if optimal debulking is performed. Many of the patients in the cisplatin arm subsequently received paclitaxel on biochemical or clinical relapse . Two other large randomised studies have looked at the role and sequence of paclitaxel in advanced ovarian cancer. Based on surgical staging data 20-30% of apparent early staged cancers will be upstaged.
The Japanese GOG have shown in a prospective randomized study of dose dense weekly regimen of carboplatin/taxol with the standard 3 weekly schedule showing an improved survival with the dose dense regimen. A meta-analysis involving 1400 patients has revealed platinum containing combinations produce higher response rates than non-platinum regimens but do not improve survival. Trials to determine the ideal number of cycles have shown that 5 or 6 cycles of chemotherapy are equivalent to 10 or 12 cycles(80-83). The most common primary sites are breast, gastrointestinal tract and uterus. For all intents and purposes it is staged and treated as for ovarian cancer, as mentioned below. Lymphatic spread is more common than previously thought while haematogenous spread is less common. Subspecialists are also more likely to affect optimal cytoreduction and resultant survival advantage (70-75). NSW 2050 The odds ratio for ovarian cancer in first and second degree relatives of ovarian cancer affecteds is 3.6 and 2.9 respectively. The discovery of filmy adhesions in the cul-de-sac fluid is suggestive of a past or chronic infection. The most common presentation is abdominal swelling (mass + ascites). The optimum dose of cisplatin is not known but several trials have failed to show an advantage by increasing the cisplatin dose.
Approximately 1 in 100 women will develop the disease and two thirds will die from their malignancy. Most bowel symptoms are not due to the presence of endometriosis on the surface of the bowel itself. History of presenting symptoms Type of symptom Site Nature of symptoms (persistent/recurring) When first noticed Duration Actions that relieve symptoms Findings to note Firm resistance on abdominal palpation Unexpected fullness Fullness with shifting dullness on percussion Hard, irregular mass in the Pouch of Douglas Adnexal masses
There are no randomised data on the role of regular CA125 and ultrasound testing but it is likely that in some patients relapses will be detectable earlier and treatment initiated to control or prevent symptoms. None of these findings are diagnostic. Patients who relapse and have responded previously to platinum based treatment may respond again to the same treatment; the likelihood of response is related to the length of time since the prior treatment (98). Patient enquiries: email@example.com, Find us Secondary cytoreduction has not clearly been shown to improve survival in patients with recurrent disease but in some patients with small volume recurrence and a reasonable disease free interval this may be considered(105, 106).
If patients are unable to be optimally debulked for technical reasons, then they may be considered for “interval re-exploration” and “secondary debulking”. Patients who are unfit and may not tolerate combination chemotherapy should be considered for single agent carboplatin. All other high risk early stage disease patients should be offered 6 cycles of combination platinum/taxane chemotherapy. The clinical scenario of apparent advanced ovarian cancer, paradoxically with normal appearing ovaries is designated as extraovarian peritoneal cancer. Other agents that are active in this setting include paclitaxel, oral etoposide, topotecan, tamoxifen and taxotere (99-104). Management options for patients in categories (i) and (ii) include commencing chemotherapy and possible “interval reexploration” after 3 cycles, while cases in category (iii) may be considered for immediate re-exploration. Defined after complete surgical staging.
Abdominal discomfort, gastrointestinal or urinary symptoms, abnormal bleeding and weight loss are frequent symptoms. The number of patients who are alive at 10 years is less than 10%.
Hospital Provider Number: 0027350Y, Priority Access Prostate Cancer Assessment Service. Patients operated upon at other institutions prior to referral will fall into 3 categories (i). There is no consensus as to the optimal way of following patients after primary therapy. Abdominal discomfort, gastrointestinal or urinary symptoms, abnormal bleeding and weight loss are frequent symptoms. Withdrawl due to toxicity was higher in the DD arm. The average age at diagnosis is 50 years. Diagnosis is made at laparotomy. High Risk Disease: Stage IC and Grade 3(Stage IA and IB). Patients who are either unfit for surgical staging or it is felt that re-staging is inappropriate should be considered for adjuvant chemotherapy. 119-143 Missenden Road, Camperdown NSW 2050 If initial surgery is performed by a certified gyneacological oncologist, then interval surgery has not been shown beneficial. Ascites and pleural effusion (Meigs Syndrome) can also occur with benign ovarian tumours. • Large bowel The area behind the womb and in front of the rectum is called the Pouch of Douglas and endometriosis here often causes deep pain and painful intercourse, know as dyspareunia. Patient survival compares to patients with suboptimally debulked disease. This was despite the fact that many of the patients in the non-paclitaxel arm were treated at relapse with paclitaxel. There is no evidence that SLL improves outcome after completion of therapy and is not routinely recommended. One trial comparing 100 mg/m2 vs. 50 mg/m2 of cisplatin in conjunction with cyclophosphamide demonstrated an initial survival advantage that was not seen with further follow up. However if the surgery is thought to influence further management then this can be considered. The published survival results would suggest an inferior survival of patients receiving neoadjuvant chemotherapy compared to patients primarily optimally debulked. The outcomes for the combination arm were not different from the single agent cisplatin arm but the single agent paclitaxel was inferior in terms of survival and response rate. Those affected are usually postmenopausal. Australia. Added to the complications of administration this is not recommended unless there is considerable experience in this route of administration within a specialised unit (90, 91). However, it can rule out colon cancer, which can cause some of the same symptoms… However if initial suboptimal surgery is performed by a non certified gyneacological oncologist, then survival may be enhanced. While the majority are sporadic, 5-10% may have an hereditary component. Email us
Physical signs suggestive of malignant change in an ovarian tumour include bilaterality, fixation in the pelvis, nodularity on the surface or in the Pouch of Douglas, solid or semi-solid consistency and ascites. Variables associated with a negative SLL are: (i) initial stage (ii) tumor grade (iii) size of residual tumor (iv) the size of the largest metastatic disease (v) the number of lesions present prior to treatment (vi) the type of chemotherapy (vii) and CA-125 regression (94-97). Platinum combinations have a small (15%) survival advantage over single agent platinum out to the eighth year of follow up. Surgical staging accurately determines the extent of disease allowing for tailored postoperative therapy. For each 10% increase in maximal cytoreduction there is an associated increase in median survival of 5.5%(76). A higher proportion (55%) were suboptimally debulked compared to US trials. Rather, they are usually due to irritation from implants and nodules located in adjacent areas, such as the Pouch of Douglas, uterosacral ligaments, and rectovaginal septum. The prognostic features in these patients are the age of the patient, performance status, lower stage, smaller residual volume post surgery, serous pathology and the fall of CA125 following chemotherapy.
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