Q)You have just performed a laparotomy on a 60year old woman and found an inoperable adenocarcinoma of her right ovary. Justify your subsequent management.
Explain diagnosis to the patient: Cancer advanced. Removal could have caused complications with bowel/bladder/ureters/death intra-operatively or in the immediate post-operative period. De-bulking tumour does not improve survival.
Tailor management according to patient\'s wishes and level of fitness.
Discuss chemotherapy.Pros:May result in reduction in tumour bulk in advanced ovarian ca. Reduction in tumour bulk may help if and when surgery needed for bowel obstruction. May shrink tumour enough for surgical excision after chemo completed. May improve survival but individual response difficult to predict.
Cons: side effects and routes of chemo.
Offer a follow up appointment to discuss matters further/ clarify any questions/concerns.
Liase with oncology team and palliative care services to manage symptoms.
Eg Ascites: parencentesis; Anaemia: top-up transfusions; Pain: step wise approach using analgesia ladder. Secretions: hyoscine.
Liase with social workers re support care at home. Refer to hospice for respite care. Occupational therapy, to assess level of support needed at home and if any physical aids required.
Keep GP informed.
Consider referral to psychologist as diagnosis may result in depression.
I\'m probably daft, but really struggled with this one.
Posted by clarice M.
p.s
I really want to put down intraoperative biopsy, but given that the term \"adenocarcinoma\" is already mentioned in the question, I don\'t know if this would be appropriate.
Posted by Mark D.
i doubt debulking does not improve prognosis\"
i feel
inform diangosis sensitively
arrange MRI ,chest xary for radilogical staging.
refer to GOC
willlneed pleural fluid tap to detect malig cells - if positv stage 4b
if neg -
aggresive or optimal debulking according to stage/fitness/ wishes of pt ( can be done even in stage 3)- given in shaw.
if stage 4 b then chemo palliative intent
brief the pt with onco nurse. prognosis, 5 yr survival, hpe rep.
aim to keep tumor mass less than 1.5 cms for optimal response to chemo.
post op chemo after 6 weeks either single agent or TAX+_ carboplt dep on the fitness of pt.
counsel on efficacy,risk s n side eff of chemo on immediate n long term QOL.
f/o
if recurr - re chemo if was carboplat sensitive if resistant may consider 2 nd line agents but no single agent can be recomended - as none proven to improve 5 yr survival.
paliative care.
supp gr,
Posted by clarice M.
Mark,
I\'m not sure that debulking will improve survival in this particular patient with inoperable cancer.
Neoadjuvant chemo has the advantage of shrinking the tumour mass with subsequent optimal cytoreduction. It also \"selects\" patients in whom aggressive surgery may not have improved survival anyway due to a chemo-resistant tumour.
Mr Ayuk, any thoughts, comments and suggestions?
Posted by Manoj M.
I would not argue about debulking is beneficial or not because the question says \'\'inoperable\'\' and subsequent management.
Place of surgery done cancer unit or cancer centre
planned or emergency surgery
Examine liver, spleen,under surface of diaphragm etc to know extent of surgical staging.
Tissue confirmation is important beneficial for chemotherapy( primary ovarian or metastatic ovarian)
Thromboprophylaxis
Dont forget cancer specialist nurse and emotional support for patient and carers.
Posted by Anjum M.
Farther surgery for malignant bowel obstrution in pts with advanced cancer must be justified on the basis of acheiving a significant benifit
Symptoms of bowel obstrution can be relieved by antiemetic,antisecretory,analgesic corticosteriods
Posted by Amr G.
Hi every body,
well for this particualr question there is a lot to comment about:
1. Inoperability may implicate an under pre operative evaluation of this woman.
2. Being inoperable doesnt help a lot in Staging of this particular woman, which is mostly Satge 3 c or over.
3. Optimum debulking is proved to affect future prognosis and survival however weighing the risk and benifit for this particular patient I dont think it would affect survival porsitively.
4. Post operative re investigation has to be done as MRI, CXR, aspiration of pleural effusion if not already been done preoperatively in order to be able to counsel this woman properly regarding her prognosis , 5 years survival and options of treatment which include chmotherapy aiming for interval debulking.
4. Multidisciplinary team has to particiapte (Gyn Oncologist surgeon, Clinical oncologist, Pathologist and Psychiatric if needed for supprot)
