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Forum Name: Ovarian Cancer

Question: 2nd recurrence of clear cell Ovarian Carcinoma need help.


 indrasis - Mon Sep 15, 2008 4:03 am

My mom under went total hysterectomy with partial omentectomy in March 2006. When her CA 125 was 46.8.
Biopsy 1
Biopsy report revelaed 'CLEAR CELL' carcinoma of left ovary along with cervex.
Chemo:
Received 6 cycles of Cisplatin(300)+Taxol (60) upto September 2006.
CA 125 showed gradual decrease and remained stable from September 06 to in April 2007.CA 125 in April 2007=11.4.
In Dec 07 she was diagonised with an Omental cake of 3.17x2.7cm. Infracolic omentectomy done in January 08.
Biopsy 2:
Peretoneal washing showed no malignancies.but omental cake showed infiltrating malignant cells.
CA 125 came down to 22.4 in February 08.
Chemo 2:
She received 4 cycles of lipodox(doxrubicin) and cyclophosphamide and 2 cycles of 5FU(Oral).
Again in September 08 her CA 125 showed increase to 128. And CT scan revealed only One 3.17x2.44Cm Retroperetonial coeliac node.

My mom is totally asymtomatic and living with full energy and activities. Her Onco surgeon is suggesting wait and watch for 6 months for another CT and CA 125.But medicine Doctor for 1 month for another CA 125 and FNAC if possible as they both say it's an unususal kind isolated recurrence for Clear cell.

My questions are
1) Can we ensure that this is a recurrence?
2) What is the progress rate of the disease as it is always recurring in an isolated and single place and is one enlarged lymph node a better recureence than leisons or soft tissue mass?
3)If it is recurrence Should we go for surgery followed by chemotherapy or only chemothrapy?
4)Now what is the best chemo regimen for her?
Pls help me as I am waiting for a better treatment option for her.
 Dr. Safaa Mahmoud - Wed Oct 08, 2008 1:22 pm

User avatar Hello,
Ovarian cancer is the fifth common cancer in females in the United States. Epithelial tumors are the most common pathological subtypes of ovarian cancer that include clear cell histology.

The primary treatment is appropriate surgical staging and optimum debulking (a residual of <1cm). Comprehensive staging laparotomy, total abdominal hysterectomy (TAH) and bilateral salpingo-oopherectomy (BSO) compose the standard surgical approach. A biopsy or resection any suspicious area or LN should be done accordingly. The omentum should be resected from the transverse colon (an infracolic omentectomy).

Most cases are given chemotherapy after adequate surgical staging and optimal debulking except for stage Ia-b grade 1(tumor confined to one or two ovaries without ascites or positive peritoneal wash).
Standard chemotherapy regimen is composed of
Paclitaxel, 135 to 175 mg/m2 (given before carboplatin or cisplatin, or Docetaxel 60-75 mg/m2) and
Carboplatin, AUC 5 to 7.5 (or, cisplatin, 75 mg/m2).

According to the information you provided, your mother was staged II (at least) for which optimal debulking then adjuvant chemotherapy is recommended.

Patients who relapse after 6 month interval from treatment can be offered platinum containing therapy including:
Carboplatin+Gemcitabine
Carboplatin+Paclitaxel
Oxaliplatin+Docetaxel
Other active agents include etoposide, cyclophosphamide, ifosfamide, vinblastine, vincristine and liposomal.

5FU (and leucovorin) mainly in combination with oxaliplatin has been tested only in phase II studies and was proved to be active in platinum sensitive epithelial ovarian cancer patients, however it is not yet part of the standard of care in recurrent ovarian cancer.

Patients who have relatively long disease free interval (>6mo) and develop a localized resectable recurrence can go a second optimal debulking and chemotherapy.
Watchful waiting is an acceptable approach for those who have a rising CA125 as a sole evidence of disease relapse.

Regarding your question of how to ensure that this is a recurrence, a rising CA125 and development of new lesion by CT scan are strong evidences of disease recurrence on which many oncologist take treatment decisions.

Pelvic and para-aortic lymph node metastases are not uncommon in ovarian cancer. Although an isolated celiac node metastases is unusual presentation exclusion is not possible especially with rising CA125. Pathological evaluation of this node is the only way to confirm its nature.

Although your mother was progressing on chemotherapy, she has a relatively low tumor burden and a good general condition that makes her chances with salvage approaches very encouraging. There are different chemotherapy regimens that can be utilized in her condition as mentioned above. Going for surgery before second line chemotherapy is a decision taken by both medical and surgical oncologists.

Follow up with her doctor is essential and you can discuss with him all your questions. If you would like to go for a second opinion it is also a valid option.

Please keep us updated.
Best regards.
 indrasis - Sun Dec 21, 2008 2:14 am

Thank you doctor for your exellent reply. To update you more on my mother's report I would like to let you know her present report what was done a week back.

Recent USG after 4 months from last test which revealed a paraaortic coeliac node with dimension 3.17x2.44Cm report shows the old node has increased in size to 4cmx3cm and another 2 more nodes with smaller dimension of 2x2.5 cm.

Most of the doctors are suggesting Gemicitabine with Carboplatin for 2 cycles followed by Retroperetoneal Lymph node dissection. And probably from st week of January,09 she will be under treatment.

My questions are
1) As I came to know that Isolated recurrence of lymh nodes have exellent progonostic outcome than recurrence in other organs.

2) From the history of the disease can we say that Disease is slow progressing or A less aggressive disease?
3) Would Chemo be the only solution for her (I mean do nodes response to chemo? and is Surgery must? )and if Surgery is done what is the statistics of long term remission considering her history of disease.

I am sorry to load a lot but you can understand the way we depend on doctors an specially when we get chance to ask something to an expert like you.
Thanks a lot again
Indrasis
 indrasis - Sun Dec 21, 2008 2:17 am

Forgot to tell you that her CA125 raised to 536 from 128 in this 4 monts.

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