Dr. Sabyasachi Parida, Sr. Consultant, Surgical Oncology at KIMS Hospital was invited by the Global Cancer Institute to present an interesting case at their Gynae-Oncology Tumor Board on 18th October 2021. Global Cancer Institute is a non-profit organization focused on improving survival rates for underserved cancer patients worldwide. It works directly with physicians in developing countries to improve death rates from cancer by propagating simple interventions and programs that are proven to accelerate diagnosis, access and treatment.
Dr. Parida presented a challenging case of recurrent carcinoma Ovary in a patient, who had already undergone two major surgeries, once 9 years ago (Hysterectomy, removal of both ovaries and fallopian tubes, excision of Sigmoid colon deposit) and again 6 years ago (excision of right paracolic deposit, Rectal Deposit and precaval lymph nodes). She had her 2nd recurrence in the left side of her lower abdomen about 3 years back, but was put on chemotherapy with apparently good response. She had a large abdominal Hernia after her previous surgeries, had received multiple chemotherapy regimens, with significant cardiac toxicity (cardiomyopathy), Peripheral nerve toxicity (Grade IV Peripheral Neuropathy). All treatments were done at major institutions in Bhubaneswar and outside. BRCA mutation testing done outside was reported as negative (2019).
She had presented to KIMS with a recurrent lesion (3rd recurrence) in the left side of her lower abdomen in 2021 that was causing significant indentation of Left External Iliac Vein for 31mm and abutting Sigmoid colon, left external iliac artery and left ureter. Further evaluation did not reveal distant disease. Imaging was discussed with Dr. Manoranjan Mohapatra, Professor, Radiology and surgical plan made. CTVS backup requested, which was kindly provided by Dr. Chandan Kumar Ray Mohapatra, Consultant, Cardiothoracic Surgery.
The case was discussed in detail in The Tumour Board at KIMS and the plan of management explained comprehensively to the patient and her family members. Treatment of Ovarian cancer is preferably done by Primary Cytoreductive Surgery that removes the Uterus, ovaries, fallopian tubes, omentum (abdominal fat apron), peritoneal deposits with or without pelvic, paraaortic lymph node dissection. Secondary Cytoreductive Surgery usually removes recurrent disease and needs careful evaluation of the merits of surgery before embarking on another major invasive procedure.
Tertiary Cytoreductive Surgery involves a more complex decision making process and is an even more complex procedure and is applicable to a carefully selected subset of patients. The selection for surgery looks into the disease behaviour, response to chemotherapy, disease free interval, site of recurrence, patient symptoms and functional status among others.
In this case, the solitary site of recurrence required bowel resection and possible vascular surgery as indicated by the MR Angiography. The resection had to be precise, carefully avoiding any spillage of tumour or fecal matter, both of which would have led to disease upstaging/recurrence, contamination leading to intra abdominal abscesses. In addition to this, the patient had a large abdominal Hernia which required complex surgery, mesh repair. Any tumour spillage, contamination with fecal matter would have led to serious complications, disease recurrence, progression.
This challenging case was operated by Dr. Sabyasachi Parida and Dr. Saroj Ranjan Sahoo, both Senior Consultants, Surgical Oncology at KIMS. Preoperative left ureteric Stent placement done by Dr. Sumit Panda, Consultant, Urology. Patient underwent exploration of her abdomen, adhesiolysis, excision of the tumor deposit in to-to with the Sigmoid colon. All adjacent structures like vein, artery, ureter could be safeguarded with careful dissection and contamination of abdominal cavity by fecal matter avoided.
Restoration of bowel continuity was maintained by stapled Colorectal anastomosis, followed by reconstruction of her abdominal wall defect with Abdominal component release (anterior), placement of a large mesh. She did not have any significant bleeding or intra-operative complications. She is doing well. Further management was discussed in the Tumor Board at KIMS.
Experts from GCI appreciated the novelty of the case and its management and discussed further management, mutation tests and follow up. Present in the Multidisciplinary Team meeting were: Dr. Ilan Atlas, Head of Unit Gynaec Oncology at The BARUCHPADEH Medical Center, Bar Ilan University, Israel; Dr. Lan G. Coffman, Assistant Professor of Hematology- Oncology, University of Pittsburgh School of Medicine (focuses in research and treatment of Ovarian cancer); Dr. Anuja Jhingran, Professor, Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, Texas; Dr. Don S. Dizon, Director of Women’s Cancers, Lifespan Cancer Institute, Clinical Director, Gynaecologic Medical Oncology, Rhode Island Hospital.
The discussion opened up new dimensions that needed to be explored and reinforced the decisions taken in KIMS Tumor Board on further management.
Other invited Oncologists who presented their cases were: Dr. Katia Roque Perez, Instituto Nacionalde Enfermedades Neoplásicas from Lima, Peru and Dr. Elene Mariamidze from Acad. F. ToduaMedical Center, Tbilisi, Georgia, both of whom presented different cases of Carcinoma Cervix.
Meetings like this offer an insight into practice in different parts of the world and encourage collaboration, eventually leading to patient benefits and improvements in quality of care