ORIGINAL RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10006-1923 |
A Case Series of Peritonectomy done in Different Histopathological Patterns of Ovarian Cancer Cases: A Critical Analysis
1–4Department of Gynecological Oncology, Acharya Harihar Postgraduate Institute of Cancer, Cuttack, Odisha, India
Corresponding Author: Agniv Sarkar, Department of Gynecological Oncology, Acharya Harihar Postgraduate Institute of Cancer, Cuttack, Odisha, India, Phone: +91 7980060869, e-mail: sarkaragniv@yahoo.in
How to cite this article: Sarkar A, Mahapatra M, Parija J, et al. A Case Series of Peritonectomy done in Different Histopathological Patterns of Ovarian Cancer Cases: A Critical Analysis. J South Asian Feder Obst Gynae 2021;13(5):297–300.
Source of support: Nil
Conflict of interest: None
ABSTRACT
Background: Peritoneal dissemination is the most common mode of spread for cancer ovary. Total peritonectomy (PRT) refers to removal of all peritoneum and total omentectomy. Here we have analyzed PRT in five different histopathological variants of ovarian cancer.
Case descriptions: Five different cases were operated in our institute in last 1 month. All are having different histopathological patterns and underwent cytoreductive surgery (CRS) with PRT achieving surgical complexity score (SCS) of 8. They were not associated with any major complications due to proper PRT. PRT has been done here by blunt dissection.
Discussion: The PRT is feasible with acceptable complication rate and hospital duration. In our case series, only two people had major injury that too due to the tumor properly not due to PRT.
Conclusion: The PRT must be done in all cases of carcinoma ovary as part of the CRS procedure. It is reproducible, feasible, and without much complication.
Keywords: Cytoreductive surgery, Epithelial ovarian cancer, Peritonectomy, Surgical complexity score.
INTRODUCTION
Peritoneal metastasis is the most common metastasis in ovarian cancer. These cases usually recur with intra-abdominal and pelvic metastasis along with ascites. These cases are diagnosed as stage III or IV ovarian cancer with diffuse PC.1,2 Treatment of these condition is usually based on cytoreduction surgery (CRS) combined with systemic carboplatin- and paclitaxel-based adjuvant chemotherapy.
Despite good response by these agents, 50% of the cases recur in 2 years after chemotherapy and almost all cases recur by 5 years.3
In most of the cases, natural history of EOC happens to be confinement of disease to the abdominal cavity. For this reason, new integrate therapeutic strategies have emphasized the role of local aggressive treatments represented by maximal CRS peritonectomy (PRT) combined with loco-regional (hyperthermic intraperitoneal chemotherapy) HIPEC.4,5
Peritonectomy (PRT) associated with HIPEC has been used since the second half of the 1990s in the treatment of ovarian PC, as well as in other primary and metastatic peritoneal surface cancer. Complete parietal peritonectomy (CPP) includes the removal of all peritoneum including parietal and pelvic peritoneum and total omentectomy. selective parietal peritonectomy (SPP) refers to selective removal of diseased peritoneum. Total omentectomy includes the removal of both greater and lesser omentum.6–8
Here we are discussing five cases of PRT done for different histopathological patterns of ovarian cancer and analyzed the perioperative morbidity as well as feasibility of performing the surgery without much of the complication.
CASE DESCRIPTIONS
Case 1
A 40-year-old woman complained of abdominal distension for 8 days with pain abdomen. She is P2L2, with both vaginal delivery and last childbirth 13 years back. On examination eastern cooperative oncology group (ECOG)—0, BMI—19.8, moderate ascites on abdominal examination and per vaginal examination revealed right-sided ill-defined lesion of 6 × 6 cm and left fornix fullness. Her CA125 level was 594 IU/L; contrast enhanced CT scan (CECT) reveals bilateral ovarian mass of 8 × 6 × 6 and 6 × 4 × 4 cm3 with no lymphadenopathy. Her endoscopy and colonoscopy were normal. She was planned for primary cytoreduction. Frozen section showed serious cystadenocarcinoma. She was subsequently discharged on day 7. Her HPE report came out to be high-grade serous carcinoma (HGSC) with omental and peritoneal deposits of 3 × 2 cm. She was staged to be IIIC.
Case 2
A 64-year-old woman complained of abdominal distension for 21 days with pain. She has no other comorbidity. She is P4L4 all VD LCB—21 years. On examination, she had ECOG—0, BMI—21.2, a 10 × 8 cm-sized mobile nontender solid cystic mass felt in the right-sided iliac fossa region with ascites. Same finding was found on PV examination. Her investigation showed CA125—233.4 IU/L and carcinoembryonic antigen (CEA)—14.1 IU/L. Her endoscopy and colonoscopy were normal. CECT showed a mass of 12.4 × 10 × 8 cm predominantly solid with cystic degeneration present with ascites and no nodal involvement. She underwent CRS with PRT. Frozen section showed endometrioid adenocarcinoma. She was subsequently discharged on day 8. Her HPE report showed to be endometrioid carcinoma of ovary with lymph node positivity. She was staged IIIa.
Case 3
A 58-year-old woman came with the complain of abdominal distension for 1 month associated with anorexia. She is P2L2 all VD. Clinically she is cachectic, ECOG 1, BMI—16.6, moderate ascites with 28-week-sized cystic mass with reduced mobility. Ascitic tapping had mucinous characteristics. CA125 level was 102.4, CEA—118 IU/L. Her endoscopy and colonoscopy was normal. Her CECT report showed a large cystic well-defined 21 × 16 cm-sized mass with ascites and the presence of para-aortic lymph node enlargement. Her fine needle aspiration cytology (FNAC) report showed to be mucinous neoplasm, and she subsequently underwent CRS with PRT. She was discharged on day 14. Her HPE report showed mucinous cystadenocarcinoma of ovary with peritoneal deposits of 3 × 3 cm. She was staged IIIC.
Case 4
A 30-year-old woman came with the complain of abdominal distension for last 15 days associated with anorexia. She is P3L3 all VD and LCB—7 years. Clinically she was cachectic, ECOG—1, BMI—17, gross ascites with 36-week-sized predominantly solid mass with variegated appearance and reduced mobility. Her CA125— 626 IU/L, CEA—36.44 IU/mL, AFP—598 IU/L, β-hCG—10.26 IU/L, LDH—523 IU/L. CECT reveals a large 42 × 30 cm mass with ascites and enlarged para-aortic lymph nodes and peritoneal deposits. She underwent CRS with PRT and subsequently discharged on day 7. Her HPE report showed mixed germ cell tumor with yolk sac (50%), dysgerminoma (30%), and choriocarcinoma (20%) with positive lymph nodes and large peritoneal deposits. She was staged IIIC.
Case 5
A 23-year-old nulliparous patient presented with abdominal distension for 3 months. On clinical examination, she was ECOG—1, BMI—22.5. Fixed bilateral mass with POD deposits were found. She was subsequently planned for NACT for three cycles after FNAC reveals high-grade serous tumor. She was readmitted for IDS. Her prechemo CA125 was 1600 IU/L. Rest all markers were normal. CECT showed 12 × 10 cm-sized heterogeneous cystic mass with omental thickening.
Her postchemo CA125 was 92.1 and postchemo CECT showed 10 × 8 cm-sized mass with no omental thickening reported. She was put for IDS with PRT and discharged after 8 days (Tables 1 to 3 and Figs 1 and 2).
| Case | Age | BMI | Parity | ECOG | CA125 | CEA/LDH/AFP | Lymph node on CECT | Omentum/peritoneum on CECT |
|---|---|---|---|---|---|---|---|---|
| Case 1 | 40 | 19.8 | P2L2 | 0 | 594 | 1.03 | NIL | NIL |
| Case 2 | 64 | 21.2 | P4L4 | 0 | 233.4 | 14.1 | NIL | NIL |
| Case 3 | 58 | 16.6 | P2L2 | 1 | 102.4 | 118 | PALN+ | 3 × 3 cm peritoneal deposit |
| Case 4 | 30 | 17 | P3L3 | 1 | 626.6 | AFP—598 LDH—423 β-hCG—8.37 CEA—36.4 |
PALN+ | 3 × 4 cm deposit |
| Case 5 | 23 | 22.5 | NULLI | 1 | 1600 PRE |
CEA—1.06 AFP—6.02 LDH—250 |
NIL | NIL |
| 92.1 POST | β-hCG—0.25 |
| Case | PCI | CC | SCS | Duration | Blood loss | Complication |
|---|---|---|---|---|---|---|
| Case 1 | 18 | 1 | 8 | 2.5 hr | 400 mL | Seromuscular breach of bladder |
| Case 2 | 12 | 0 | 8 | 2.5 hr | 500 mL | Nil |
| Case 3 | 39 | 3 | 8 | 3.5 hr | 1 L | Bowel injury |
| Case 4 | 18 | 1 | 8 | 3 hr | 500 mL | Nil |
| Case 5 | 13 | 2 | 8 | 3 hr | 700 mL | Nil |
| Case | Stay | SSI | SAIO | Drain collection | HPE | Stage |
|---|---|---|---|---|---|---|
| Case 1 | 7 | + | + | 2 L in 6 days | HGSC | IIIC |
| Case 2 | 8 | − | + | 1.2 L in 4 days | ENDOMETROID | IIIA |
| Case 3 | 14 | − | − | 3 L in 10 days | MUCINOUS | IIIC |
| Case 4 | 7 | − | 2 L in 6 days | MGCT | IIIC | |
| Case 5 | 8 | + | − | 2.5 L in 6 days | HGSC | IIIA |
Fig. 1: CRS with SCS 8
Fig. 2: Postleft peritonectomy
DISCUSSION
In our institute, we operated five different cases of carcinoma ovary with CRS and PRT in 1 month. We achieved optimal cytoreduction (CC0,1) in four cases having PCI score within 20. One case having PCI 39 was suboptimally debulked because of the presence of disease in bowel and other viscera. Total parietal and pelvic PRT was done in all the cases with mean SCS 8 in all cases. Two cases had postoperative subacute intestinal obstruction that was found to be due to electrolyte imbalance and managed medically. However, our subsequent experience guided us that late initiation of roughage and prolong postoperative liquid diet for 80-90 hours reduce the chances of SAIO. Two patients had SSI which was not related to the procedure and analyzed to be associated with diabetes and poor nutritional status again reduces with early ambulation and albumin infusions postoperatively. Apart from one case, rest of the cases were completed within 3 hours which is reasonable as PRT performed by our institute is a blunt method which is done with ease and rapidity without much blood loss. Intra-abdominal collection on an average 2-2.5 L requiring drain to be placed for average 5 days. However, we saw with albumin infusions and octreotide injection. This collection can be reduced. Only two cases had major complication, one of which was bowel injury and another was bladder seromuscular tear. The bowel injury was because of the locally advanced disease and occurred during surgical clearance not related to PRT. Bladder seromuscular tear occurred during the process of pelvic PRT which was managed with few stitches of vicryl 2'0. Average hospital day duration was comparable to CRS without PRT. We did PRT with blunt dissection technique and there were no complications associated with the technique of PRT (Figs 3 and 4).7,8
Fig. 3: Subdiaphragmatic stripping
Fig. 4: Postoperative picture
CONCLUSION
Cytoreductive surgery with PRT with complex SCS score is feasible in case of carcinoma ovary after proper selection of patients with acceptable complication rates and duration of hospital stay. PRT by blunt dissection is easily duplicable, less time-consuming, and without much complication. Hence, it should be an integral part of surgical exercise of CRS for all histopathological patterns of carcinoma ovary irrespective of the availability of concurrent HIPEC therapy. However, long case series with follow-up are required to further validate PRT as an integral part of CRS irrespective of HIPEC.
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