To measure the importance of accessory chemotherapy after surgical direction of advanced malignant ovarian malignant neoplastic diseases in forecast and endurance of patients.
A prospective multidimentional survey was performed to analyze the intervention of all instances of Malignant ovarian tumors diagnosed and treated at the section of Gynaecology and OBs, Jinnah Postgraduate medical Centre, in coaction of Oncology section Jinnah Postgraduate medical Centre Karachi, during January 2001 boulder clay June 2002 is undertaken.
Patients profile consists of a thorough history, physical scrutiny, probes and diagnosing as were recorded in Performa. Data was analyzed by SPSS version 17.
During this survey period, Entire 16 instances of ovarian malignance were diagnosed and treated. Entire Gynecological malignances admitted during this survey period were 70. Among these ovarian malignance was the 2nd commonest with 22.85 % incidence rate following cervical malignant neoplastic diseases ( i.e, 54.28 % ) .
Majority of the patients have advanced disease at the clip of diagnosing, i.e, that is why these patients can non be treated with surgery entirely. Consequently, accessory chemotherapy has become a major intervention mode for this disease in progress phases.
Ovarian malignant neoplastic diseases, laparotomy laparoscopy, chemotherapy, radiation therapy, Intra peritoneal chemotherapy.
Ovarian Cancer is among one of the most deadly gynecological malignant neoplastic diseases. For more than two decennaries, Epithelial carcinoma of the ovary has been the figure one slayer of U.S Women.1
Approximately one in 70, American adult females develop ovarian carcinoma accounting for 4 % of all malignant neoplastic diseases in adult females. In United land, the incidence is 14.0 per 100,000 women.2
White females had well higher rates of ovarian malignant neoplastic disease than the black race. Similarly its rates are high in North America and Northern Europe and low in Japan.3
In a survey of gynecological malignant neoplastic disease in Faisalabad ( Pakistan ) , Ovarian malignant neoplastic disease was the most often found gynecological malignant neoplastic disease, incidence rate is 38.0 % .4
S.Jamal at EL, ( 1993 ) besides reported ovarian malignant neoplastic disease as the commonest gynecological malignance in their study.5
The primary intervention for early phase ovarian malignant neoplastic disease is surgery, which should imply a entire abdominal hysterectomy in add-on to bilateral salpingo-oophorectomy, and with or with out lymph nodes removal with complete surgical theatrical production of the disease. In state of affairss of boundary line ovarian malignant neoplastic diseases, where future birthrate is of import, a one-sided ovariectomy may be an option. For these patients and patients with phase I a good differentiated tumors, no extra therapy is indicated. These patients have a 10 old ages relapse rate of merely 10 % .6 All other patients with early phase ovarian malignant neoplastic disease should have accessory therapy as these have a 10 old ages relapse rate of 30-40 % .
More than two 3rd of instances are advanced at the clip of diagnosing, i.e, phase III and IV,7 and these patients can non be cured with surgery entirely. Consequently an accessory chemotherapy has become a major intervention mode for this disease. Cytoreductive surgery to cut down the diameter of the largest residuary mass to less than 1-2 centimeter consequences in better response to chemotherapy.
Since the late 1970 ‘s Platinum based chemotherapy, ab initio Cisplatin and more late Carboplatin, has been used as combination chemotherapy in advanced instances of ovarian malignant neoplastic diseases. However, despite improved response rates, Pt based combinations appear non to confabulate any extra advantage in footings of endurance as compared to individual agent Pt.
With cisplatin and cyclophosphamide intervention, long term control may be expected in less than 10 % of adult females with incompletely resected phase III and less than 5 % of adult females with phase IV disease.8 The forecast for patients with advanced ovarian malignant neoplastic disease remains hapless with reported 5 old ages survival rates runing between 15-20 % .9
Taxanes comprise of a new category of chemotherapy agents. These are originally obtained from the bark of Taxus brevifolia works. The petroleum infusion from this works is noticed to hold anti-cancer activity in 1963. Paclitaxel, the first taxane was identified and purified from the works in 1971.
Comparison of combination of paclitaxel & A ; Cisplatin with old intervention at that clip i.e cisplatin and cyclophosphomide, as first line chemotherapy in adult females with sub optimally debulked phase III, or phase IV ovarian malignant neoplastic disease demonstrated a significantly higher major response rate ( 25 % versus 19 % ) , and a 14 month over all advantage in endurance in favor of the paclitaxel incorporating arm.10 After this survey, cisplatin and paclitaxel are recommended as first line intervention for patients with ovarian malignant neoplastic disease.
But due to inordinate myelosuppression and centripetal neuropathy, unusual toxicity profile including hypersensitivity reactions, hairloss etc. are noted. Recent attempts are focused on measuring Carboplatin combination with paclitaxel.11 Another taxanes docetaxel, which has shown response rates of over 20 % in relapsed ovarian malignant neoplastic disease is presently being studied in combination with cisplatin in clinical tests.
Patients who do n’t react or get worse after initial chemotherapy have a comparatively hapless opportunity of remedy. Second line chemotherapy is given in patients who do n’t react to platinum compounds. Taxanes in assorted dose agenda achieve response rates of 10-50 % with average overall endurance of 10-12 months in patients with platinum furnace lining disease.12 Other drugs such as topotecan, gemcitabine and doxorubicin have shown activity as 2nd line intervention in Pt immune ovarian cancer.13
Intraperitoneal chemotherapy delivered high concentration of drugs straight to the tumor in peritoneal pit. It is most effectual in patients with little sized residuary tumor. Mitoxantrone and taxol are used in little volume in Pt furnace lining ovarian cancer.14
Patients and methods
A prospective multidimentional survey to analyze the function of accessory chemotherapy in all instances of malignant ovarian tumors diagnosed and treated at section of diagnosed and treated at section of Gynaecology and OBs in coaction with oncology section of Jinnah station alumnus medical centre Karachi, during January 2001 boulder clay June 2002 is undertaken.
Patients were admitted through out patient ‘s Department of Gynaecology and OBs, JPMC. In entire 52 Patients had undergone surgical intervention for ovarian tumors, out of which 16 were found to hold malignant ovarian tumor.
Patient ‘s profile consists of a elaborate history including her age, para, showing ailments, associated ailments, continuance of symptoms, any intervention taken for these ailments prior to admittance, etc.
History of weight loss, anorexia and intestine wonts, catamenial history, household history of malignant neoplastic disease were besides recorded. Socioeconomic position of Patients was noted every bit good.
A full general physical scrutiny every bit good as systemic scrutiny was performed with exceptional accent on abdominal and pelvic scrutiny.
Probes include all the baseline probes like complete blood count, liver and nephritic map trials, serum electrolytes etc. X beam thorax, venters and pelvic girdle, serum CA-125 degrees, Intravenous pyelography, echography, Doppler imagination, C.T Scan and MRI etc were besides performed.
After surgery patients were refered to oncology section where they were registered and chemotherapy was given to them as decided by oncologists. Afterward they were admitted for chemotherapy intervention farther follow up was done in OPD. A specially designed proforma was used to enter information which was analyzed by SPSS version 17 with descriptive statistics.
This survey was conducted at Department of Gynaecology and OBs in coaction with Oncology Department, Jinnah postgraduate medical centre, from January 2001 to 2002.
Gynecological malignances admitted during the survey period were 70. Among which cervical carcinoma was the most common malignant neoplastic disease i.e, 54.28 % ovarian cances ranked as the 2nd most common gynaecologic malignance with 22.85 % ( n=16 )
During this survey period, 52 laparotomies were performed in entire for ovarian tumors. Out of which 16 ( 30.76 % ) were malignant and 36 were found benign tumors. ( Table I )
Age of the patients ranges between 15-80 old ages with 68.75 % were below 40 old ages of age. Majority of patients ( 75.0 % ) were married and multi parous i.e, ( 43.75 % ) and 6 patients were nulliparous i.e ( 37.50 % ) merely 4 patients ( 25.0 % ) were menopausal.
Sing clinical presentation of ovarian carcinomas, bulk of the patients i.e, 14 patients ( 87.50 % ) were presented with hurting in venters followed by abdominal distention in 8 patients ( 50.0 % )
Menstrual abnormalities were present in 3 patients ( 18.75 ) while backache in 5 patients ( i.e, 12.50 % ) each.
Duration of symptoms was less than 6 months in most of the patients i.e, 10 patients ( 62.50 % ) .
Adenexal mass was the most common clinical determination in scrutiny presented in 14 patients ( 87.50 % ) , ( Table II. )
Entire abdominal hysterectomy bilateral salpingo-oophorectomy and Infracolic omentectomy with or without lymph nodes remotion was the intervention in most of the patients ( 7 patients i.e 43.75 % ) . Staging of the tumor shows that 8 patients ( 50 % ) were holding phase I disease, 3 patients ( i.e 18.75 % ) had phase II disease and phase III disease each. While 2 patients ( 12.5 % ) were presented with phase IVdisease.
Histopathology showed predomination of epithelial tumors, found in 11 patients ( i.e 68.75 % ) .
Majority of patients ( 14 patients i.e 87.50 % ) received chemotherapy after primary surgery. Chemotherapy was non advised to one patient with low hazard malignance. One patient with krukenberg tumor was planned to hold chemotherapy but she expired before having it. ( TableIII )
Most of the patients suffered from GI jobs like sickness, purging and diarrhea ( 6 patients i.e, 37.50 % ) . Five patients ( 31.25 % ) ailments of febrility, while 4 patients had icterus and disturbed liver map trials, so their chemotherapy was stopped till their trials become normal and so restarted once more. Patients with haematologic toxicity presented with anaemia, low white blood cell counts and low thrombocytes count received blood or thrombocytes transfusion consequently ( Table-IV ) .
Entire 3 patients expired. All belonged to present III and IV disease. Two patients of phase I lost follow up. Rest of the patients were on a regular basis followed up in out patient clinics. ( Table V )
There have been assortment of intervention modes used for intervention of ovarian malignant neoplastic diseases since the early 1970 ‘s including surgery, chemotherapy and seldom radiation therapy. Despite all these progresss in intervention, the 5 twelvemonth endurance rate by phase for the disease has changed small, staying at around 30 % over all.
The chief ground for the hapless out semen is late diagnosing. Patients normally present with advanced disease.
Surgery is considered as the best intervention for the ovarian malignant neoplastic diseases. All our patients included in this survey underwent surgery. Different processs were performed harmonizing to extent of disease. These include recommended processs of Entire Abdominal Hysterectomy, bilateral salipingo-oophorectomy, Omentectomy with or without pelvic nodes removal to Unilateral salpingo-oophorectomy etc.
Histologic distribution of ovarian malignant neoplastic diseases in our survey showed the predomination of Epithelial ovarian carcinoma accounting for 68.75 % of all instances, which is consistent with other surveies. Costa MJ15, besides described serous epithelial carcinoma as the most preponderantly happening epithelial carcinoma in their survey ( i.e, 65.4 % ) .
Following primary surgery, all of our patients received systemic endovenous combination chemotherapy largely in 6 classs as prescribed by Oncologist. Patients were transferred to Radiology Department of Jinnah Post Graduate Medical Centre, where they received systemic chemotherapy harmonizing to tumour scaling and theatrical production. Patients with tumors of low malignant potency were non subjected to chemotherapy. None of our patients received Intraperitoneal chemotherapy.
Now a yearss, Intra peritoneal chemotherapy is preferred over endovenous chemotherapy. Multiple surveies have shown that regimens including intraperitoneal chemotherapy are superior with respect to progression free endurance and overall endurance in adult females with phase III, residual less than 1 cm epithelial ovarian malignant neoplastic disease in the short and average term compared to the standard 6 rhythms of endovenous chemotherapy16. The long term disease survival rate at 8 old ages is, nevertheless, remained unchanged.17
Dr. Joan L, Walker, MD and colleagues,18 in a comparative survey identifies the challenges associated with the disposal of Intraperitoneal chemotherapy in concurrence with endovenous chemotherapy. They conclude that intra peritoneal chemotherapy ‘s success is dependent upon appropriate surgical resection, patients choice and preparation of doctors and nurses.
Sing side effects, GI perturbations including sickness, purging and diarrheas were the commonest. Some patients besides ailments of abdominal distention which was developed due to ascites and metastasis in other variety meats, which is consistent with other surveies, demoing anemia, weariness, giddiness etc. Bowel symptoms, leucopenia, impermanent hairloss and thrombopenia etc.
Prognosis and endurance:
Out of entire 16 instances reviewed, two patients ( 12.50 % ) were lost to follow up. One patient was expired prior to chemotherapy. Of staying 13 patients, 10 ( 62.50 % ) were alive. Most of these patients were presented with early phase disease. 3 out of 5 patients, who presented with FIGO phase III and IV were died due to this deadly disease.
Surgery is said to be the definite intervention for ovarian malignant neoplastic disease but is non the complete intervention. Adjuvant chemotherapy, has an of import function in pull offing these patients side by side with surgical direction. Now a yearss, Intraperitoneal chemotherapy is more popular than the everyday systemic endovenous chemotherapy. With the careful choice of the patients, intraperitoneal chemotherapy has been associated with addition in survival rates in the initial tests. Consequences of farther tests will make up one’s mind the optimum manner of chemotherapy in ovarian malignant neoplastic disease intervention.