Ovarian carcinoma: Abdominopelvic irradiation following reexploration

doi:10.1016/S0090-8258(88)80023-4

Gynecologic Oncology

Volume 31, Issue 3, November 1988, Pages 396-401

https://doi.org/10.1016/S0090-8258(88)80023-4 Get rights and content

Twenty patients with ovarian cancer, who following reexploration were left with residual disease nodules of <2 cm diameter, received abdominopelvic irradiation. Of these patients 18 had previous chemotherapy. Fifteen patients completed treatment, 13 of whom had prior chemotherapy. Six of the 18 patients with invasive tumors were alive and disease free 18–53 months postradiotherapy, while only 4 patients had died at the time of follow-up. No patient with residual nodules >1 cm remained disease free. There was no difference in outcome between patients with microscopic or macroscopic <1 cm residuum. Complications were acceptable with 3/20 (15%) developing treatment-related intestinal obstruction.

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Cited by (10)

Is there place for radiotherapy in the treatment of advanced ovarian cancer?
1999, Radiotherapy and Oncology
Background and purpose: Irradiation of advanced ovarian cancer has been performed during the years 1976–1984 with six-field technique. Results of this treatment in a long follow-up have never before been evaluated.
Material and methods: Seventy-five patients with stage IIb–IV of invasive ovarian cancer have been treated with a combination of surgery, radiotherapy and chemotherapy. The results of the treatment were compared with 98 patients treated during the year 1991–1992 with surgery and chemotherapy only.
Results: After controlling for the differences in background factors between the groups considered, there was still a significantly better survival rate for the patients treated with radiotherapy.
Conclusion: The results suggest that the role of radiotherapy in advanced ovarian cancer should be investigated in a prospective randomized trial.
Whole abdominal radiotherapy following second-look laparotomy for ovarian carcinoma
1999, Gynecologic Oncology
Aim. The safety and efficacy of whole abdominal radiotherapy was evaluated as salvage or consolidation treatment for ovarian cancer patients treated with primary surgery and chemotherapy, followed by second-look laparotomy (SLL). Overall survival and acute and late toxicity of treated patients were assessed.
Methods. Patients were recruited between April 1981 and June 1994. All patients had SLL performed at Royal Prince Alfred Hospital after completion of primary chemotherapy. Data collected included demographic details, diagnosis, tumor stage, histology, grade, adjuvant chemotherapy, and radiotherapy. Radiation dose and fractionation, field size, boost volume and dose, failure to complete treatment and treatment interruptions, renal dose, and acute and late toxicity were recorded.
Results. Fifty-one patients were evaluated; the median age was 51 years. Median follow-up for patients still alive was 62 months. Prior to 1988, chemotherapy comprised oral chlorambucil, with or without cisplatin (n = 25), while after this date all patients (n = 26) received primary cisplatin-based therapy. A radiation dose of 22.5 Gy over 22 fractions was planned to the whole abdomen followed by a pelvic boost of 22 Gy in 11 fractions. Radiotherapy was completed in 37 (73%) patients. Treatment interruptions were necessary in 12 (24%) patients. Thrombocytopenia, neutropenia, nausea, vomiting, and diarrhea were the main causes of incomplete or interrupted treatment. Late bowel toxicity was seen in 6 (12%) patients, 2 of whom required laparotomy to relieve obstruction. There were no treatment-related deaths. Seven of the 51 patients are alive and free of disease, 2 died from other causes, and 2 are alive with evidence of recurrent or progressive disease. Mean follow-up time for surviving patients is 78.5 months. Overall survival at 2, 5, and 10 years was 65, 27, and 10%, respectively. Residual disease after primary surgery, smaller preirradiation tumor residuum, and completion of radiotherapy were independently associated with improved overall survival.
Conclusion. In this poor-prognosis group of patients, a combined approach of surgery, chemotherapy, and radiotherapy, while associated with acceptable toxicity, may not afford a prolongation of survival.
Salvage whole abdomen radiation therapy: its role in ovarian cancer
1993, International Journal of Radiation Oncology, Biology, Physics
$Purpose$ : In spite of high initial response rates, many patients with epithelial ovarian carcinoma eventually fail their primary treatment. Further treatment with second-line regimens has been ineffective in producing durable responses. Thus, whole abdomen radiation therapy was evaluated as a salvage therapeutic modality as to its feasibility, efficacy, and toxicity.
$Methods and Materials$ : Between June 1983 and June 1990, 44 patients who failed one or more chemotherapeutic regimens were treated with whole abdomen radiation therapy. Forty patients had epithelial carcinoma of the ovary and the remaining had primary adenocarcinoma of the peritoneal cavity. Radiation was delivered with an open-field technique and 2500 cGy were planned to the whole abdomen, with a boost when indicated. Prior to radiation, the amount of residual disease after debulldng was noted to be microscopic in one-half of the patients and macroscopic in the other half. Pelvis alone was the site of residual disease in 14 patients, and upper abdominal involvement was found in 30.
$Results$ : Five patients (11%) were unable to complete the planned therapy secondary to acute toxicity. The 4-year actuarial survival and recurrence-free survival rates for the entire group were 23% and 22%, respectively. The survival and recurrence-free survival rates for the group with microscopic residual disease at 37% and 42% were significantly better than those for the patients with macroscopic residual disease at 9% and 5% (p < 0.005; p < 0.001) at 4 years, respectively. Patients with disease limited to pelvis only had a recurrence-free survival of 56% compared to 0% when the upper abdomen was involved (p < 0.005). The abdomino-pelvic cavity was the first site of recurrence in 28 of 31 patients in whom the site of recurrence could be determined. Eight patients (18%) experienced bowel complications, of whom five needed surgical intervention.
$Conclusions$ : Whole abdomen radiation therapy with a pelvic boost is feasible with acceptable acute and late toxicity. It is effective in patients with minimal residual disease.
Is there a role for consolidation or salvage radiotherapy after chemotherapy in advanced epithelial ovarian cancer?
1993, Gynecologic Oncology
Cure rates following surgery and platinum-containing chemotherapy in advanced epithelial ovarian cancer are only 20-30%. Relapse rates even after complete chemotherapy responses or those leaving only microscopic residual disease are disappointingly high at 30 to 80%. Strategies to improve outcome, consolidate the results of surgery and chemotherapy, or salvage those with residual disease include whole-abdominopelvic irradiation. This paper reviews its usage to date in 28 trials. The results of sequential therapy are generally disappointing, possibly because of inappropriate patient selection, toxic regimens, underlying biological factors, and difficulties interpreting the uncontrolled studies. Tumor residuum appears to be one factor predictive of survival: no residuum, 76%; microscopic or <5 mm, 49%; macroscopic, 17%. Other factors may be tumor grade and patient age. Appropriate selection of patients for controlled studies of sequential radiotherapy after surgery and chemotherapy include those with negative second-look laparotomy who had large residual Stage III presentations prechemotherapy, are over 50 years of age, or who have grade 3 tumors. Others are those with microscopic residual disease, grade 1 or 2. If therapy is to be successfully completed with minimal morbidity, abdominal radiotherapy should be limited to ⩽25 Gy, initial chemotherapy to six courses, and surgery to initial debulking and second-look laparotomy.
Twice-daily, split-course abdominopelvic radiation therapy after chemotherapy and positive second-look laparotomy for epithelial ovarian carcinoma
1991, International Journal of Radiation Oncology, Biology, Physics
Between July 1983 and December 1988, 34 patients with ovarian carcinoma received whole abdominal irradiation in an attempt to eliminate residual disease following second-look laparotomy. Three additional patients who had initial complete responses to chemotherapy were treated for a recurrence of their disease. All patients had been treated with chemotherapy that included cisplatin and cyclophosphamide. Three patients had also received doxorubicin with some or all chemotherapy cycles. Thirty Gray of abdominopelvic radiation therapy (APRT) was delivered using a twice-daily, split-course schedule. Eleven patients also had a boost of 9–20 Gy to sites of residual disease. Treatment was well tolerated. Only one patient did not complete therapy and two patients had 1-week prolongations of treatment because of hematologic toxicity. Thirty-two percent of patients had grade 2 neoplasms and 61% had grade 3 disease. Three patients with grade 1 tumors continue to have no evidence of disease 20–50 months after irradiation. Patients with grade 2 and 3 neoplasms who had microscopic residual disease prior to APRT had relapse-free survival rates at 3-years of 10% and 14%, respectively. Twelve patients with gross residual disease had rapid recurrences (median time to relapse, 4.9 months) and all have died of their disease. Although 14 patients (38%) have experienced small bowel obstructions, all of these had known recurrent abdominal disease at the time. Twenty patients (54%) had undergone more than two abdominal surgeries prior to APRT, and several were noted to have extensive adhesions at second-look laparotomy. None of the five patients currently believed to be free of disease has experienced a small bowel obstruction. Radiation is only one of several factors that contributed to bowel obstructions. Although APRT may be able to eliminate residual disease in a small proportion of patients with microscopic residual disease after chemotherapy, the aggressive biology of tumors that respond incompletely to chemotherapy and the compromises in radiation dose and schedule that must be made in these heavily treated patients probably contribute to the disappointing results of this treatment.
Surgical management of radiation enteropathy
1991, Surgical Clinics of North America
Radiation enteropathy occurs in a significant percentage of patients whose gynecologic cancers are treated with radiation. Acute enteritis usually is self-limiting, whereas chronic enteritis often results in bowel obstruction or fistula. The underlying lesion is a progressive endarteritis. Nutritional support and wide resection or bypass of involved bowel is optimal management, with intraoperative findings dictating the best course. Recurrent cancer may complicate the situation.

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Gynecologic Oncology

References (20)

Combined cyclophosphamide, adriamycin and cis-platinum in advanced ovarian cancer resistant to chlorambucil and cis-platinum

Gynecol. Oncol.

CHAP II therapy for ovarian cancers following primary treatment with platinum-based combination chemotherapy

Gynecol. Oncol.

Whole abdominal and pelvic irradiation in patients with minimal disease at second-look surgical reassessment for ovarian carcinoma

Gynecol. Oncol.

Intestinal obstruction in ovarian cancer

Gyncecol. Oncol.

Lancet

A review of second-look laparotomy for ovarian cancer

Gynecol. Oncol.

Clinical Oncological Society of Australia and Ludwig Institute for Cancer Research (Sydney)

Gynecol. Oncol.

cis-Dichlorodiammine platinum (ii) in advanced ovarian carcinoma

Med. J. Aust.

Chemotherapy of drug-resistant ovarian cancer: A Southwest Oncology Group Study

J. Clin. Oncol.

Ovarian cancer: Schedule modification and dosage intensification of cyclophosphamide, hexamethylmelamine, adriamycin, and cis-platin regime (CHAP II)

Cited by (10)

Is there place for radiotherapy in the treatment of advanced ovarian cancer?

Whole abdominal radiotherapy following second-look laparotomy for ovarian carcinoma

Salvage whole abdomen radiation therapy: its role in ovarian cancer

Is there a role for consolidation or salvage radiotherapy after chemotherapy in advanced epithelial ovarian cancer?

Twice-daily, split-course abdominopelvic radiation therapy after chemotherapy and positive second-look laparotomy for epithelial ovarian carcinoma

Surgical management of radiation enteropathy