Radiation for reccurent ovarian ca.

[alexpiper]

My mom has a recurrent epithelial (serous) ovarian carcinoma diagnosed first in  June 2005 - stage IV (liver parenchyma solitary focal change). After surgery and standard taxol/carbo she was in CR for 2 years. After retreatment with same chemo for recurrence in late 2007 (peritoneal carcinoma) she was in CR for only 3 months. She will undergo surgery in few weeks for removal of 2 small pelvic implants (under 2cm) and one of her doctors proposed a radiation treatment if the disease is indeed localised to pelvis only (pelvic radiotherapy). We are very receptive to this idea but in order to make a educated decision, I would be very grateful if you could answer the following questions:

1. Is it true that in case her cancer reoccurs in the radiated area at any point - chemo would not work on it?
2. Would whole abdomen radiation be superior to radiating pelvis only?
3. Is whole abdomen radiation with pelvic boost radiation considered the best radiotherapy for localised ovarian cancer recurrence?

[Annekathryn Goodman, M.D.]

Dear Alex,

there are varying views about radiation for ovarian cancer.  There also maybe regional differences in how radiation is used and considered in the treatment of ovarian cancer. For instance, there is more experience with radiation in Canada. In the United States, most gyn oncologists are reluctant to use it except for very specific conditions.

Recurrence ovarian and peritoneal cancer is a really hard problem. For your mother, if she has recurred 3 months after chemotherapy, her cancer  most likely has developed a resistance to platinum.  Many gyn oncologists would recommend consideration of doxil in that setting.

secondary surgical removal of cancer is usually considered for an isolated recurrence and usually for a recurrence that occurs more than 6 months after completion of chemotherapy.

this is because early recurrences are usually not isolated and therefore may not really be resectable.

Having said that, your mother's doctor knows her the best, has examined her, and has looked at her scans - so that doctor is in the best position to recommend surgery.

The problem with radiation is that the radiation will destroy bone marrow in the location of the radiation. For women who face the prospect of needing more chemo, this will reduce their ability to get more chemo because of lower blood counts. Additionally radiation causes some pretty harsh side effects on the bowel. Women with ovarian cancer do have a tough time with bowel obstructions just from their cancer. radiation adds an additional risk of bowel problems.

So I guess I am a bit opinionated on this. I would reserve radiation for poorly controlled pain (say from a metastases to bone or to a lymph node with nerve impingement) or because of vaginal bleeding from tumor recurrence in the vagina.

Otherwise, I would lean more to consideration of other chemo.

This s a tough problem. I wish you all the best.

[Annekathryn Goodman, M.D.]

Hi There,
here is a recent European review. the main place radiation has been used is in consolidation after first line therapy. Not in recurrence. As I said, for recurrence , radiation has been used to palliate symptoms and suffering.
best wishes

Int J Gynecol Cancer. 2008 Mar-Apr;18 Suppl 1:44-6.Links
Radiation therapy and biological compounds for consolidation therapy in advanced ovarian cancer.Auranen A, Grénman S.
Department of Obstetrics and Gynecology, Turku University Hospital, Turku, Finland.

Consolidation therapy is used in order to maximize the benefit of first-line therapy and to improve the progression-free and overall survival of patients. In women with advanced epithelial ovarian cancer, tested maintenance and consolidation strategies following first-line chemotherapy include high-dose chemotherapy, radiation therapy, intraperitoneal radionuclides including those linked to an antibody, and biological and immunologic agents. This review focuses on the current understanding of the benefit of radiation therapy and biological agents used as consolidation in women with advanced ovarian cancer. Whole abdominal radiation has given promising results only in the subgroup of patients with pathologic complete response. However, this treatment modality is associated with considerable intestinal toxicity. Single treatment with intraperitoneal radionuclides, either alone (32P) or in combination with an antibody (90Y-muHMFG1) has not improved survival. Biological agents used for consolidation include, eg, alpha- and gamma-interferon, tanomastat, a matrix metalloprotease inhibitor and oregovomab, a murine antibody that targets CA125. Randomized trials with these agents have not demonstrated any significant improvement in the overall survival of ovarian cancer patients. Currently, two ongoing studies (GOG 218, ICON7) are examining the potential of bevacizumab in the maintenance therapy of advanced epithelial ovarian cancer. Evaluation of new agents is indicated in order to achieve long-term disease-free survival in these patients. Toxicity and ease of administration must be reflected against the benefits of therapy.

here is an American reviewNat Clin Pract Oncol. 2006 Nov;3(11):604-11. Links
Ovarian cancer: a focus on management of recurrent disease.Herzog TJ, Pothuri B.
Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University, Herbert Irving Cancer Center, 161 Ft Washington Avenue, New York, NY 10032, USA. ***@****

Surgery and chemotherapy form the cornerstone of the treatment for ovarian cancer. Currently, the standard of care for primary ovarian cancer is platinum and taxane-based therapy. Even among women with advanced and suboptimal disease (i.e. tumors greater than 1 cm) following surgery, the clinical efficacy of chemotherapy is noteworthy. Despite the favorable response characteristics, however, most women with advanced-stage ovarian cancer will relapse, including about 50% of women who have no evidence of disease after primary therapy. A multitude of treatment options are available at the time of recurrence, but there is no clear consensus about how these patients should be managed. Options include surgery, chemotherapy, hormones, and sometimes, radiation therapy. The sequence, combinations of treatment, and manner in which any or all of these options should be employed in an individual patient, which heretofore have not been standardized, are the subjects of ongoing clinical investigations.

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[alexpiper]

Thank you so much for your reply Dr. Goodman. I forgot to mention several facts in the original e-mail:

1. Radiotherapy is only one of the options. During the surgery, the surgeon will take a large number of biopsies (20-30). If they all come back clear - or if only pelvic area is affected, they will consider radiation. Otherwise chemo.
2. We had 2 CT and one MRI done in the past 2 months and the picture has consistently been the same without any evidence of new tumors. There was also no evidence of present tumor mass growth. The differential diagnosis is a lymph node. If it is really a solitary lymph node - radiation would be an option.
3. Another option mentioned was a combination of radiation and systematic treatment of some sort.

I have to admit that I was surprised when my Mom's doctor mentioned radiation. Then he went to explain his rationale and discussed some of his more recent experience using radiation - the numbers seemed very impressive. In his opinion it works well but only for a certain patient population - those patient who do not have any current histological evidence of disease spreading beyond pelvis.