婦科腫瘤第153542號健康諮詢

目前就診醫生告知於膀胱上的腫瘤無法於減積手術完全清除(因擔心膀胱破裂)，

採用化療(靜脈注射方式，配方為Paclitaxel carboplatin，每三周做一次)

腫瘤指數CA125的歷史數值為:

減積手術前-->CA125為9160

減積手術手術後-->CA125為4510

第一次化療後(注射化療後第三周抽取血液檢測)的CA125為2850

第二次化療後(注射化療後第三周抽取血液檢測)的CA125為1705

第三次化療後(注射化療後第三周抽取血液檢測)的CA125為1235

第四次化療後(注射化療後第三周抽取血液檢測)的CA125為871


醫生告知可能我母親對化學藥物有抗藥性，現在第五次化療處方與先前相同，但施打改為每周打一次(劑量較三周打一次的少，但三周加總的劑

量，會比三周一次施打的增多一些)


目前我母親的血液檢查白血球/紅血球，每次可達可化療的要求，肝，腎功能每周檢驗正常

體重維持一定，可正常作息/進食，每日規律慢走20分鐘，身體狀況看來與正常人相同

問題

1.想請教對我母親病況建議的治療方針?


2.閱讀相關資訊了解減積手術後的殘餘腫瘤，會與治癒率相關，請教是否此時還需做第二次的手術治療?


3.閱讀相關資訊了解腹腔內化療的方式療效較靜脈注射佳，

但目前就診醫生表示腹腔內化療僅適用於減積手術後腫瘤小於1公分的患者?

且腹腔內化療副作用較多，想請教我母親的病況適合的治療方式?(是否以腹腔內化療的方式療效較好?是否某些特定的醫院對腹腔內的化療較有經驗?)



麻煩醫師協助 非常謝謝您的協助!!
醫師您好，我母親(63歲)於4月份於醫院診斷出卵巢癌(病理報告為:漿液分化不良型，期別:3C,詳細病理報告與手術紀錄貼於補充說明)





病理報告如下

Diagnosis:


Ovary,right,oophorectomy,--serous adenocarcinoma,high-grade Fallopian tube,right,

salpingectomy,--serous tubal intraepithelial carcinoma,focal



Omentum,debulking--serous adenocarcinoma,metastatic


Urinary bladder,base.debulking--serous adenocarcinoma,metastatic



Lymph node,external iliac,right,dissection--carcinoma,metastatic(5/5)


Lymph node,external iliac,left,dissection--carcinoma,metastatic(1/1)


Lymph node,obturator,right,dissection--carcinoma,metastatic(3/3)


Soft tissue(labeled as lymph node),obturator,left,dissection--free of tumor


Lymph node,para-aortic,dissection---carcinoma,metastic(4/4)

Gross description:

Specimen:Right salpingo-oophorectomy, a piece of oemntum, bladder base tumor, and bilateral

pelvic and para-aortic lymph nodes in fresh state

Right ovary:2.1*1.0*0.6cm in size,with a gray and solid tumor measuring 1.2*0.6*0.5cm in

size involving the ovarian surface and parenchyma


Right fallopian tube:4.7cm in length and 0.4cm in diameter,unremarkable


Pelvic lymph nodes:Nine in total,up to 2.1cm in greatest diameter


Para-aortic lymph nodes:Four in total, up to 2.0cm in greatest diameter


Omentum:15.8cm*10.5*2.0cm in size, with multiple gray and firm tumors
measuring up to 7.0*6.5*2.0cm in size


Bladder base tumor:Two tissue fragments,gray and firm, measuring up to 2.5*1.6*0.7cm in

size

A1-5:Omentum

B1-2:right ovary(for all section)

B3:right fallopian tube

C1-2:right and left external iliac lymph nodes

C3-4 and C5:right and left obturator lymph nodes

C6-7:para-aortic lymph nodes

D1-2:bladder base tumor(all for section)

Microscopic description:

Histologic type of right ovary:Serous adenocarcinoma.involving the cortical stroma with the

tumor size more than 5*5mm


Histologic grade:Poorly differentiated(Grade3)

-Growth pattern:Solid(Predominant),glandular and micropapillary(Score 3)

-Nuclear plemorphism:Moderated to marked(score 3)

-Mitotic activity:>26/10 HPFs,with frequent atypical forms(score 3)

-Total score:9


Nuclear grade:High-grade(grade 3)

Destructive stromal invasion:Present

Stromal response:Desmoplastic

Tumor necrosis:Mild

Psammoma bodies:Absent

Lymphocytic infiltration:Mild

Lymphovascular space invasion:Present

Capsular invasion:Present

Right fallopian tube:Serous tubal intraepithelial carcinoma,focal

Omentum:Serous adenocarcinoma,metastatic(>2cm in greatest dimension)

Bladder base tumor:Serous adenocarcinoma,metastatic

Lymph nodes(Positive/Total):(pN1)

External iliac:
right:5/5, left:1/1

Obturator:
right:3/3. left:0/0

Para-aortic:4/4

Extranodal extension:Present

Histologic pattern in nodal metastases:Mainly micropapillary

pTNM:pT3cN1


Reference:

P12-06616

Lymph node,para-aortic,CT-guided biopsy,--adenocarcinoma,metastatic(CK7 /CK20-/WT-1 /TTF-1

-/p53 ),consistent with serous type

手術紀錄如下:
Operation:

Debulking surgery(RSO Cytoreduction surgery infracolic omentectomy ascites cytology)


Preopr Diagnosis:

suspect SSPC


Postopr Diagnosis:


suspect SSPC


Anesthesia:

ETGA


Drainage&Tubes:

one J-vac at CDS through the right abdomen


器械及紗布數量確認:相符


EBL(手術出血量):600cc

Path/Opr Finding:

OP finding

1.Supraumbilical midline vertical skin incision

2.Uterus:absent

3.Adnexa

Left:absent

Right:atrophy

4.Ascites:serous,about 300ml

5.Bilateral pelvic lymph nodes:normal(-),enlarged( ),indurated( )

6.Omentum:Omentum cake about 15*10*2 cm and adhesion to bladder base area

7.bladder base tumor about 3*2*1 cm, adhesion to omentum cake
Tumor excision was performed and residual tumor about 1.5*1*1 cm at bladder surface

8.Liver:grossly normal&smooth
Subdiaphragmatic surface:smooth

9.para-aortic lymph node normal(-),enlarge( )2*1*1 cm. indurated( )

10.After the operation,suboptimal debulking surgery was achieved

11.residue tumor:1.5*1*1cm at bladder base surface

EBL:600ml

BT:nil

Cx:nil


Procedure:

1.Put the patient on the lithotomy position

2.Vaginal douching, on Foley, skin disinfection with beta-iodine, and skin draping

3.Make midline vertical skin incision and open the abdominal wall layer by layer

4.Serous ascites 300ml, send for cytology

5.Apply auto-retractor and pack up the intestine to expose omentum

6.omentum cake adhesion to bladder base.Step by Step clamp, cut and ligate the omentum

7.Clamp,ligate and cut right round ligament

8.Clamp, cut and ligate right infundibulo-pelvic ligament

9.Tumor excision of bladder base tumor

10.Open the bilateral retroperitoneum to expose the external iliac artery and obturator
nerve.Dissect of the bilateral pelvic lymph node


11.Open the retroperitoneum to expose the aorta.Dissect the para-aortic lymph node
Put one sugecell and suture the peritoneum with2-0 vicryl

12 insert a J-Vacat the cul-de-sac

13.Close the abdomen layer by layer

14.Skin approximation with Apose


非常謝謝醫師的協助!!

2012-08-13 00:13:47