Epithelial ovarian cancer (EOC) always remains the most lethal gynecologic malignancy, guideline-recommended treatments for advanced ovarian cancer is primary debulking surgery followed by platinum-based chemotherapy. However, relapse would almost occur. Conventional treatment for recurrent EOC is chemotherapy and/or cytoreduction. Despite nowadays some targeted agents available in ovarian cancer including PARP inhibitors, Anti-angiogenic agents, immunotherapies, the patients would eventually die of chemo-resistance.
The role of secondary cytoreductive surgery in recurrent ovarian cancer is yet controversial. For platinum-sensitive recurrent ovarian cancer, secondary cytoreductive surgery increases post-recurrence survival2. However, Coleman RL et al. randomly assigned patients with recurrent ovarian cancer with platinum-sensitive. They concluded secondary surgical cytoreduction followed by chemotherapy did not result in longer overall survival than chemotherapy alone3. The postoperative residual tumor mass is the most relevant clinical prognostic factor. Indication to Secondary cytoreductive surgery should be individualized. Complete cytoreduction improve the prognosis in the setting of recurrence4. Early diagnosis of recurrence maybe the key of the possibility and necessity of surgery.
One particularity of our case is early diagnosis of recurrence. Regular follow-up and early diagnosis of recurrence is of great importance for EOC after primary therapy. If the recurrence is isolated, there maybe has chance of secondary cytoreductive surgery and relatively good prognosis. Unfortunately, cases presenting isolated recurrences are uncommon since most cases are exhibiting disseminated lesions at the time of diagnosis. The rigorous surveillance of patients after initial treatment is a challenging question in clinical practice. We think the suspicion of recurrence should be considered once the serum CA125 levels elevated to more than 15 U/ml or two times of its lowest level. In this case report, PET-CT discovered metastatic loci in early-stage even if the serum tumor marker remains in normal range. Highly alertness of recurrence in the follow-up of Epithelial Ovarian Cancer patients is important. With the help of high quality of image, clinicians could properly monitor patients, distinguishing relapse patterns and preform correct management.5
Unfortunately, most of the recurrent lesions were near or adhered by surrounded important organs such as ureter, vagina, cyst, intestine or rectum. Sometimes tumors could not be removed because their removal would cause severe functional disability or life-threatening bleeding. Since reported by Brunschwig in 19486, the pelvic exenteration (PE) has become an important method to treat pelvic malignancies. However, such management of cancer has remained controversial because of its severe functional disability or heavy hemorrhage especially when the tumor fixed to the pelvic sidewall. New treatment strategies for unremovable lesion in Secondary cytoreductive surgery for recurrent ovarian cancer are needed.
Another particularity and advantage of our case is partially tumor resection with salvage 125I brachytherapy which did not interfere with the functional outcome of the patient and received good effects.
For EOC, radiotherapy is not a routinely therapy. In recent years, studies have reported favorable outcomes in patients with recurrent epithelial ovarian cancer (EOC) treated with SBRT or IFRT 7, 8. Early in 1991,Iodine-125 interstitial implants as salvage therapy for recurrent gynecologic malignancies including one ovarian carcinoma has been reported9. As one kind of the radiotherapy, 125I brachytherapy has several advantages when compared to the other kinds of radiotherapy. Its benefit is boosted by natural increases in local dose. 125I seed local treatment can reduce the tumor burden, relieve local symptoms and improve quality of life of patients. Now 125I brachytherapy has increasingly been used for other sites of disease, such as central nervous system, head and neck tumors, lung, hepatic and pancreatic cancer and so on. Efficacy and safety of iodine-125 radioactive seeds brachytherapy has been approved10, 11.
In 1999, there has been American Brachytherapy Society (ABS) recommendations for the clinical quality assurance and guidelines of permanent prostate brachytherapy with 125I12. In 2018, Chinses expert consensus statement on computed tomography-guided 125I radioactive seeds permanent interstitial brachytherapy has been developed13.
In radiotherapy-naive patients with unresectable isolated recurrent gynecologic malignancies, 125I implants are feasible and may possibly contribute to survival14. Unlikely as cervical carcinoma or endometrial carcinoma, radiotherapy is not usually been used in patients with ovarian epithelium cancer. As a result, 125I brachytherapy is a hopeful therapy for recurrent EOC.
The success of 125I brachytherapy is dependent on and the size of tumors and the accurate placement of radioactive seeds15. Usually, all the 125I seeds implantation was performed with CT or ultrasound guidance. In our case, 125I seed implanted directly under the vision of operation. On the one hand, tumor burden is reduced by surgery; on the other hand, 125I implantation is more accurate and safer. Combination of surgery and 125I seed implantation did not interfere with the functional outcome of the patient and received good effects.