Tags: CA-125, chemotherapy, endometrial cancer, HIPEC, HITEC, malignant tumors malignant tissue, ovarian cancer, remission, surgery, treatment
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Targeted treatment for ovarian cancer to be studied at University Hospitals
Tuesday, February 28, 2012
CLEVELAND, Ohio — Physicians at University Hospitals Case Medical Center are developing four clinical trials to test a therapy that has been around for several decades, but which only recently has been used to treat ovarian, endometrial (uterine) and select other gynecologic cancers.
The studies, which physicians hope to begin this spring, have been designed for a very specific patient population — no more than a couple dozen women with ovarian or endometrial cancer will be enrolled in each one. The trials will help researchers compare and learn relatively quickly how to use heated intraperitoneal chemotherapy, or HIPEC, as effectively as possible, said Dr. Robert DeBernardo, a gynecologic oncologist at UH and assistant professor at Case Western Reserve University School of Medicine.
The procedure, administered in the operating room right after surgery to remove malignant tumors or tissue, flows a hyperthermic — or heated — sterilized chemotherapy solution through catheters directly into a patient’s abdominal cavity. The heat makes cancer cells “leak” so chemotherapy can enter the cells more effectively.
The effect of chemotherapy delivered directly to the abdomen is more potent than intravenous delivery, which takes longer to reach the intended area. And because the targeted delivery of HIPEC minimizes the rest of the body’s exposure to the treatment, it helps reduce some side effects, such as hair loss.
“Giving chemotherapy in the [operating room] is complicated, but it’s not something that can’t be done,” DeBernardo said. “We need to really show: Is this a beneficial therapy?”
Not only will the studies shed light on how well HIPEC controls when and where the cancer recurs, but they will also focus closely on side effects, costs and the length of hospital stays.
Here are the Phase 1 trials:
• A study involving the use of heated chemotherapy for ovarian cancer that has spread to the chest. What the surgical team has dubbed HITEC (the “T” coming from the word intrathoracic) is performed after minimally invasive lung surgery. “To my knowledge, no one has treated ovarian cancer [that has spread to] the chest like this,” DeBernardo said.
• A study for advanced ovarian-cancer patients whose cancer is in remission following surgery and chemotherapy. The patients will undergo HIPEC to prevent recurrence.
• A study for patients whose cancer recurs; HIPEC will be performed following surgery.
• A study for patients who undergo chemotherapy prior to surgery and HIPEC during the surgery.
Ovarian cancer is especially challenging to treat, as it is often not detected until it has spread. The cancer antigen 125 blood test, which can detect elevated levels of CA-125 — a trait often found in women with ovarian cancer — is not recommended as a screening test in women with an average risk of the disease because elevated levels can signal many other conditions.
Over the past two decades, treatments have evolved and improved, says DeBernardo.
Not only has it become easier to perform aggressive tissue-removing surgery (the primary way to diagnose ovarian cancer), but surgeons have become more specialized in cancer-tissue removal. Women also are able to better tolerate treatment.
“The thing about women with ovarian cancer [is,] we don’t cure very many people with ovarian cancer,” DeBernardo said. “We can control it, we can keep it at bay. But it almost always comes back. That’s where HIPEC comes in. It may improve things.”
The Cleveland Clinic began treating abdominal cancers — appendix, colorectal, gastric, ovarian and peritoneal mesolthelioma (a cancer of the lining of the abdominal cavity) with HIPEC in 2010. UH followed suit last summer, with DeBernardo working with other surgical oncologists and general surgeons to launch the program at UH Seidman Cancer Center.
Buoyed by the results of a national study that appeared in 2006 in the New England Journal of Medicine that showed a higher rate of survival for women with ovarian cancer who were treated with HIPEC versus intravenous chemotherapy, hospitals began to explore the HIPEC option.
“The unfortunate fact is, even though it’s good science, there is still only a minority of women getting offered that treatment,” DeBernardo said. The reasons are varied, and include that not all women have ready access to a hospital with a gynecologic on-
cologist or other skilled staff who are able to integrate HIPEC as part of treatment.
Last August, led by DeBernardo, UH launched a dedicated HIPEC program for gynecological cancers. The surgical team performed its first HIPEC treatment in August 2011. Since then, there have been more than two dozen cases.
Jan Belleville of Hubbard was DeBernardo’s first HIPEC patient.
Other than feeling something — not pain, but something — in her lower abdomen in the summer of 2006, Belleville had no reason to think it was ovarian cancer.
“I had had fibroids and thought that was all it was,” said Belleville, 68. But it wasn’t.
Belleville was diagnosed with Stage 4 ovarian cancer, which by then had spread through her abdominal cavity to her liver. Her first surgery included radiation therapy. Chemotherapy followed.
After being in remission for a year, Belleville’s cancer returned to her liver. She had another operation, followed by more chemotherapy and radiation. The cancer went into remission for six months, then came back. After more chemotherapy, remission again for three months. But the cancer came back again. This time it had spread to her lungs.
After treating Belleville with different types of chemotherapy that proved ineffective, DeBernardo and his colleague, Dr. Jason Robke, decided to do something else.
Last summer, they approached her about having HIPEC/HITEC surgery. She would be their first case.
“I never have doubted that I was being guided in the right direction,” Belleville said.
In late July, she had the first of two HIPEC/HITEC operations, on the left side of her chest. Four weeks later, surgeons operated on the right side. Those surgeries — which were each roughly three hours long, including about 90 minutes for administering the chemotherapy — were the seventh and eighth since she was first diagnosed.
The surgeries stabilized Belleville’s levels of CA-125, the protein in the blood that is found in ovarian cancer cells at a much higher level than in normal cells.
Shortness of breath and lack of energy earlier this month prompted more tests; X-rays detected spots on her lungs, evidence that the cancer had returned there.
Despite the news, Belleville and her husband went ahead with a planned vacation to Florida. Last week, she started intravenous chemotherapy.
“I think it bought me a really nice Thanksgiving, a beautiful holiday over Christmas,” an upbeat Belleville said about the six-month remission that followed her HIPEC/HITEC procedure. “I don’t consider this [recurrence] a setback.”
Tags: body weight, chemotherapy, Epithelial ovarian cancer, obesity, ovarian cancer, survivor rates
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Body Weight Makes No Difference in Ovarian Cancer Survival
By Todd Neale, Staff Writer, MedPage Today
Published: December 30, 2008
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
BIRMINGHAM, Ala., Dec. 30 — Obese patients with epithelial ovarian cancer do not appear to have worse survival than their slimmer counterparts, a retrospective chart review showed.
Obese and non-obese patients had similar progression-free survival (17 versus 11 months, P=0.14) and overall survival (48 versus 40 months, P=0.37) following primary cytoreductive surgery that resulted in similar rates of optimal debulking, Kellie Matthews, M.D., of the University Alabama at Birmingham, and colleagues reported online in Gynecologic Oncology.
All patients received chemotherapy administered according to their actual body weight. Often, chemotherapy is administered based on ideal weight, which may lead to insufficient doses for obese patients, according to the researchers.
Some past studies have suggested that obesity is an independent predictor of lower survival in patients with epithelial ovarian cancer, but others have not. Few have included information on differences in rates of optimal debulking between obese and non-obese patients, the researchers said.
To explore the issue, they reviewed charts for 304 patients with FIGO stages II to IV epithelial ovarian cancer from a gynecologic oncology database from 1996 to 2005.
All patients underwent primary cytoreductive surgery followed by IV taxane and platinum-based chemotherapy dosed according to actual body weight.
Nearly a quarter (23.4%) were obese and the rest had a body mass index of less than 30 kg/m2.
Obese and non-obese patients had similar disease stage, grade, and histology, rates of platinum sensitivity, and administration of chemotherapy.
Obese patients were significantly more likely to be younger than 65 (P=0.02) and to be black (P=0.01).
There were no significant differences between the groups in estimated blood loss, time spent in the operating room, or operative complications. Only wound complications were more common in the obese group (11% versus 2%, P<0.001).
Rates of optimal debulking — defined as a lack of residual tumors greater than 1 cm in diameter — were similar in obese and non-obese patients (52% versus 51%, P=0.88), in spite of potential challenges to the surgical treatment of obese patients.
Such potential difficulties include comorbid chronic illnesses, administration of anesthesia, operative complications, and technical challenges, the researchers said.
“This demonstrates that any disadvantage obesity affords in the treatment of ovarian cancer is likely not related to the surgeon’s ability to achieve optimal cytoreduction,” the researchers said.
Although obese patients had a lower recurrence rate (68% versus 79%, P=0.04), there were no significant differences in progression-free and overall survival between the two groups.
The authors acknowledged that the study had several limitations, including the retrospective design, a trend toward poorer outcomes in underweight women that could not be compared with outcomes in obese women because of small patient numbers, potential selection bias, and optimal debulking rates that were lower than those found in other studies.
Sensitization of ovarian cancer cells to cisplatin bygenistein: the role of NF-kappaB November 25, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
Tags: anti-apoptotic genes c-IAP1, Bcl-2, Bcl-xL, chemotherapy, DNA binding, Genistein, NF-kappaB, ovarian cancer cell line A2780, pancreatic cancer, Platinum-resistance (PR), prostate cancer, PS cell line, soy isoflavone, survivin
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Sensitization of ovarian cancer cells to cisplatin bygenistein: the role of NF-kappaB
Platinum-resistance (PR) continues to be a major problem in the management of epithelial ovarian cancer (EOC). Response to various chemotherapeutic agents is poor in patients deemed PR.
Genistein, a soy isoflavone has been shown to enhance the effect of chemotherapy in prostate and pancreatic cancer cells in vitro and in vivo by reversing chemo-resistance phenotype. The goal of this study was to investigate the effects of combination therapy with genistein and cisplatin as well as other cytotoxic conventional chemotherapeutic agents in platinum-sensitive (PS) and resistant EOC cells.
Methods: The PS human ovarian cancer cell line A2780 and its PR clone C200 cells were pretreated with genistein, followed by the combination of genistein and either cisplatin, taxotere or gemcitabine. Cell survival and apoptosis was assessed by MTT and histone-DNA ELISA.
Electrophoretic mobility shift assay (EMSA) was used to evaluate NF-kappaB DNA binding activity. Western blot analysis was performed with antibodies to Bcl-2, Bcl-xL, survivin, c-IAP and PARP.
Results: Reduction in cell viability, and corresponding induction of apoptosis was observed with genistein pretreatment followed by combination treatment with each of the drugs in both cell lines. The PS cell line was pretreated for 24 hours; in contrast, the PR cell line required 48 hours pretreatment to achieve a response.
The anti-apoptotic genes c-IAP1, Bcl-2, Bcl-xL, survivin and NF-kappaB DNA binding activity were all found to be down-regulated in the combination groups.
Conclusions: This study convincingly demonstrated that the current strategy can be translated in a pre-clinical animal model, and thus it should stimulate future clinical trial for the treatment of drug-resistant ovarian cancer.
Author: Leigh A Solomon, Shadan Ali, Sanjeev Banerjee, Adnan R Munkarah, Robert T Morris and Fazlul H Sarkar
Credits/Source: Journal of Ovarian Research 2008, 1:9
Thalidomide For Ovarian Treatment November 23, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
Tags: birth defects, cancer center, chemotherapy, chronic disease, Epithelial ovarian cancer, gynecologic oncology, medical school, ovarian cancer, thalidomide, topotecan.
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Thalidomide For Ovarian Treatment
Nov. 22, 2008
Washington: Thalidomide, a drug banned in the 1950s for causing birth defects, is showing promise as a safe and effective treatment for women with recurrent ovarian cancer, according to a new study.
In the study, led by Levi Downs, Jr., M.D., assistant professor and a researcher of gynecologic oncology at the University of Minnesota Medical School and Cancer Center, Phase II clinical trial was randomized.
“For some women, ovarian cancer has become a chronic disease. The standard chemotherapy regimens can put recurrent cancer in remission, often more than once. However, when the cancer resists the standard treatments, we need new options for treatment,” Downs said.
The study compared the effectiveness and safety of the combination of thalidomide and topotecan, a chemotherapy often used for ovarian cancer, versus topotecan alone for treatment of recurrent epithelial ovarian cancer in patients who had received prior treatment.
Epithelial ovarian cancer is a disease in which cancer cells form in the tissue that covers the ovary.
In the study, 75 women were evaluated who were randomly assigned to receive either the combination of thalidomide and topotecan or only topotecan.
“We found that patients who received topotecan plus thalidomide showed an overall response rate of 47 percent compared to 21 percent response in patients who received only topotecan. In patients receiving topotecan plus thalidomide, 30 percent achieved a complete response, meaning the cancer went away, compared to 18 percent for patients only getting topotecan,” Downs said.
“Furthermore, patients getting topotecan plus thalidomide had a longer cancer-free period after treatment than those receiving topotecan alone. What all of this means is that while thalidomide may not cure ovarian cancer, it may broaden the treatment options available to physicians and provide more hope to women diagnosed with the cancer,” Downs added.
The study has been published in the journal Cancer.
Straight talk about ovarian cancer November 16, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
Tags: arthralgia, ascites, chemotherapy, constipation, deep vein thrombosis, diagnostic tests, diarrhea, DVT, early signs, Epithelial cancers, Germ cell cancers, incessant-ovulation theory, inflammation theory, mucositis, myalgia, neuropathy, ovarian cancer, pituitary/gonadotropin hypothesis, prevention, radiation therapy, remission, screening, Stromal cell cancers, surgery, treatment, tumor markers
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Straight talk about ovarian cancer
VIRGINIA R. MARTIN RN, AOCN, MSN
Nursing2005 April 2005 Volume 35 Number 4 Pages 36 – 41
Learn how to help patients recognize and defeat this insidious malignancy.
Learn how to help patients recognize and defeat this insidious malignancy.
ACCORDING TO AMERICAN Cancer Society (ACS) estimates for 2005, 22,220 women will develop ovarian cancer and 16,210 will die of it. The leading cause of death from gynecologic cancer in the United States, ovarian cancer has historically had a poor prognosis, largely because over 70% of women affected have advanced disease at diagnosis.
But medical science is gaining ground. Thanks to improved diagnosis, staging, and treatments, 5-year survival improved from 37% in the 1970s to 53% in 1998. Let’s review how this insidious disease progresses, how you can help someone who has it, and what you need to know about promising screening methods that could lead to earlier detection and treatment.
Deep, changing organs
The ovaries are solid, slightly nodular, almond-shaped organs lying deep in the pelvis. Their hidden location, plus the fact that their size, shape, position, and histology change over a woman’s lifetime, help explain why ovarian cancer isn’t readily detected in the early stages. According to the National Comprehensive Cancer Network (NCCN), the median age at diagnosis is 63. This malignancy is rare in women under age 30.
Three major theories about the causes of ovarian cancer prevail:
* The incessant-ovulation theory zeroes in on how the monthly ovulatory cycle affects the ovaries. This theory holds that the epithelium may be more apt to mutate with each ovulation, so failure to break the cycle, as with pregnancy, increases the chance of mutation.
* The pituitary/gonadotropin hypothesis implicates elevated gonadotropin levels. Normally, the ovarian epithelium invaginates and forms inclusion cysts and clefts, but overstimulation by gonadotropins might trigger proliferation with subsequent malignant transformation.
* The inflammation theory considers monthly ovulation a possible cause of chronic inflammation and mutation in the epithelial cells that lead to ovarian cancer.
The causes of ovarian cancer are unclear, but genetic and endocrine factors raise the risk. (See How the problem starts .) The most significant link is a positive family history, which is present in 10% of women with the disease. Three hereditary syndromes in which ovarian cancer occurs more commonly affect certain families with a history of early breast and ovarian malignancies and hereditary nonpolyposis colorectal cancer.
Other factors associated with ovarian cancer include nulliparity, giving birth for the first time when over age 35, exposure to talc or asbestos, endometriosis, pelvic inflammatory disease, and living in a western industrialized country. On the bright side, researchers have identified seemingly protective factors, including a history of oral contraceptive use, giving birth before age 25, tubal ligation, breast-feeding, and hysterectomy.
Most commonly, ovarian cancer spreads via the peritoneal fluid that continuously circulates through the abdomen. Other routes for metastases are through the lymphatic fluid or by direct tumor extension. Bloodborne metastasis is rare, and this cancer rarely spreads beyond the abdomen, even when advanced.
Retrospective studies indicate that over 70% of women with ovarian cancer have symptoms for 3 months or longer before diagnosis. But the early signs and symptoms can be nonspecific, including increased abdominal size, bloating, early satiety, abdominal pain, indigestion, vaginal bleeding, and changes in bowel and bladder habits. Because these symptoms can be vague, a woman may not pay much attention to them.
Teach your female patients to always investigate any of these symptoms if they occur.
When a woman does seek treatment and an ovarian mass is discovered, the clinical approach depends on clinical findings. If she’s premenopausal, the health care practitioner will probably monitor her for a few ovulatory cycles and investigate further if the mass doesn’t disappear. In a postmenopausal woman, any ovarian mass must immediately be investigated for cancer.
Diagnostic imaging and tumor markers
Diagnostic tests to detect ovarian cancer include the following:
* transvaginal and abdominal ultrasound. A transvaginal approach provides better visualization of the ovaries than the transabdominal method, but the location of the ovaries varies in each woman, so a combination of both approaches is recommended.
* computed tomography (CT) scan of the abdomen and pelvis
* a blood test for the tumor marker cancer antigen 125 (CA-125), which can be elevated in ovarian cancer. Although an ovarian mass can cause an elevated CA-125 level, so can endometriosis, pregnancy, liver disease, or fibroids, so the marker isn’t specific.
Additionally, a woman can have ovarian cancer and a normal CA-125 level; only 50% of women with stage I disease have an elevated level. For this reason, the CA-125 isn’t recommended as a screening tool for healthy women, but it can be useful in women with diagnosed ovarian cancer.
Surgery: First and foremost
Surgery is the mainstay of treatment for ovarian cancer, and a gynecologic oncologist has the most training to perform the exploratory laparotomy. The goals of surgery are to determine a definitive diagnosis, to stage the disease if cancer is present, and to remove as much of the tumor as possible. (See Staging ovarian cancer .) The procedure includes a total abdominal hysterectomy, bilateral salpingo-oophorectomy, scraping the abdominal surface of the diaphragm, peritoneal cytology, omentectomy, pelvic and para-aortic lymph node sampling, and peritoneal and random biopsies.
Although disease stage is the key prognostic factor for ovarian cancer, other factors influence outcome. They include the volume of cancerous tissue remaining after surgery, histologic type and grade, the woman’s age, and her overall condition or performance status. (See Rating performance .) A woman whose performance status is 0 to 2 is more likely to respond to chemotherapy, experience less toxicity, and have better outcomes. Findings associated with a poorer prognosis include a clear cell, mucinous, or poorly differentiated (unclear cell type) tumor, and diagnosis after age 69.
Is additional treatment warranted?
If your patient has well-differentiated stage IA or IB ovarian cancer that’s been surgically removed, she’s considered low risk and needs no further treatment. The oncologist will determine a follow-up plan.
Stage IA or IB ovarian cancer with a poorly differentiated tumor and stages IC, II, III, and IV disease are classified as high risk, and the patient requires chemotherapy. Scientists are still seeking the optimal regimen, but early clinical trials have shown that combination therapy with a platinum compound such as cisplatin or carboplatin is superior to using a single agent. The NCCN states that paclitaxel/carboplatin is the preferred regimen. (See Exploring chemotherapy options for other choices.)
A complete remission from cancer means all signs and symptoms disappear; remission after initial therapy that lasts 5 years may be considered a cure. Although 75% to 80% of women with ovarian cancer achieve a complete remission after initial therapy, 80% of them have a recurrence. Unfortunately, recurrent disease isn’t curable, so researchers are exploring strategies to prevent or delay recurrence, such as improved induction and maintenance regimens and the use of intraperitoneal chemotherapy.
Currently, intraperitoneal therapy is recommended only in the context of a clinical trial, but researchers have been studying it closely because ovarian cancer tends to stay in the abdomen. Study results show higher rates of progression-free survival and overall survival, but the challenges of administering therapy and managing toxicity are formidable.
Remission and monitoring
A typical woman with complete remission from ovarian cancer undergoes regular CA-125 monitoring and periodic abdominopelvic CT scans to check for recurrence. In most cases of recurrent disease, the CA-125 level rises above normal before the woman develops symptoms. Even when the CA-125 level is elevated, most oncologists don’t start chemotherapy unless a pelvic examination or abdominopelvic CT scan indicates disease recurrence; treating measurable disease lets the practitioner identify a response.
If a woman’s cancer recurs, her response to initial chemotherapy and the length of time until recurrence help determine subsequent therapy. If she achieved complete remission and didn’t have a recurrence for more than 6 months after completing initial therapy, her disease is considered drug sensitive and she’ll probably receive the same regimen.
Ovarian cancer that recurs less than 6 months after a woman achieves a complete remission is considered drug resistant . If the cancer doesn’t respond to initial therapy at all, it’s labeled drug refractory . Drug-resistant or drug-refractory disease is typically treated with a different agent, or the woman may be offered the option of participating in a clinical trial. If curing ovarian cancer isn’t possible, the patient may receive salvage therapy , which is chemotherapy to help manage symptoms and possibly prolong survival.
When recommending a treatment approach for recurrent disease, the oncologist considers the woman’s prior responses, quality of life, toxicity profile, current symptoms, disease volume, the ability of her gastrointestinal system to absorb drugs, her age, other illnesses, and social issues.
Radiation therapy may be included in the palliative treatment plan and may help if the patient has uncontrolled vaginal bleeding or pain. Radiation to the entire abdomen isn’t often considered because it’s toxic. For recurrent disease in a specific area, a radiation oncologist should outline a treatment plan. The goal of all palliative treatment is to balance the toxicities with quality of life.
Providing education and support
Research indicates that the more a patient feels threatened or harmed by cancer, the more education and support she needs. With ovarian cancer, her psychosocial and physical challenges might include advanced disease at diagnosis, repeated cycles of aggressive treatment, little respite from therapy, and a poor chance of survival. Your challenges are to address her psychosocial needs while preparing her for treatment and helping her manage adverse reactions to treatment and advanced disease.
Preoperatively, educate your patient and her family about the surgical procedure for ovarian cancer and what to expect afterward. Explain that after surgery, you’ll monitor her for infection, circulatory complications, fluid and electrolyte imbalances, and pain, and that you’ll work with the surgeon to manage any problems.
If your patient will receive chemotherapy, teach her and her family about the major adverse reactions. Explain how to prepare and respond if she develops fatigue, nausea, vomiting, hair loss, diarrhea, constipation, mucositis, neuropathy, arthralgia and myalgia, or myelosuppression.
Problems such as depression and anxiety are common when a patient faces serious illness and possible death. She may need help coping with such issues as premature menopause; loss of fertility; altered body image, sexual function, and family relationships; impaired functional capacity; financial problems; and loss of spiritual well-being.
Assess her for mood changes, feelings of worthlessness, inability to concentrate, fatigue, insomnia, impaired functioning, agitation, restlessness, and apprehensiveness. Review her medical history, current medications and treatments, nutritional status, pain rating, elimination pattern, and sexual history for factors that may contribute to depression.
Listen to her concerns and refer her to support services, such as the local chapter of the ACS. Managing her symptoms, participating in a support group, meeting with a mental health professional, and taking antidepressant or antianxiety medication all can help resolve depression and anxiety.
Finally, if cure isn’t an option, you can give your patient and her family tremendous support when you help them cope with end-of-life decisions and involve the hospice team when the time is right.
Managing the effects of advancing disease
Complications of advancing ovarian cancer can pose significant nursing challenges. Here’s a review of assessment findings and management strategies for common problems.
Ascites , accumulation of fluid in the peritoneal cavity, occurs when channels that normally remove fluid are blocked or when cancer cells prevent absorption of peritoneal fluid. Symptoms include early satiety, dyspnea, increased abdominal girth, constipation, and pain.
Suspect ascites if your patient has a protuberant abdomen with bulging flanks, an everted umbilicus, diminished bowel sounds, shiny or taut abdominal skin, and dullness to percussion in dependent areas of the abdomen. (For details, see “Assessing for Ascites” in the February issue of Nursing2005 .) An abdominal ultrasound usually confirms the diagnosis.
The treatment for ascites is removing the fluid. The oncologist may perform paracentesis in the office or in the radiology department with ultrasound guidance.
Intestinal obstruction involving the small or large intestine may plague a patient with progressing ovarian cancer. Tumor growth in the abdomen or adhesions can cause a partial or complete obstruction that interferes with peristalsis. An obstruction can be acute or chronic. Signs and symptoms of acute obstruction include acute abdominal distension and pain and projectile vomiting. Symptoms of chronic obstruction include abdominal distension and discomfort, constipation, and nausea and vomiting.
Hyperactive bowel sounds may be the first sign of acute intestinal obstruction as the bowel tries to move digestive contents past the blockage. Teach your patient to recognize problems and to immediately contact her health care provider if they occur.
A patient who develops an acute intestinal obstruction may need hospitalization and insertion of a nasogastric tube to decompress her bowel. Because a woman with advanced cancer may already be debilitated, surgery is considered only if conservative interventions fail or she’s in acute distress.
Deep vein thrombosis (DVT) is a risk for all cancer patients because of prolonged immobility, tumors that decrease or obstruct blood flow, and hypercoagulability associated with cancer. Common signs and symptoms include unilateral leg edema or pain accompanied by tenderness, warmth, and erythema. The treatment for DVT includes anticoagulation therapy and possibly placement of a filter in the inferior vena cava.
Malnutrition is one of the greatest challenges for a woman with ovarian cancer. Treatments or advancing disease may take away her appetite, causing her to lose weight. This wasting syndrome is called cancer cachexia , an advanced state of protein-energy malnutrition. Besides weight loss, signs of cancer cachexia include decreased subcutaneous tissue, edema, abdominal distension, dry skin, and behavioral changes such as irritability. Cancer patients with weight loss generally have poor performance status, poor response to chemotherapy, poor median survival, and possibly a greater infection risk.
Measures to protect the patient from malnutrition include treating the underlying problem, delaying chemotherapy, getting a nutrition consult, and medications (such as corticosteroids, megestrol, hydrazine, dronabinol, nabilone, oxandrolone, growth hormones, and medroxyprogesterone). Advise her to eat frequent, small meals served at room temperature; eliminate disagreeable food odors; get help with food preparation; and use nutritional supplements.
Lymphedema , an accumulation of lymphatic fluid in the interstitial tissue, occurs when the tumor blocks the lymphatic system or when lymph nodes have been removed. Lymphedema associated with ovarian cancer affects the legs. The affected leg maintains full sensation, but with edema, range of motion decreases and the skin feels tight to the patient.
Your patient should be referred to a knowledgeable practitioner in lymphedema management. The severity and grade of lymphedema determine the interventions, which may include range-of-motion exercises, meticulous skin care to reduce the risk of skin breakdown, elevation, massage or physical therapy to manually aid drainage, compression bandaging, or sequential pump therapy.
Pleural effusion occurs when the rate of pleural fluid production exceeds its removal rate from the pleural space, such as when a tumor invades the thoracic duct, or when ascites fluid seeps through the diaphragm. Signs and symptoms may include dyspnea, decreased or absent breath sounds, decreased tactile fremitus, or dullness to percussion. An effusion is treated by draining the fluid via thoracentesis or insertion of a tunneled indwelling pleural catheter.
What about screening and prevention?
Current screening methods for ovarian cancer aren’t sensitive or specific enough for routine use. A woman with a positive family history, however, should have a formal risk assessment with an extensive family history, education, risk estimation and counseling, optional genetic testing, and specific screening and prevention strategies. Screening strategies often include a rectovaginal pelvic exam, a CA-125 blood test, and transvaginal ultrasound.
Scientists are exploring the natural history of ovarian cancer to develop cost-effective, sensitive screening strategies. Researchers studying cell proteins are developing a test that tracks trends in multiple tumor markers specific for ovarian cancer. The first published study reported 18 of 18 stage I cancers and 63 of 66 healthy controls accurately identified, yielding 100% sensitivity and 95% specificity. A yet-unpublished study accurately identified 22 of 22 cases of early stage I disease, 81 of 81 cases of stage II to stage IV disease, and 68 of 68 cases of benign disease. The test must be validated and standardized before being used as a screening tool.
Prevention strategies for ovarian cancer may include a prophylactic bilateral oophorectomy in high-risk women who’ve finished childbearing. Other prevention strategies being used in clinical trials include the use of oral contraceptives and other drugs such as acetaminophen and the synthetic retinoid, fenretinide.
Finally, you have many opportunities to improve the outlook for ovarian cancer. Educate your female patients about the signs and symptoms and emphasize the importance of reporting “insignificant” symptoms that could be early warning signs. Early detection and treatment offer the best chance for survival.
Education, support, and hands-on care
Patient outcomes for ovarian cancer are getting better as detection and treatment methods improve. When you give a woman the education, support, and hands-on care she needs to combat this malignancy, you bolster her ability to successfully fight back.
How the problem starts
Three major categories of ovarian cancer have been identified:
Epithelial cancers , arising from the cells lining or covering the ovaries, account for 90% of ovarian malignancies. Epithelial cancers are further classified as serous (most common), endometrioid, clear cell, mucinous, and poorly differentiated.
Germ cell cancers start in cells destined to become ova.
Stromal cell cancers start in the connective tissue cells that hold the ovaries together and produce female hormones.
Staging ovarian cancer
Stage I: Tumor limited to the ovaries
IA , limited to one ovary, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsule intact
IB , limited to both ovaries, no tumor on the ovarian surface, no malignant cells in ascites or peritoneal washings, capsules intact
IC * , limited to one or both ovaries, tumor on ovarian surface, capsule ruptured, ascites or peritoneal washings containing malignant cells
Stage II: Tumor involving one or both ovaries with pelvic extension
IIA , extension or metastasis to the uterus or tubes, no malignant cells in ascites or peritoneal washings
IIB , extension to other pelvic tissues, no malignant cells in ascites or peritoneal washings
IIC * , pelvic extension, ascites fluid or peritoneal washings containing malignant cells
Stage III: Tumor involving one or both ovaries, peritoneal implants outside the pelvis or regional lymph node metastasis
IIIA , gross tumor limited to the true pelvis, negative nodes, microscopic peritoneal metastasis beyond the pelvis
IIIB , macroscopic peritoneal metastasis 2 cm or less in greatest dimension beyond the pelvis
IIIC , abdominal implants greater than 2 cm in greatest dimension or positive regional nodes
Stage IV: Tumor involving one or both ovaries, metastasis greater than 2 cm in greatest dimension beyond the pelvis. If pleural effusion is present, cytologic test results must be positive. Parenchymal liver metastases equals stage IV.
The Eastern Cooperative Oncology Group established the following scale to rate the effects of cancer and its treatments on the patient.
0 Normal activity, asymptomatic
1 Symptomatic, fully ambulatory
2 Symptomatic, in bed less than 50% of the time
3 Symptomatic, in bed more than 50% of the time but not bedridden
4 100% bedridden
SELECTED WEB SITES
Women’s Cancer Network and CancerSource
Last accessed on March 3, 2005.
Virginia R. Martin is the clinical director of ambulatory care at Fox Chase Cancer Center in Philadelphia, Pa.
The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
Exploring chemotherapy options
The current standard regimen for advanced ovarian cancer is paclitaxel (Taxol) and the platinum compound carboplatin. Alternatives are docetaxel (Taxotere) with carboplatin or paclitaxel with cisplatin, another platinum compound.
Recent clinical trials found no difference in survival between patients receiving carboplatin with either docetaxel or paclitaxel, but the docetaxel/carboplatin group had a greater incidence of myelosuppression. Those receiving paclitaxel/carboplatin had more neuropathy. Newer drugs being combined with carboplatin and paclitaxel are topotecan, liposomal doxorubicin, and gemcitabine.
The Gynecologic Oncology Group (GOG), a research group funded by the National Cancer Institute, is currently conducting a clinical trial for high-risk early-stage disease comparing three cycles of paclitaxel/carboplatin followed by surveillance versus paclitaxel alone weekly for 24 weeks. The GOG is also proposing a clinical trial on the use of carboplatin and paclitaxel combined with bevacizumab to treat advanced ovarian cancer.
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Bookman MA, et al. Optimal therapy of advanced ovarian cancer: Carboplatin and paclitaxel vs. cisplatin and paclitaxel (GOG 158) and an update on GOG0 182-ICON5. International Journal of Gynecological Cancer . 13(6):735–740, November/December 2003.
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Howell D, et al. Women’s experience with recurrent ovarian cancer. Cancer Nursing . 26(1):10–17, February 2003.
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Federation Internationale de Gynecologie et d’Obstetrique (International Federation of Gynecology and Obstetrics).
* Knowing whether rupture of the capsule was spontaneous or caused by the surgeon and whether peritoneal washings or ascites was the source of malignant cells helps the clinician decide whether a case should be categorized as stage IC or IIC. [Context Link]
When Silent Cancer Speaks Loudly November 14, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer.
Tags: chemotherapy, genetics, hospice, mother, ovarian cancer, silent cancer, stage, treatment plans
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When Silent Cancer Speaks Loudly
Part 1: How Ovarian Cancer Beat My Mother
By Suja S. Amir
Freelance Wirter – United States
The word cancer strikes a chilling chord with most people. It sends out the message of fear and death. It creates mental images of the physical side effects of chemotherapy and the flashing symbol of “radiation”.
Cancer, although extremely prevalent in Western society, is unfortunately a condition that educates most only after direct experience through friends, family or other loved ones. My education about cancer was no different. My mother was diagnosed with ovarian cancer on the 29th of August 2008. From that point on, everything was different.
Prior to the 29th, my mind was on other things. Ramadan was on its way and I was excited. I have a habit of “practicing” fasts to prepare my mind and body for Ramadan and this year, it was more important for me since the days were longer. I started my practice fast mid-August and shortly after my first few, I got a call from my mother saying she was admitted to the hospital for abdominal pain. She was admitted by her gastroenterologist, a physician who is specialized in treating disorders related to the digestive system.
The normal worries ran through my mind about the possibilities of my mother’s condition. At 68, she was in pretty good health. My mother’s occupation as a registered nurse meant she was extremely vigilant about her health and check ups. Recently, my mom was even more conscientious about her health as my father had passed at age 70 (of natural causes) in February 2007. She had high blood pressure and had her thyroid removed six months prior, but nothing that stood out.
There wasn’t a family history of any other condition that crossed my mind. She had mentioned some earlier symptoms to me, but they were vague. Abdominal distention, early satiety (feeling full early), and bloating all seemed to point towards a gastrointestinal problem. She had gotten every test known prior to her admission and everything was normal before August.
A Harsh Reality
When the final diagnosis came on the 29th of August, it felt like I was hearing something about someone else, someone else’s family. This couldn’t possibly be happening to my mother. It was a harsh reality to face. Listening to the doctor explain the diagnosis, the treatment plans and the outlook felt extremely unreal. She was diagnosed with ovarian cancer, stage IIIc (the cancer metastases are larger than 2 centimeters). For all intents and purposes, that didn’t make much sense to me. Although the doctor took his time and explained everything very eloquently, I was still a bit “shell shocked”.
After I put down the phone, I did what most of us do. I went to the “Google Dr.” and searched for some answers. I had a ton of questions. Questions like, why wasn’t this caught earlier? What tests could she have gotten to find out about this earlier? Weren’t there some signs to tell her that this was going on? Why did they only find out so late in the stage of ovarian cancer? What is chemotherapy? Will chemotherapy cure her? Is there a genetic component?
The list of questions just went on and on through my mind. As I did my internet research, I kept seeing a phrase that just sent chills every time I saw it. Ovarian cancer is sometimes called the “silent cancer”. I thought, silent? Silent??? That’s the LAST thing you want to hear about any medical diagnosis. And given the severity of any cancer, silent is not what comes to mind. You want to know that there are identifiable symptoms and tests. You want to know that there are tests that can accurately diagnose in order to optimize the treatment plans. But everything I was reading or hearing from the doctors as the days went on did not give me much more to go on. I was left with the idea that my mom was in agonizing pain from a “silent” cancer, a cancer that essentially crept up on her over a matter of weeks.
Chemotherapy was ordered because the doctors felt the tumor was too large for operation and felt chemotherapy would help shrink the tumor. My mother’s abdomen was extremely distended and looked as if she was about seven months pregnant. Oddly, her abdomen had looked normal only a few weeks prior. My brother and I sat with her, watching how she was grappling with the idea of cancer. My mother was now dealing with a situation she could not understand herself. My mother’s thirty years as a registered nurse, who took care of patients with worse conditions, did not know how to be on the other side.
As Ramadan started, my anxiety went up about how I was going to manage being able to help my mom and fast. The only thing that kept me going was the thought that Allah doesn’t place a burden on a person greater than he/she can bear. I knew that fasting would drain me, but looking back, I doubt that I would have been able to focus if I was not fasting. Fasting sharpened my goals and sharpened my mind towards Allah. Fasting allowed me to ignore the worldly distractions that kept arising daily.
One night, as I sat next to my mother holding her hand a few days after her chemotherapy, I was gazing at the TV above her bed and just sat there, dumbfounded at the TV program. It was a telethon for cancer. “Stand Up To Cancer.” What? Ironically, the month of September is Cancer Awareness month. I was sitting there, by her bedside, just watching these people talk about all types of cancers, the need for awareness, the need for research and it just felt unreal.
It was only a few days after the chemotherapy treatments that my mother’s condition worsened. The outlook was grim. She was not improving and the pain of this tumor pressing on her internal organs was making it more difficult to breath. My brother, a cardiologist, who had taken time off to help with my mom had started looking more and more worried. I saw his frustration and helplessness. It must have been torturous for him to be a trained medical professional, but not have any idea or ability to help rid my mom of the pain she was experiencing. We sat next to her as the days passed, with nothing more than hugs, kisses and prayers to offer. No amount of medicine, visits from nurses or doctors were helping her condition.
Her oncologist came in one day to meet with us and said, “I was really hoping that the chemotherapy would have shrunk this tumor by now. But this is the most aggressive case of ovarian cancer I have ever seen. It is probably best to just make her comfortable now.” With that, my brother’s face just went pale. None of us wanted to give up on her ability to fight this disease, least of all my brother. He had been trying so hard to be there for my mom the way he felt my father would have wanted him to be. I know he took this as some sort of failure on his part, but it really was God’s will.
We moved her to hospice care and she was moved to our house. My kids decided they needed to be close to her and used her room as a play room. She died on September 14th, 2008. I was blessed with three weeks with my mother from the time of diagnosis to the time she left this world. I was blessed because I was given time to spend with her before she left us. I had time to talk to her, express my feelings to her and tell her exactly how much she meant to me. After all that has happened, I am left with the cloud of cancer, which is now “in the family”.
Education about ovarian cancer is important and any woman should educate herself as much as she can about it. Next week I will tell you what I’ve learnt in the second part of this series.
Suja S. Amir has a B.S. in Psychology from Virginia Commonwealth University. She has ten years of experience in nonprofit management in the US. She can be reached by sending an e-mail to firstname.lastname@example.org.
Leg Swelling (Lymphedema) in a Patient With Gynecologic Cancer November 14, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer, tubal cancer, uterine cancer, vaginal cancer.
Tags: cancer, cancer of the vulva, cernival cancer, chemotherapy, endometrial cancer, Fallopian Tube Cancer, gynecologic cancer, immune system, leg lymphedema, leg swelling, lymph nodes, lymph vessels, lymphatic system, ovarian cancer, quality of life, radiation, uterine cancer, vaginal cancer
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Leg Swelling (Lymphedema) in a Patient With Gynecologic Cancer
Lower-Extremity Lymphedema in a Patient With Gynecologic Cancer
Kathleen Appollo, RN, BSN, OCN
Oncology Nursing Forum – Vol 34, No. 5, 2006
H.F. is a 56-year-old woman who presented to the gynecologic oncology department at a major comprehensive cancer center after an endometrial biopsy revealed an International Federation of Gynecology and Obstetrics grade III serous carcinoma of the endometri- um. In addition to relevant endometrial cancer statistics, she received information about choices for treatment. The standard surgical treatment at the cancer center consists of a total abdominal hysterectomy with bilateral salpingo-oophorectomy, pelvic lymph node dissection, and para-aortic lymph node sampling. The acute and chronic side effects of surgery were discussed, including develop- ment of lower-extremity lymphedema. H.F. was informed that the lymphedema could occur anytime after surgery and she would need to monitor for lymphedema development for the rest of her life.
After preoperative testing, H.F. had an uneventful surgical procedure and routine postoperative course. The ﬁnal pathology showed high-grade stage IIIC papillary serous carcinoma deeply invading the endometrium, with spread to a left para-aortic lymph node. As result, her oncologist recommended both radiation and chemotherapy.
H.F. completed all therapy and was scheduled to return every three months for evaluation. She was cautioned to maintain skin integrity by applying moisturizers and sunscreen as needed and to avoid sources of trauma, injury, infection, and constriction to the lower extremities. In addition, she was encouraged to maintain her weight with a healthy diet and she was advised to return to the lymphedema specialist for lymphedema control.
She understands that she must be diligent in her care to maintain control. H.F. knows that she should be joyous that she is free from cancer but often wonders about the sacriﬁces that she has made in the quality of her per- sonal life. She did not feel the need to seek professional psychiatric help but did join a support group. Although the members of the group all have cancer, none has lymphedema.
Even so, H.F. has found that sharing difﬁculties with others has helped her to cope, and she feels good when she has helped another deal with a difﬁcult issue. Although she has not returned to her former music activities, she has found that helping others in the support group has given her the same satisfaction that she felt when her music brought happiness to others.
Lymphatic System and Lymphedema
Lymph is extracellular fluid composed of water, fats, proteins, bacteria, and waste products. The lymphatic system is an inter connected network of organs, lymph vessels, and lymph nodes that transports lymph from body tissues to the bloodstream, helping to maintain body ﬂuid balance. It also is a major component of the body’s immune system.
The superficial lymphatic capillaries are made up of endothelial cells that overlap but do not form a continuous connection. Each cell is anchored to surrounding tissue by ﬁlaments that pull on the cells in response to changes in tissue pressure. As the cell is pulled by the ﬁlament, ﬂuid drains into the vessel. Pressure changes occur during muscle contraction, respiration, and arterial pulsation and when the skin is stretched. Lymph ﬂows into progressively larger deep vessels that have one-way valves to ensure that the ﬂuid moves away from tissues in a slow, steady, low-pressure system. Afferent vessels carry lymph into lymph nodes, where the lymph is ﬁltered of cellular waste products, pathogens, and cancer cells and where lymphocytes are added.
Efferent vessels carry lymph out of the lymph nodes to return to circulation. Lymph drains from the lower limbs into the lumbar lymphatic trunk, joining the intestinal lymphatic trunk and cisterna chyli to form the thoracic duct that empties lymph into the left subclavian vein (Casely-Smith & Casely-Smith, 1997; Mortimer, 1998).
Lymphedema occurs when lymph remains in the tissues because the lymphatic system is unable to transport interstitial ﬁltrate (Foldi, 1998; International Society of Lymphology, 2003). Primary lymphedema is a result of an absence of or abnormalities in lymphatic tissue. Secondary lymphedema, which is the focus of this discussion, results when the ﬂow of lymph is interrupted because of malignancies, surgery, infection, trauma, or postradiation ﬁbrosis and the lymph remains in the tissue.
Incidence and Risk Factors
Although much has been written about upper-extremity lymphedema after breast surgery, information about lower-extremity lymphedema is lacking. The literature varies widely about the number of patients affected. In one study, the incidence of lymphedema in patients after a hysterectomy with lymph node removal was 20% (Ryan, Stainton, Slaytor, et al., 2003). Another study reported a 3.4% incidence rate in patients following endometrial staging surgery, including hysterectomy, bilateral salpingo-oophorectomy, and lymph node dissection (Abu-Rustum et al., 2006). A retrospective series of staging surgery for endometrial cancer followed by radiation therapy reported an incidence of 4.6% (Nunns, Williamson, Swaney, & Davy 2000).
H.F. was at risk to develop lymphedema after her surgery for endometrial cancer because of the disruption of lymphatics and lymph nodes during staging surgery. She was at additional risk because of the postoperative radiation. Other risk factors are believed to include injury, trauma, heat changes, infection to the extremity, and weight gain and decreased mobility (Brewer, Hahn, Rohrbach, Bell, & Baddour, 2000; Mortimer, 1998).
Although research is lacking to support many recommendations for the prevention of lymphedema (Ridner, 2002), education regarding measures that are believed to reduce risk include protecting the skin from trauma and infection. Those measures were discussed with H.F. postoperatively and at each ofﬁce visit. The plan is based on the concept that any action or condition that predisposes a patient to or increases swelling may disrupt the ﬁne balance of drainage after surgery (Mortimer, 1998). In addition, open skin may lead to infection, which can occur more easily in stagnant, protein-rich lymph ﬂuid, a perfect medium for bacteria growth (Brewer et al., 2000). Because deep vein thrombosis and cancer recurrence can cause swelling, they were ruled out before H.F. was referred for complex decongestive therapy. Her treatment began with manual lymphatic drainage, a gentle massage that starts proximally to encourage the flow of lymph from the distal extremity. More lymph is encouraged to move into the normally functioning lymphatics (Cheville et al., 2003; Foldi, 1998; Lerner, 1998).
Massage was followed by padding of the extremity and application of short stretch compression bandages with gradual pressure changes distally to proximally. That type of bandaging helps the ﬂow of lymph to the nodal basins (Cheville et al.; International Society of Lymphology, 2003).
H.F. was taught the techniques so that she could continue maintenance therapy at home. She was encouraged to practice manual lymphatic drainage, use compression bandages at night, wear a ﬁtted compression garment, follow meticulous skin care guidelines, protect the leg from trauma and injury, and perform muscle-building exercises. H.F. also was taught to wear the compression garment especially during air travel because changes in atmospheric pressure may increase the pressure balance in the leg (National Lymphedema Network, 2005).
Quality of Life
Lymphedema may have a profound effect on the lives of cancer survivors (Kwan et al., 2002; Ryan, Stainton, Jaconelli, et al., 2003). H.F. described a heavy, achy feeling in her leg, which has been reported in patients with breast cancer before swelling occurred (Armer, Radina, Porock, & Culbertson, 2003). Pain assessment is crucial in helping patients to cope. An over-the-counter medication may sufﬁce, but some patients may need prescription-strength pain medication, making individual assessment critical.
H.F. stated that her pace was slower in her walks. In patients with breast cancer, fatigue often is a troublesome symptom affecting quality of life (Armer & Porock, 2002). Pacing activities or decreasing distances may help to maintain stamina. Pacing also may deter swelling that is associated with strenuous or long-distance exercise. The need for sleep medication should be evaluated because insomnia caused by leg discomfort or worry may contribute to fatigue.
Changes in wardrobe often are necessary when swelling occurs (Ryan, Stainton, Jaconelli, et al., 2003). Alteration in body image may result in changes to regular social activities and may lead to social isolation (Tobin, Lacey, Meyer, & Mortimer, 1993). Referrals to support groups or individual therapy sessions may be indicated depending on patient preference. H.F. found that she gained much by participating in a support group and thereby moved from one type of social interaction to another. Healthcare professionals must be sensitive to lifestyle changes as well as the ﬁnancial burden that may result from a forced change in wardrobe.
With increased survival after cancer treatment, the long-term sequelae caused by cancer treatment should be recognized and treated. Patients must be informed about the potential lifelong side effects of treatment. Although H.F. was informed about the possibility of lymphedema development, many patients have reported that they were not informed about this life-alterating condition until they developed symptoms (Beesley, Janda, Eakin, Obermair, & Battistutta, 2007; Ryan, Stainton, Jaconelli, et al., 2003). Continued research is needed to determine the best interventions to decrease the side effects of treatment and maximize quality of life.
Kathleen Appollo, RN, BSN, OCN can be reached at appollok @mskcc.org, with copy to editor at ONF Editor@ons.org.
Leg Swelling and Ovarian Cancer November 14, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer.
Tags: causes, chemotherapy, foot swelling, leg edema, leg lymphedema, leg swelling, lower limb lymphedema, lymph node removal, lymph system, node biopsy, ovarian cancer, radiation, risk factors, treatment
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Arm and Leg Swelling After Cancer
With the advent of better and more effective cancer treatments, the survival rate for all cancers has risen dramatically. With this progress, a new and often misunderstood and misdiagnosed complication has arisen.
Many cancer survivors , having overcome cancer, find themselves with sudden and often unexplained swelling, usually of the arms or of the legs.
This swelling occurs because of one of several factors.
First, the swelling begins after lymph nodes have been removed for cancer biopsies.
Second, the swelling may start as a result of radiation damage to either the lymph nodes and/or the lymph system.
Due to either the removal of lymph nodes or damage to the lymph system, your body is no longer able to rid itself of excess fluids. The fluids collect in the limbs effected and swelling beings.
This swelling is called lymphedema. The swelling that occurs is permanent, and while it is not curable it is treatable.
Permanent Leg Swelling
****In the situation of any permanent leg swelling whether the cause is known or unknown, the diagnoses of lymphedema must be considered****
There are several groups of people who experience leg swelling from known causes, but it doesn’t go away or unknown causes where the swelling can actually get worse as time goes by.
This group includes those who have had the injuries, infections, insect bites, trauma to the leg, surgeries or reaction to a medication. When this swelling does not go away, and becomes permanent it is called secondary lymphedema.
Another extremely large group that experiences permanent leg swelling are cancer patients, people who are morbidly obese, or those with the condition called lepedema. What causes the swelling to remain permanent is that the lymph system has been so damaged that it can no longer operate normally in removing the body’s waste fluid. In cancer patients this is the result of either removal of the lymph nodes for cancer biopsy, radiation damage to the lymph system, or damage from tumor/cancer surgeries. This is also referred to as secondary lymphedema.
Group three consists of people who have leg swelling from seemingly unknown reasons. There may be no injury, no cancer, no trauma, but for some reason the leg simply is swollen all the time.
The swelling may start at birth, it may begin at puberty, or may begin in the 3rd, 4th or even 5th decade of life or sometimes later. This type of leg swelling is called primary lymphedema. It can be caused by a genetic defect, malformation or damage to the lymph system while in the womb or at birth or be part of another birth condition that also effects the lymph system. This is an extremely serious medical condition that must be diagnosed early, and treated quickly so as to avoid painful, debilitating and even life threatening complications. Treatment should NOT include the use of diuretics.
What is Lymphedema?
Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.
A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.
What are the symptoms of Lymphedema?
If you are an at risk person for leg lymphedema there are early warning signs you should be aware of. If you experience any or several of these symptoms, you should immediately make your physician aware of them.
1.) Unexplained aching, hurting or pain in the leg.
2.) Experiencing “fleeting lymphedema.” This is where the limb may swell, even slightly, then return to normal. This may be a precursor to full blown leg lymphedema.
3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for example the foot, or between the ankle and knee. This is an indication of early lymphatic malfunction.
4.) Any arm inflammation, redness or infection.
5.) You may experience a feeling of tightness, heaviness or weakness of the leg.
How is Lymphedema Treated?
The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual decongestive therapy (MDT), there are variances, but most involve these two type of treatment. It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally. With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.
What are some of the complications of lymphedema?
1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immuno-deficient.
2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.
3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.
4. Loss of Function due to the swelling and limb changes.
5. Depression – Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.
6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.
7. Sepsis, Gangrene are possibilities as a result of the infections.
8. Possible amputation of the limb.
9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.
10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.
11. Chronic localized inflammations.
Can lymphedema be cured?
No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.
Welcome to Ovarian Cancer Info November 11, 2008Posted by patoconnor in cancer, gynecological cancer, ovarian cancer.
Tags: cancer, chemotherapy, leg edema, leg swelling, lymph nodes, lymph system, lymphedema, ovarian cancer, polycystic ovarian syndrome, radiation
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Someone might ask, why would a man start a blog on ovarian cancer?
The answer really is quite simple. I had an aunt that past away from it. By the time it was detected, it was beyond treatment and had spread throughout her body. There was nothing that the doctors were able to do. Statistics indicate that ovarian cancer is now the fourth major cause of death from cancer for women. Clearly, not enough attention is being focused on this disease.
The females in my family also have a horrible ratio of ovarian problems including polycystic ovarian syndrome, my own lovely daughter included.
So it is a very relevant and important topic to me.
It is also important because of a complication that is becoming more and more prevelant among ovarian cancer survivors and that is called lymphedema. Lymphedema is a condition of leg swelling which results from lymph node removal, damage to the lymph system from radiation or from chemotherapy. I will have a complete page of information on this complication which will include how to recognize it, treatment and outcome.
I am a thirteen year survivor of a b-cell lymphoma and a fifty-six year hereditary lymphedema patient.
The information I want to provide involves symptoms, diagnoses, treatments, complications and I will include peer reviewed clinical studies relating to ovarian cancer.