QUARTERLY REPORT JULY 2011
HOPES AND BOUNDARIES IN MODERN CANCER THERAPY
Odyssey and purgatory of a patient with ovarian carcinoma
In spring 2006, an ovarian carcinoma was diagnosed in G.H., a patient born in 1952.
Treatment in a university hospital in Munich and by an oncologist in privat pracitice:
April 2006 extended radical surgery with ovariectomy on both sides, excision of focal liver lesions and resection of mesenteric metastases. Despite the satellites of cancerous tissue identified, the extended procedure - which was complicated by a preexisting hysterectomy – was categorized as "R0," i.e. a radical, oncologically complete operation. Thereupon, until
September 2006 six cycles of chemotherapy: Carboplatin and Paclitaxel. Side effects were those that were to be expected given the intensity of the chemotherapy. Nevertheless, there was a recurrence of the disease and in
November 2007 a repeat laparotomy with removal of the spleen and segments of the peritoneum, an extended left hemicolectomy and removal of other areas of satellite tumor tissue. The operation was not without complications:
December 2007 when a colon suture ruptured, a right hemicolectomy was performed as well. The peritonitis caused by a leak in colon tissue had spread to the right groin / upper leg. Following this, suppuration appeared in the vicinity of both lungs.
January 2008 endoscopic irrigation treatment of the pleural empyemae on both sides.
January 2008 resumption of the chemotherapy that had already begun at the time of the surgeries, again with Carboplatin in six cycles.
February 2008 final surgical remediation of the pleural empyema on both sides.
March 2008 disposition of a drainage due to a retroperitoneal abscess.
July 2008 in response to recurrence of the retroperitoneal abscess, another drainage was installed.
February 2009 relaparotomy for final surgical remediation of the abscess.
In July 2009, however, recurrences were detected: metastases in the liver. The response was now an extended chemotherapy lasting till November, with six cycles of Carboplatin, this time with the addition of Gemzar (Gemcitabine). As in preceding situations, this chemotherapy also produced only temporary success. In
February 2010 a repeat laparotomy was performed, with removal of the gall bladder, separation of accretion, detection of live tumor cells in spite of chemotherapy, repeat resection of colon tissue with renewed intestinal anastomosis. Thereafter, in
September 2010 several cycles with a new chemotherapy agent: Caelyx (liposomal Doxorubicin).
March 2011 a positron emission tomography scan carried out at the university revealed a new, multiple-noduled liver metastases with metastases of the lymph nodes in the hepatic portal vein (see Illustration 1a). At the same time, tumor markers increased. A tumor consultation, also held at the university, understandably determined no further surgical interventions. From a radiation-oncological standpoint as well, the condition appeared to be no longer treatable using conventional X-ray-based radiation therapy, given the inevitable collateral damage to the remaining healthy liver tissue as a result of scatter radiation typical for X-ray radiation.
Treatment at the Rinecker Proton Therapy Center
May 2011 proton therapy. A whole-body (see Illustration 1b) and targeting CT-scan at the RPTC confirmed the findings presented above. The therapy planning with proton scanning revealed adequate protection of healthy liver tissue with this new radiation treatment method (see Illustrations 2 and 3). Another decisive benefit is that here the proton scanning can be carried out stereotactically, with only five sessions of 5 x 7 Gy (RBE), with little impact upon the patient's general condition or upon new chemotherapy options. It is also the high daily dosage permissible with proton scanning - because the radiation is focused on the tumor tissue - that leads to a high-impact effective tumor dose with this brief radiation exposure. The pinpointed exposure to beams of protons is undertaken using the intubation apnoe technique (see second Annual Report online, the latest publications by the RPTC, article: "Scanning proton beam radiotherapy under functional apnoe"); this ensures optimal protection of surrounding tissue through complete immobilization of the liver against breathing movement. The patient recovered well from the treatment.
From a surgical point of view, the university committed a high level of expertise to undertaking everything, truly everything, that could be done to reduce the volume of the tumor (known as "debulking"). This accomplishment was not compromised in any way by the surgical complications encountered; that the surgeries were feasible and survivable in the first place is an excellent testimony to the quality of care provided. From a chemotherapeutic standpoint as well, the modern standard of this field was fully brought to bear on the patient's condition – with the typical side effects and the typical clinical course during treatment: the remaining tumor cells mutate, new or changed oncogenes are activated, and resistance repeatedly forms even in changing chemotherapeutic agents. How could likelihood of these resistances have been reduced? Through reduction in the numbers of cells in the tumors and their metastases. This had been attempted with all of the surgical methods available. The question thus remains as to whether earlier use of high-precision, local proton scanning would have further reduced the numbers of mutation-prone tumor cells.
By her own opinion, this courageous patient weathered the difficult surgeries and the equally difficult side effects of the chemotherapy well, and had a very positive view of the time on earth granted to her. We wish her all the best and express our gratitude to her for the opportunity to publish her medical history.