The gold standard for ovarian cancer treatment. Ovarian cancer treatment in Germany. Why should a patient with ovarian cancer visit Odrex Medical House

Modern methods of diagnosis and treatment of stage I-IV ovarian cancer are available at the Odrex Medical House.

Ovarian cancer is the third most frequently diagnosed oncopathology in gynecology after cervical and uterine cancer. The disease can be primary, with the location of the focus in the epithelium of the ovary, and metastatic - with a focus of cancer cells in another organ.

Ovarian cancer occurs at any age: in adolescents and young women, mainly germ cell tumors are detected, in patients older than 50 years - malignant adenocarcinomas. The symptoms of the initial stages of this type of cancer are "disguised" as diseases of the digestive system and bladder, so in 60% of cases it is diagnosed in the later stages.

Symptoms of ovarian cancer

The first stage of the disease is asymptomatic and is diagnosed by ultrasound of the pelvic organs. Signs of ovarian cancer, characteristic of the third or fourth stages, are:

• Drawing pains in the lower abdomen.
• Weight loss.
• An increase in the volume of the abdomen due to the accumulation of fluid in the abdominal cavity (ascites).
• Dyspareunia, pain during sexual intercourse.

If untreated, a malignant tumor grows from the ovary into neighboring tissues. Cancer cells metastasize hematogenously (transferred with blood to other organs), and contact - cancer develops in the organ where the tumor touches. There are 4 stages of ovarian cancer, and at each of them in the Odrex Medical House, the patient is ready to provide qualified medical care.

Why should a patient with ovarian cancer visit Odrex Medical House?

Malignant neoplasms in the ovary are of a different nature and structure. The main ones are serous, endometriotic, mucinous, clear cell and mixed tumors. Of decisive importance in the fight against the disease is the determination of the molecular profile of the tumor - this allows the doctor to prescribe an effective drug to the patient in her clinical case.

In the Odrex Medical House, biological materials (tissue, blood) are taken for high-precision clinical tests. We also have unique expensive equipment for endoscopic operations (laparoscopy). This reduces the burden on the patient's body and allows her to recover much faster after surgery.

Diagnosis of ovarian cancer

The diagnostic department of the Odrex Medical House is equipped with modern equipment for detecting ovarian cancer at an early stage.
If gynecological oncology is suspected, we use:

• Ultrasound examination of the pelvic organs;
• Blood test for tumor markers;
• Magnetic resonance imaging of the pelvic organs, computed tomography of the abdominal cavity and chest with intravenous contrast - allows you to determine the presence or absence of secondary foci of cancer;
• Express biopsy of ovarian tissues after laparoscopy (performed at advanced stages of the disease if it is impossible to remove the tumor)

Based on the results of the research, the oncogynecologist draws up a treatment regimen and makes a prognosis.

Treatment of ovarian cancer at Odrex Medical House

To treat ovarian cancer, our doctors use surgical removal of the tumor and chemotherapy.
At the first stage of the disease, the oncogynecologist performs the removal of the ovary affected by cancer, in some cases, also the removal of the uterus, cervix, omentum and regional lymph nodes.
In our clinic, in 70% of cases, the operation is performed laparoscopically: several punctures are made on the anterior wall of the abdominal cavity. Through them, a mini-video camera, endoscope and surgical instruments are inserted to remove the tumor.

2-3 days after the operation, the patient spends in the inpatient department of the Odrex Medical House, under the supervision of a doctor and junior medical staff. The recovery time after laparoscopy is 10 days.

Treatment of the third and fourth stages of ovarian cancer depends on the location of metastases. In this case, the doctor prescribes therapy after receiving the results of histology and the necessary instrumental studies.

Each of the stages of the disease requires treatment with chemotherapeutic drugs, which the oncogynecologist selects on an individual basis.
In 60% of cases, ovarian cancer is diagnosed at stage III-IV, when the tumor metastasizes to the abdominal cavity, liver, lungs, and lymph nodes.

Every year, 152 thousand women die from this type of cancer in the world. Do not reduce the chances of recovery, seek advice and help from the oncogynecologists of the Odrex Medical House!

Kuzmicheva Larisa Petrovna

I want to convey my gratitude to the gynecologist Olga Nikolaevna Kulish, who performed a gynecological operation on me on January 15, 2018. Thank you so much! I am very glad that I met such a professional doctor. This is a doctor from God. Dear women, do not look for other ways to improve your health.

If there is at least one chance for recovery, when contacting Olga Nikolaevna, you will receive it. And personally to you, Olga Nikolaevna, my husband and I wish you health, good luck, happiness, well-being and have more opportunities to give people the most precious thing - health.

Kuzmicheva Larisa Petrovna

The exact cause of ovarian cancer, like most other cancers, is unknown to science. And yet, most often this disease is associated with the so-called "continuous ovulation". We are talking about a condition in which for many years the ovaries of a woman are deprived of a kind of "vacation", that is, a temporary suspension of the process of formation of eggs in them. Such a "rest" is possible during pregnancy, during periods of breastfeeding, with the use of oral contraceptive drugs (suppressing ovulation). So the likelihood of ovarian cancer increases in women with an early age of onset of menstruation (when the ovaries begin to function actively), and also in the absence of pregnancies that ended in childbirth. In addition, the disease often develops in overweight and obese women who smoke, lead a sedentary lifestyle, and prefer foods high in animal proteins. The risk of ovarian cancer can increase up to 23-54% with specific defects in certain genes (BRCA1 or BRCA2) - such gene "breakdowns" are detected in one in 500 women. Most often, this type of oncology develops during the postmenopausal period, but young women with families and children can often become its victims.

REFERENCE "MK" Ovarian cancer ranks eighth in the structure of cancer incidence. Every year about 140 thousand women of different ages die from it. In 2012, more than 12,500 Russian women learned about this diagnosis.

More than 220,000 women worldwide are diagnosed with ovarian cancer every year. And most often, alas, the disease is detected already at serious stages - this happens in 70% of cases! After all, it absolutely does not make itself felt until the tumor affects other tissues and organs, which implies a common process and, unfortunately, a poor prognosis for the course of the disease. Only in the last stages of the disease do symptoms appear: intense abdominal pain, menstrual irregularities. If the tumor has already become large, metastases to the lymph nodes and other organs are possible. And in this case, both standard chemotherapy and surgical treatment, alas, are ineffective. Relapse of the disease occurs within 5 years in 75-90% of patients with advanced ovarian cancer - and then it is no longer possible to stop the progression of the disease.

However, today there is an innovative targeted (targeted) therapy for the treatment of this disease, which helps even in the later stages. It is based on special antibodies that purposefully block the growth of blood vessels in malignant tumors. The drugs deprive the tumor of nutrition, thereby stopping the malignant process, which can significantly increase the life expectancy of patients.

In Western countries, such therapy has already been recognized as the gold standard for the treatment of ovarian cancer; it is recommended by the American and European communities (NCCN, ESMO), the Russian Society of Chemotherapists-Oncologists (RUSSCO). But - alas. Today, in Russia, such drugs are not readily available, and the recommendations of the communities remain only on paper due to the impossibility of providing medicines to all patients who need them...

Surgical, radiation and chemotherapy methods are used to treat ovarian cancer.

Surgical treatment is considered the main one. Most oncologists are confident that all patients with ovarian tumors should be treated with surgery. This is due to the impossibility of making a perfectly accurate diagnosis of cancer: if the doctor makes a mistake in determining the stage of the tumor, then refusing to operate can lead to irreparable consequences.

For cancer, one or both ovaries are removed, or a supravaginal or complete removal of the uterus is performed.

Why is it sometimes necessary to remove both appendages with a cancerous tumor in one of the ovaries? The fact is that the risk of developing a malignant process in the second ovary is very high. After some time, the cancer may recur, and the patient will again have to undergo treatment.

Simultaneously with the operation, treatment with chemotherapeutic drugs is used. The goals of this therapy are:

• prevention of metastasis and re-development of the tumor;
• impact on probable residual elements of cancer cells;
• inhibition of tumor growth;
• facilitating the life of the patient in advanced cases.

Radiation therapy is never used as a standalone treatment. The task of irradiation is to ensure a high percentage of the effectiveness of surgical and drug exposure.

The protocol for the treatment of ovarian cancer is determined only after a thorough examination of the patient: the condition of the urinary system, liver is assessed, a blood test is performed. During chemotherapy, the blood is examined several times, at least once a week.

In addition, the choice of treatment regimen depends on the following circumstances:

• from the presence of concomitant diseases;
• from the picture of blood;
• from the weight of the patient;
• from the histological type of the tumor;
• from the stage of the process.

Surgical treatment of ovarian cancer

The operation is the main link in the successful treatment of a cancerous tumor. Currently, the intervention is carried out using laparotomy - through an incision above the pubic zone. Simultaneously with the operation, the surgeon takes materials for further research. These may be tissue samples or fluid that has accumulated in the abdominal cavity.

• Ovariectomy is the resection of one or two appendages.
• Pahysterectomy is an operation that is performed at later stages of tumor development, when the uterus also has to be removed.
• Extirpation is the complete removal of the uterus with the ovaries, omentum and cervix.

If the tumor affects only the reproductive system, then the doctor removes the uterus with appendages, the nearest lymph nodes, and sometimes the vermiform appendix (appendix).

If the ovarian cancer was invasive, then some elements of the digestive and urinary systems also have to be removed.

Immediately after surgery, the patient is prescribed a course of medication and, in some cases, radiation therapy.

Palliative surgery for ovarian cancer is performed when the process is at an advanced stage, and it is not possible to completely cure the patient. The essence of palliative care is to alleviate the condition of the patient and to prolong life as much as possible.

Radiation therapy

The principle of radiation therapy is the effect of radioactive rays on the area of ​​malignant lesions. The rays contribute to the destruction of cancer cells, affecting healthy tissues to a much lesser extent.

Most often, radiation is prescribed for cancer recurrence, as well as for palliative treatment, to reduce pain, discomfort and slow down the progression of the process.

Radiation treatment is carried out in stationary conditions. To alleviate the condition of patients, one to ten sessions may be needed, the duration of which is determined by the oncologist. Chemotherapy can be taken along with the course of radiation therapy to completely control the cancer process.

If radiation is prescribed after surgery, then its purpose is to destroy cancer cells that could probably remain in the body.

With the growth of a tumor in the tissue of the abdominal organs, as well as with the accumulation of fluid, there is no point in prescribing radiation therapy, because radioactive rays can have a negative effect on healthy nearby organs.

Treating ovarian cancer with chemotherapy

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to kill a tumor. These drugs inhibit the development of malignant cells. They are injected into a vein or artery.

It is noticed that ovarian cancer is extremely sensitive to chemotherapy drugs. In many patients, the pathological focus becomes much smaller, and in the early stages of the process, even a complete cure can occur.

Chemotherapy is used after surgery to prevent re-growth of the tumor. In addition, special medications can reduce the size of the neoplasm before surgery and somewhat reduce the negative manifestations of the disease.

Chemotherapy courses for ovarian cancer are carried out on an outpatient basis, for 4-5 months, with short breaks. In total, from 2 to 4 courses are carried out.

Sometimes drugs are injected directly into the abdominal cavity, through a catheter. This method allows to increase the survival rate of women with malignant tumors. However, with intra-abdominal administration, adverse effects may occur, for example, severe pain, infection, and diseases of the digestive system.

The most common medicines for ovarian cancer are:

• Carboplatin - 100 mg / m² for five days;
• Paclitaxel - 175 mg / m² during the day;
• Topotecan - 1.5 mg / m² for 5 days;
• Cisplatin - 15-20 mg / m² for 5 days;
• Docetaxel - 75-100 mg / m² once, every three weeks;
• Gemcitabine - 1 mg / m² on the first, eighth and fifteenth day every 28 days;
• Etoposide - 50 mg / m² for 21 days;
• Vepezid - 50 mg / m² for 21 days;
• Bevacizumab (Avastin) 5-10 mg/kg every 2 weeks.

Cytotoxic drugs are almost never prescribed as an independent treatment, but only in combination with each other. For example, the combination of Taxol + Carboplatin for ovarian cancer is called the "gold standard" of treatment. This combination is less toxic than the similar Cyclophosphamide-Cisplatin combination, but just as effective. Taxol with Carboplatin provide relatively fast results and guaranteed 6-year patient survival.

Doxorubicin, or Kelix for ovarian cancer is often used in conjunction with Cyclophosphamide or taxanes. At the same time, there is no increase in the toxic effect of drugs. Kelix is ​​usually administered intravenously (2 mg/mL), but for other drugs, a different route of administration can be chosen. For example, oral cyclophosphamide is prescribed at a dosage of 1-2 mg/kg per day.

Avastin for ovarian cancer has been used relatively recently. This is one of the new bevacizumab-based drugs that inhibit the development of a malignant tumor. Avastin is administered only by intravenous drip. Another variant of administration, including intravenous inkjet, is prohibited.

Another of the recently popular anticancer drugs - Refnot - is a tumor tissue necrosis factor (thymosin α-1). This is a fairly strong cytostatic and cytotoxic agent with a minimum number of side effects. However, Refnot for ovarian cancer is not used as often: it is usually prescribed for the treatment of breast cancer.

In addition to antitumor drugs, doctors often prescribe immunomodulators - these are drugs that support the human immune system in a “combat” state. The use of immunomodulators is still controversial in the ranks of medical professionals. Some of them consider such drugs useless in oncology, while others are sure of their necessity. Thus, there is an opinion that the most common drug Roncoleukin in ovarian cancer increases antitumor immunity, which significantly increases the effectiveness of chemotherapy. In addition to Roncoleukin, such medications as Timalin, Mielopid, Betaleukin and interferons have a similar effect.

Thermoperfusion for ovarian cancer

Thermal perfusion is one of the oncology treatment options, which involves thermal effects on tissues. High temperature damages the protein structure of cancer cells, while not affecting healthy areas, which can significantly reduce the size of the neoplasm. In addition, thermotherapy increases the sensitivity of tumor tissues to radiation and chemotherapy.

The essence of thermoperfusion is the treatment of the ovaries and nearby organs that have undergone a cancerous lesion with a warm antitumor agent (up to 44 ° C), which significantly increases the effectiveness of its action.

In addition to the antitumor effect, this method also has a number of side effects. These are swelling, increased thrombus formation, bleeding, pain. Over time, these symptoms go away on their own. Less often, dyspeptic disorders can occur, as well as exacerbation of chronic diseases of the cardiovascular system.

Thermotherapy is currently undergoing active clinical trials. This is done in order to increase the effectiveness of the method and eliminate its possible negative consequences.

Treatment of ovarian cancer with folk remedies

Is it possible to cure a cancerous tumor with the help of folk recipes? The question is moot. The vast majority of specialists in traditional medicine do not welcome the use of folk remedies, especially in the form of self-treatment. Attempts to cure the tumor on your own can lead to an aggravation of the process, and precious time to start timely treatment can be lost.

Nevertheless, quite a lot of recipes are known, the authors of which promise to get rid of ovarian cancer soon. We invite you to familiarize yourself with some of them.

• The active use of mint for problems in the genital area is known: for example, with heavy menstrual bleeding, with painful menopause, etc. Mint is successfully used for ovarian cancer: it is customary to take half a glass of flea mint tea orally three times a day. During treatment, you can do douching with the same solution. To prepare this tea, you need to brew 20 g of mint leaves in 500 ml of boiling water and leave for 2 to 3 hours.
• Flaxseed oil and flaxseed in ovarian cancer is used very often. The dosage of oil is from 1 tsp. up to 1 st. l. in the morning and in the evening. You can take it in the form of capsules, which are sold in pharmacies. To do this, you need to drink at a time from 10 to 14 capsules. Flaxseed is used in the amount of 3 tbsp. spoons mixed with 200 ml of water. Such a "cocktail" must be drunk three times a day, at least for one month.
• Hemlock has a good reputation in the fight against cancer - it is used to treat many malignant tumors. Hemlock in ovarian cancer (especially in combination with other methods) can lead to a positive result. The tincture of this plant should be taken with a gradual increase in dose: starting with 1 drop per 200 ml of water 1 time per day before meals, increasing to 40 drops. Simultaneously with the amount of the drug, the amount of water also increases (for every 12 drops + 50 ml). After reaching 40 cap. the dosage is reduced in the opposite direction, 1 drop per day. The amount of water is also reduced by 50 ml every 12 drops. The duration of such treatment is as long as it takes for complete healing.
• Many consider ordinary oats to be the first cure for malignant tumors. An infusion of oats for ovarian cancer is prepared very simply: one glass of oat grains is poured into an enameled container and poured with 1000 ml of water, brought to a boil and boiled over low heat for about 20 minutes. After that, they are removed from the fire and insisted in a warm place for at least 2 hours. The broth is filtered and divided into three doses. Drink 30 minutes before meals three times a day. It is not recommended to cook a decoction in advance for several days, it is better to take fresh.

No one excludes the effectiveness of alternative treatment. However, before using such methods, consultation with an oncologist should be mandatory.

Treatment of ovarian cancer by stage

Treatment of ovarian cancer at stage 1 is most often carried out only through surgery. In this case, the surgeon makes a hysterectomy, bilateral salpingo-oophorectomy and excision of the omentum. In addition, biopsy materials and peritoneal fluids are removed during surgery. In most cases, stage 1 does not require additional treatment other than surgery.

Treatment of ovarian cancer in stage 2 is carried out by analogy with the first stage, but radiation therapy or systemic chemotherapy is additionally prescribed, which involves the use of platinum-based drugs in conjunction with alkylating drugs or Paclitaxel.

Treatment of stage 3 ovarian cancer requires a combined approach that combines surgery and mandatory chemotherapy. The intraperitoneal variant of chemotherapy is often used, with the use of Cisplatin and various combinations with it.

Treatment for stage 4 ovarian cancer is more complex and less optimistic. The main methods of influencing such a tumor are:

• cytoreductive surgery is the removal of one main affected part of a cancerous growth that cannot be removed completely;
• systemic chemotherapy - the use of Cisplatin or Carboplatin in combination with taxanes or other similar drugs;
• consolidating or maintenance treatment is the appointment of more than six consecutive courses of chemotherapy, which allows you to delay the development or completely avoid relapses. This treatment is most suitable for patients with chemosensitive tumors.

Treatment of ovarian cancer in Israel

The treatment of cancerous tumors in Israel is carried out in modern high-tech medical centers, which are equipped with special specialized departments for the treatment of female oncology. Treatment is carried out simultaneously by a number of specialists - a surgeon-oncologist, a gynecologist-oncologist, a chemotherapist-oncologist and a radiologist. Most medical institutions in Israel are represented by eminent professors known throughout the world.

Equally important is the availability of the most modern diagnostic and treatment equipment in clinics. A lot of attention is paid to the development of medicine in this country, including priority funding from the state. Therefore, medical centers, as a rule, have a powerful diagnostic base, thanks to which complex examinations can be carried out in just a few days.

Chemotherapy treatment in Israel is based on the use of the latest medicines developed according to the latest clinical studies.

For foreign patients, a coordinator who speaks the necessary language is always provided.

Upon admission, patients must undergo a mandatory examination, which for ovarian cancer can cost about $ 6,000. Surgery costs about $20,000, and one chemotherapy course costs about $3,000.

Treatment of ovarian cancer in Germany

In Germany, there is a special program for the use of advanced technologies in the daily practice of oncology clinics. This is due to insufficient early diagnosis of cancerous tumors.

Needless to say, doctors in German medical institutions are especially pedantic and highly qualified, and clinic equipment is presented with the latest technology.

For each case and each patient, a consultation is always assembled, which determines an individual treatment approach.

The most common standards of treatment for ovarian cancer in Germany are:

• surgical system "Da Vinci" (remote robotic surgery);
• radiosurgery "Cyber ​​Knife System";
• internal radiation exposure to the tumor;
• ultrasonic ablation method;
• treatment with monoclonal antibodies.

Surgery in Germany can cost approximately $3,000 to $10,000. The price for one course of chemotherapy treatment ranges from $10,000 to $15,000.

New in the treatment of ovarian cancer

• In the United States of America, a regimen for the treatment of ovarian cancer using photodynamic therapy has been developed. The development is based on the fact that a cancerous tumor is detected in most cases only when metastases begin to spread to other organs. After that, the operation and chemotherapy no longer have the necessary effectiveness. Therefore, a new method of treatment was invented, which is called photodynamic therapy. The patient is invited to take a special drug - Phthalocyanine, which produces active oxygen that can have a detrimental effect on cancer structures under the influence of infrared rays. In addition, gene therapy is prescribed, which reduces the degree of protection of cells from active oxygen. This therapeutic method can be combined with surgical treatment, which reduces the likelihood of intoxication of the body.
• In the UK, a new revolutionary anticancer drug Olaparib has been developed. The goal of this drug is to extend the life of patients with ovarian cancer by at least five years. Olaparib is currently being tested and will soon be available for treatment.

Rehabilitation after ovarian cancer treatment

After treatment for ovarian cancer, a number of side effects and exacerbations may occur, which must be removed or mitigated. The rehabilitation plan will be prescribed by the attending physician.

There are several options for rehabilitation therapy that can be used with a sufficient degree of effectiveness.

• Treatment with supportive drugs:
  • antiemetic drugs - Zofran, Ativan, etc .;
  • laxatives - Duphalac, etc., which are prescribed against the background of an appropriate diet;
  • hormonal drugs are medicines that normalize the hormonal background of a woman after the removal of two ovaries;
  • immunomodulating drugs - interleukin, etc.
• Psychological treatment:
  • selection by specialists of a specific diet and exercise therapy exercises;
  • involvement of social services for the care of patients;
  • psychotherapist consultations;
  • communication with patients who have undergone a similar pathology.
• Physiotherapy treatment, swimming and rehabilitation gymnastics.

Postoperative treatment with folk methods

Folk remedies, even at the postoperative stage, should be used only after approval by an oncologist. It should be noted that many drugs have contraindications for admission.

1. Boron uterus tincture: Pour 100 g of chopped grass with 500 ml of vodka and leave for 14 days in a dark place, sometimes stirring the contents. Drink 1 tsp. 4 rubles / day. Duration of admission - up to 4 months in a row.
2. A decoction or tincture of a golden mustache: carefully grind the ground part of the plant, pour boiling water and cook for a quarter of an hour, then filter and cool. Take a decoction of 100 ml three times a day, and a tincture of alcohol - 1 tbsp. l. in a glass of water.
3. Freshly squeezed beetroot juice, settled for one hour: drink, starting with 50 ml, gradually increasing the dose to 0.5-1 liter per day.
4. Infusion of hop cones: grind dry cones to a state of powder. Pour two teaspoons of this powder into 200 ml of boiling water and leave for 3 hours. Drink before meals 50 ml three times a day.

Treatment of recurrence of ovarian cancer, as well as their prevention, is carried out by such alternative methods:

• infusion of celandine with calendula: mix the raw materials in equal proportions and pour 200 ml of boiling water (can be brewed in a thermos), leave for 2 hours. Take 100 ml 3 times a day before meals;
• alcohol tincture of propolis (sold in pharmacies): take 30 drops / day.

Treatment of ovarian cancer is most effective in the early stages of tumor growth. With further spread of the malignant process, the prognosis of the disease becomes much less optimistic.

For citation: Kozachenko V.P. Treatment of patients with ovarian cancer // RMJ. 2003. No. 26. S. 1458

Russian Cancer Research Center. N.N. Blokhin RAMS

R Ovarian cancer ranks 7th in frequency, accounting for 4-6% of the total number of malignant tumors in women. According to IARC (International Agency for Research on Cancer), more than 160 thousand new cases of ovarian cancer are registered annually in the world and more than 100 thousand women die from malignant tumors of this organ. In the Russian Federation, more than 11,000 women are diagnosed with ovarian cancer every year. Over the past 10 years, the country has experienced an increase in the disease by 8.5%. In 2001, 11,788 new cases of ovarian cancer were registered in Russia, and 7,300 patients died.

In the economically developed countries of the world, ovarian cancer has the highest mortality rates among all malignant gynecological tumors, which is primarily due to the late diagnosis of the disease. The mortality rate in patients with ovarian cancer in the first year after diagnosis reaches 35%. According to the summary data of population-based cancer registries in Europe, the one-year survival rate for patients with ovarian cancer is 63%, the three-year survival rate is 41%, and the five-year survival rate is 35%. The classification of ovarian cancer is presented in Table 1.

Risk factors for ovarian cancer include: lack of pregnancy and childbirth, irrational use of hormone replacement therapy, hormonal drug treatment of infertility, hereditary factors (presence of ovarian cancer in the family).

Tumor staging is carried out on the basis of clinical examination data, the results of surgical intervention and histological examination of biopsy specimens obtained during surgery from various parts of the abdominal cavity. Correct determination of the stage of the tumor process makes it possible to determine the optimal tactics and improve the results of treatment.

Significant difficulties arise in determining the degree of prevalence of the malignant process, especially in the initial stages of the disease. In patients with malignant tumors of the ovaries of stages I-II, a targeted study reveals metastases in the retroperitoneal lymph nodes of various locations (up to 30%). In 28% of patients with suspected stage I and in 43% with suspected stage II disease, later stages of the process are established. Difficulties in detecting metastases in the retroperitoneal lymph nodes are explained by the fact that retroperitoneally, only in the para-aortic zone, there are from 80 to 120 lymph nodes, and each of them can be affected by micrometastases. The lymph nodes affected by the tumor may not be enlarged, of a densely elastic consistency, freely or relatively displaced. Therefore, 23% of patients with ovarian cancer relapse, although they were assumed to have early stages of the disease.

Patients with malignant neoplasms of the ovaries are used 3 main treatments: surgical, medicinal and radiation.

Systemic drug therapy is an integral part of the treatment process for the vast majority of patients with ovarian cancer. Practically only in the case of highly differentiated tumors 1A, B stages can be limited to surgery, which provides a 5-year survival rate of 90% or more. At the same stages, with the presence of signs of a high risk of recurrence, 35-60% of patients experience relapses after surgical treatment, which makes it necessary to conduct adjuvant drug therapy for patients in this group. Starting from stage 1C, due to the notorious non-radical surgical treatment, all patients are indicated for induction chemotherapy. The criteria for assessing the risk of recurrence are shown in table 2.

If at least one of the above signs of a high risk of recurrence is present, the process should be considered as prognostically unfavorable. In addition, it is known that serous adenocarcinomas are associated with a poor prognosis, while endometrioid tumors have a better prognosis, and mucinous and clear cell tumors occupy an intermediate position.

Oncogynecologists in practice are rarely limited to only surgical intervention. Even at the earliest stages and a high degree of tumor differentiation, they prefer to carry out prophylactic chemotherapy “just in case”. The reason is that even in patients with a favorable prognosis, most often during surgery, a biopsy of the retroperitoneal lymph nodes, a biopsy of the peritoneum and washings from it are not performed, which does not allow for the correct staging of the tumor process.

Treatment of patients with malignant ovarian tumors should , usually, start with surgery to maximize the removal of tumor masses . In this case, the stage of the tumor process is determined. The operation consists in removing the uterus with appendages and the greater omentum. A thorough examination of the abdominal cavity with a biopsy of the altered areas of the peritoneum, a cytological examination of aspirates and washings from the abdominal cavity is mandatory.

Survival of patients increases with the maximum removal of tumor masses during surgery. The five-year relapse-free survival rate in patients with stage IA and IB ovarian cancer with purely surgical treatment is 90%, not significantly different from the results of combined treatment, in which chemotherapy was additionally used. To improve the survival of patients with other stages of malignant ovarian tumors, the use of adjuvant chemotherapy is mandatory.

In the treatment of patients with advanced ovarian cancer The generally accepted method is systemic chemotherapy. . Since cytoreductive surgery is not radical, chemotherapy should be started as soon as possible after surgery - usually on the 10-12th day. When prescribing combined platinum-containing regimens, the volume of chemotherapy in this category of patients may be limited to 3-4 courses. Elderly patients as adjuvant chemotherapy can be recommended monotherapy with melphalan at a dose of 0.2 mg / kg / day on days 1-5 every 28 days, 6 courses.

First line chemotherapy

First line standard induction chemotherapy (at IC-IV stages) are platinum derivatives and combinations based on them, which significantly improved the immediate and long-term results of treatment compared to platinum-free regimens, especially in patients with small residual tumors.

Cisplatin - one of the most active drugs for the treatment of patients with ovarian tumors. An objective antitumor effect is noted in 32% of patients who have previously received chemotherapy with chlorethylamines or doxorubicin. When using cisplatin in patients who had not previously received chemotherapy, an objective effect was observed in 60-70% of cases, of which 15-20% had a complete effect, and a 5-year survival rate was 6%. Unfortunately, combinations with the inclusion of cisplatin are poorly tolerated by patients due to severe nausea and vomiting, the frequent development of nephro- and neurotoxicity. That is why it seems promising to replace cisplatin with less toxic carboplatin. Both drugs have approximately equal efficacy in the treatment of ovarian cancer if the doses of the two cytostatics are taken in a 4:1 ratio (i.e., cisplatin at a dose of 100 mg/m 2 is equivalent in antitumor efficacy to carboplatin at a dose of 400 mg/m 2).

There have been several randomized trials comparing the effectiveness of combinations with the inclusion of these two platinum derivatives. In all studies where carboplatin was used at a dose of 300 mg / m 2 and above in combination with other cytostatics (cyclophosphamide, doxorubicin), approximately equal efficacy was shown in comparison with that using a combination based on cisplatin. At the same time, regimens with the inclusion of carboplatin are tolerated by patients much more easily due to the lower frequency and severity of nausea and vomiting, neuro- and nephrotoxicity.

The main problem when using combinations with the inclusion of carboplatin is a more pronounced myelosuppression, which causes a reduction in doses of drugs or an increase in the intervals between courses, which negatively affects the results of therapy. Meanwhile, the obtained data show that the combination of carboplatin + cyclophosphamide is the regimen of choice in patients with advanced ovarian cancer. It is recommended to use carboplatin at a dose of 300-360 mg/m 2 and cyclophosphamide 500 mg/m 2 every 3-4 weeks.

Carboplatin . Carboplatin is a second-generation platinum-containing drug. Unlike its predecessor, cisplatin, carboplatin has less nephro- and neurotoxicity, the ability to cause nausea and vomiting. The main side effect of carboplatin is the inhibition of hematopoiesis. The frequency of objective effects when using carboplatin in previously treated patients varies from 9 to 32% and averages 24%. In three randomized trials in previously attracted patients, carboplatin at a dose of 400 mg/m 2 was shown to be equivalent in antitumor activity to cisplatin at a dose of 100 mg/m 2 and at the same time less toxic in all respects, with the exception of oppression of hematopoiesis.

The technique of combined chemotherapy of the 1st line according to the scheme: cisplatin 75 mg/m 2 (or carboplatin AUC-7) and cyclophosphamide 750 mg/m 2 with 6 courses at intervals of 3-4 weeks has found wide application.

Since the total excretion of carboplatin from the body is lower in patients with impaired renal function, on the one hand, and the level of platelets in blood tests after intravenous administration of carboplatin correlates with the area under the pharmacokinetic curve (AUC), on the other hand, to prevent myelosuppression was developed and selected Calvert's formula:

Dose (mg) \u003d (necessary AUC) x (GFS + 25),

where GFR is the glomerular filtration rate.

According to the Calvert formula, the dose of carboplatin is calculated in mg (and not in mg / m 2), allowing for the correct selection of the dose of carboplatin both in patients with reduced renal function and in patients with high renal clearance values.

The glomerular filtration rate corresponds to creatinine clearance, which can be calculated using the Cockcroft formula:

(K (factor) x (140 - age) x weight in kg) / (serum creatinine),

where K = 1.05 for women, K = 1.23 for men.

Thus, the inclusion of platinum derivatives in the regimens of induction polychemotherapy for ovarian cancer is mandatory today.

However, in Russia, such patients are often still prescribed platinum-free combinations, which cannot be considered adequate.

Pronounced nephro- and neurotoxicity, as well as emetogenicity, are a significant disadvantage of cisplatin. Along with cisplatin, in patients with ovarian cancer, a second-generation platinum derivative, carboplatin, can equally be used, in the toxicity spectrum of which myelosuppression predominates. Equivalent doses of carboplatin (4:1 in ratio to cisplatin) provide approximately equal efficacy with less toxicity, with the exception of hematological. The calculation of the dose of carboplatin using the Calvert formula (AUC 5-7) provides the optimal ratio of efficacy and toxicity of treatment (Table 3).

The most popular combinations based on platinum derivatives are PC (cisplatin + cyclophosphamide 75/750 mg/m2) and SS (carboplatin + cyclophosphamide AUC=5/750 mg/m2).

Recently, the standard first-line chemotherapy regimen is the use of platinum derivatives and taxanes. Among the latter, the most studied and widely used drugs are paclitaxel and docetaxel.

Paclitaxel is a herbal preparation obtained from yew bark. The drug stimulates the polymerization of tubulin and the formation of non-functioning microtubules, which leads to disruption of the process of mitosis and intracellular transport and, as a result, the death of the tumor cell. In a phase II clinical trial, paclitaxel was evaluated as a second-line or third-line chemotherapy regimen in patients with ovarian cancer treated with platinum. On a large number of patients, it was shown that paclitaxel in the monochemotherapy regimen is an effective drug in the treatment of this prognostically unfavorable group of patients. The frequency of objective effects lasting from 3 to 6 months is 20-36%.

It seems promising to use paclitaxel for intraperitoneal administration. The large molecular weight and size of the paclitaxel molecule cause slow absorption of the drug into the blood when administered intraperitoneally. In the abdominal cavity, a high concentration of the drug is created (more than 100 times higher than in plasma when administered intravenously), which persists for 5-7 days. A single dose for intraperitoneal administration of paclitaxel is 60 mg/m 2 . The drug is recommended to be administered weekly for 3-4 weeks. Intraperitoneal administration of paclitaxel can be used for induction chemotherapy in patients with optimally performed cytoreductive surgery, when the size of tumor formations does not exceed 0.5 cm, and also as second-line chemotherapy in patients with minimal manifestations of the disease after induction chemotherapy.

Docetaxel also has high antitumor activity. In particular, its effectiveness in combination with platinum derivatives during induction therapy is 74-84%. It is noted that combinations with the inclusion of docetaxel have less neurotoxicity.

Compliance with the optimal intensity of chemotherapy, which balances the toxicity and effectiveness of treatment, is an important factor in successful treatment, along with the correct choice of drug combination. An unreasonable decrease in the number of courses and/or doses of chemotherapy drugs, as well as an increase in the intervals between courses, inevitably leads to a deterioration in the results of treatment.

A retrospective analysis of numerous studies has shown that with an increase in the doses of cytostatics in combination chemotherapy regimens or the dose of cisplatin in monotherapy, the immediate and long-term results of treatment improve. However, the dose-response correlation exists in the range of 15 to 25 mg/m 2 /week. (or from 45 to 75 mg / m 2 1 time in 3 weeks), and further increase in dose does not lead to improved treatment results.

Compliance with the optimal frequency of treatment is an important part of successful drug therapy. . Most of the chemotherapy regimens used for ovarian cancer provide for an interval between courses of three, less often four weeks. An increase in the interval can and should be made in accordance with clear medical indications. The most common reason for an increase in the interval between courses are signs of toxicity, most often remaining by the time the next cycle begins, neutro- and / or thrombocytopenia, which is more typical for combinations with the inclusion of carboplatin. It is appropriate to recall that the absolute number of neutrophils, equal to 1.5 x 10 9 /l, and platelets, equal to 100 x 10 9 /l, is sufficient for the next course of treatment.

When using standard regimens, dose reduction is usually not required, with the exception of serious hematological toxicity (leuko- and / or thrombocytopenia of III-IV degree), complicated by fever and / or hemorrhagic syndrome, which is more often observed when carboplatin is used at doses of AUC = 6 ,5-7. The phenomena of nephro- and neurotoxicity, as a rule, do not reach a pronounced degree and do not require dose adjustment.

The correct choice of the drug regimen and adherence to the basic principles of chemotherapy make it possible to obtain an objective antitumor effect in 70-80% of patients with an average remission duration of up to 12 months.

Second line chemotherapy

The five-year survival rate of patients with stage III ovarian cancer is 20-25%, and IV - does not exceed 10%. Despite the disappearance of all signs of the disease, in the vast majority of patients in the first 2-3 years after the end of first-line chemotherapy, the disease progresses, mainly due to the appearance of intra-abdominal metastases. All these patients require second-line chemotherapy.

Second-line chemotherapy can control the symptoms of the disease in most patients, including those with tumors resistant to platinum derivatives, increase the time to progression and overall life expectancy in patients with high sensitivity to platinum, but is not capable of leading to a cure. Consequently, for the vast majority of patients, second-line chemotherapy is only palliative.

Often in patients with ovarian cancer, the appearance of symptoms of the progression of the tumor process is preceded by an increase in the level of CA-125. It is known that CA-125 is a non-specific marker for ovarian cancer, its increase may be due to the production of chronically inflamed peritoneal mesothelium after previous surgery and first-line chemotherapy. It is this circumstance that sometimes causes a moderate persistent presence or increase in the level of CA-125 shortly after the end of treatment in the absence of any signs of the disease. In the case of a slowly ongoing tumor progression, the interval between an increase in the level of CA-125 and the appearance of other symptoms of the disease can be several months, and sometimes even years.

According to supporters of the early start of chemotherapy, treatment with minimal (subclinical) volumes of the tumor mass has a great chance of achieving a clinical effect. Opponents at the same time argue that second-line chemotherapy is palliative in nature and its use in patients with no symptoms will only worsen the general condition due to toxicity, without having any effect on the prognosis of the disease.

The decision to start chemotherapy with an increase in CA-125 should take into account the opinion of the patient after her conversation with the doctor, because often the patient's emotional anxiety with an increase in CA-125 is the main reason for starting therapy.

The appearance of signs of the disease after achieving complete regression or the growth of the tumor present after the end of the first line of chemotherapy with a deterioration in the general condition are absolute signs of progression requiring second-line chemotherapy. If a recurrence of the disease occurs, the question of the advisability of performing surgical intervention may be raised. However, very often during the operation, in addition to the defined local recurrence, there are subclinical disseminations in the abdominal cavity.

The effectiveness of second-line chemotherapy depends on the length of the interval between the end of first-line chemotherapy and the onset of disease progression. The longer it is, the greater the chance of obtaining an antitumor effect during subsequent treatment. The presence of a recurrence of a disease potentially sensitive to platinum derivatives suggests the mandatory inclusion of cisplatin or carboplatin in chemotherapy. That's why it is possible to conduct second-line chemotherapy according to the same scheme that was used earlier in the first line , or a combination of a platinum derivative with a new anticancer drug. At present, even in patients sensitive to platinum derivatives, combination chemotherapy has not been shown to be superior to cisplatin or carboplatin monotherapy alone.

The set of anticancer drugs used for second-line chemotherapy is unusually large, which rather indicates that none of them allows achieving long-term remissions in most patients. The effectiveness of their use ranges from 12 to 40% with an average life expectancy of 9-12 months.

The most commonly used second-line chemotherapy is paclitaxel , if it was not used during the first line. The study of various modes of administration (single dose of 175 and 135 mg/m2, 3 and 24-hour infusion) showed that the optimal dose of the drug in terms of efficiency and toxicity, as well as ease of use is 175 mg/m2 for 3 hour. In patients whose tumors are resistant to cisplatin, second-line chemotherapy with paclitaxel can achieve an antitumor effect in 20% with an average life expectancy of 12.5 months. The use of docetaxel at a dose of 100 mg/m 2 for 1 hour in ovarian tumors resistant to cisplatin made it possible to achieve an effect in 36% of patients with an average duration of remission of 5 months.

Topotecan (Hycamtin) - a drug from the group of inhibitors of the topoisomerase I enzyme is also widely used for second-line chemotherapy. The frequency of the antitumor effect in patients with platinum-sensitive ovarian tumors was 20%, while in patients resistant to cisplatin - 14% when topotecan was administered at a dose of 1 .5 mg / m 2 / in for 5 days.

Etoposide, taken orally at a dose of 50 mg/m 2 for 14 days, was effective in 27% of patients with resistance of tumor cells to platinum derivatives and in 34% with preserved sensitivity. Liposomal doxorubicin in 82 patients with disease progression after first-line chemotherapy with platinum derivatives and taxanes made it possible to achieve an objective effect in 27% of patients with an average life expectancy for the entire group of 11 months. .

When prescribing vinorelbine at a dose of 25 mg/m 2 weekly for second-line chemotherapy in 24 patients whose tumors were resistant to platinum derivatives, the objective effect rate was 21%.

Gemcitabine is a promising drug for second-line chemotherapy. In the treatment of 38 patients with progression after the use of a combination of platinum derivatives and taxanes with gemcitabine at a dose of 1000 mg / m 2 on the 1st, 8th and 15th days every 4 weeks, an objective effect was noted in 15% of patients. Oxaliplatin is a new platinum derivative that has shown no cross-resistance with cisplatin and carboplatin. This was the basis for studying the effectiveness of oxaliplatin in patients with ovarian cancer, resistant or refractory to platinum derivatives. In the treatment of 34 patients, the frequency of objective effect in the appointment of oxaliplatin was 26%.

Unsatisfactory results in the treatment of patients with malignant ovarian neoplasms make it necessary to combine the efforts of surgeons, chemotherapists and radiologists to develop new programs and methods of treatment.

anonymously

Good evening, my mother has stage 3 ovarian cancer, as a result of which ascites has developed. We went to oncological hospital No. 62 (Krasnogorsk district). They did a laparoscopy, removed 8 liters (!) of fluid, said that there were metastases on the omentum and abdominal cavity, prescribed 3 chemotherapy (paclitaxel + carboplatin) before the operation and 3 more after. We don't know what to do. Help me please!! Should I start doing chemotherapy here or go to Israel for treatment (my friends advise me to go there)? We are afraid that the chemistry will be done incorrectly, that the equipment in the hospital is not the latest (which could prevent us from making an accurate diagnosis). How can we help mom ... Help, I beg you! ...

Good day. The regimen that the doctors prescribed is called the "gold standard" of chemotherapy in treatment, especially the way they divided the regimen (3 - operation - 3). In this situation, a lot depends on the cellular structure of cancer, on the general condition of the patient, concomitant pathology, age, etc. The chance of a radical cure is very low at this stage, but it exists. If you have the opportunity and your mother's condition allows you to contact the Israeli clinic as soon as possible, then, of course, try it. But nowhere will you be given a 100 percent guarantee of a cure. And if they start, for example, from 11/14/11, and in Israel it starts from the beginning of December, then you should not hesitate, you should start here, because every day counts. If you have any questions write, I will try to help you. Sincerely, Lisaev D.A.

anonymously

Thank you very much for the answer. Mom had her first chemo today. I'm sorry, but I can find out one more thing. Between chemotherapy courses, you need to take a break of 3 weeks. Will it be possible during this time to go to an Israeli clinic and be examined again? And, perhaps, to carry out the operation itself already there. I just want to check everything as accurately as possible. And they said whether they prescribed the right treatment for us here. We started chemotherapy in Moscow because we don't want to waste time. Tell me what you think is the most correct, please..