Introduction:
This was a 50 year old lady who came to me in 2019. She had been referred by a former patient of ovarian cancer treated by me a few years ago.
Patient History:
This lady was in extreme pain when she visited me. Her symptoms had started a few months ago when she had begun experiencing heavy menstrual bleeding followed by spotting in between the menstrual cycles. Being close to the menopausal age, she had neglected these complaints. A few weeks later, abdominal pain started, initially mild, but it, gradually increased in intensity and became continuous. This was associated with nausea, vomiting and a complete loss of appetite. A few days before our meeting, she noticed that she had developed abdominal distension. By the time she met me, she had lost almost 10kg weight over the past 6 months.
Investigations:
I asked for an urgent PET-CT Scan along with routine blood tests and a 2D ECHO. The PET Scan showed a large pelvic mass extending from the uterus into both the ovaries and the draining lymph nodes. There was extensive disease in the abdomen with ascites and cancer deposits in multiple areas.
A USG guided biopsy of one of the lesions showed a high grade endometrioid uterine cancer. Molecular profiling showed the cancer to be Microsatellite Stable. There were no underlying high risk, disease causing mutations, although TP53 was mutated.
Concerns:
The patient and her husband were anxious and scared as they both assumed death was imminent. I counselled and reassured them that treatment was possible. She was not going to die in a few weeks and she would regain her health post therapy.
Treatment Offered:
Considering the extent of disease, immediate surgery was not possible. After a discussion with the patient and her husband, I started her on chemotherapy with Paclitaxel & Carboplatin. This would reduce the disease load, treat the metastatic lesions, and prevent the cancer from spreading into the major organs like the lungs and the liver, which were currently unaffected.
The chemotherapy regimen was well tolerated. It was repeated at a 21-day interval. An interim PET-CT Scan after 3 cycles showed a good response with an 80% reduction in the cancer. A further 3 cycles cleared the cancer completely. A repeat PET-CT scan now showed no active disease. We had achieved complete cancer control.
I now explained to the patient that she required a complete surgery to consolidate the treatment.
Accordingly, she then underwent a radical hysterectomy. The uterus, ovaries, fallopian tubes and draining lymph nodes were all surgically removed. A histopathology examination of the surgical specimens showed no viable disease.
This meant that the patient had had an excellent response to treatment.
Post-surgery, once the patient had recovered, I asked her to undergo radiation. She received pelvic radiation followed by vaginal brachytherapy.
Once radiation was complete, I started her on maintenance therapy with an oral tablet called Letrozole. This would act on the ER/PR positive receptors which were detected on the uterine cancer biopsy sample. The Letrozole maintenance would act on any microscopic cancer cells , in case there were any still circulating.
Long Term Care:
The patient completed her treatment in mid-2020. Since then, she has been on oral therapy with Letrozole. She undergoes regular PET-CT Scans as a part of the disease monitoring, follows up with me and remains under my close supervision. She has remained free of the cancer till date. However, she is aware that there remains a high risk of recurrence. She maintains an excellent quality of life, works full time and enjoys vacations with her husband. She knows that modern cancer care has given her a new lease of life and is grateful for the time she is able to spend with her family.
