I have a lady with surprisingly decent KPS who has failed 4th line chemo for ovarian CA. She's extremely motivated, and her disease is entirely intraperitoneal. Would any of you consider whole abdominal radiation in this case?
Absolutely, although I haven't done it in a while - In training, used treat 150 cGy per day, sometimes with low dose oral cytoxan. I think Harvard and MDACC have some recent case series on whole abdomen treatments. Consider putting patient on steroids throughout treatment. (olanzapine 2.5 mg/ Sancuso patch / may also be helpful) as patients can get quite nauseous with extensive chemo history.
However you should consider your goals and the chance of achieving them.
You are not going to heal this patient. You will palliate. Thus, I would rather treat only the macroscopic disease and not go after all possible disease sites with a whole-abdominal RT.
I am sceptical about treating "microscopic" disease in palliative indications, especially in a patient who has failed 4 lines of chemotherapy.
If for instance she has a large mass in the pelvis, treat only that. This will certainly limit toxicity.
Of course you are trading off toxicity for efficacy here and noone will be able to tell you if that's a good call. It may very well be that this lady will develop bowel obstruction in X months from now due to some microscopic deposit on the small bowel in an area outside of what you would treat with a "disease-confined field". But it may very well be as well that this lady will never live enough to experience that.
The nccn issued an alert a couple years ago about intraperitoneal in the 1st line setting becuase of a large survival benefit. I dont know how effective it is in the 5th line and hyperthermic- which is usually accompanied by debulking in other cancers- should be done by someone with a lot of experience like Sugarbaker in DC.- If patient has failed chemo and a parp, I would expect really low response rates and it can have awlful toxicity like renal failure.. Gyn oncs outside of Hopkins, in my experience, almost never seem to give the intraperitoneal chemo.
HIPEC data is very unreliable and does not, overall, seem to show a benefit for ovarian cancer. Outside of clinical trial I would not recommend HIPEC for Ovarian cancer, period.
IP chemo (without hyperthermia) has significantly more data, but something like the Armstrong regimen after failing 4 lines (which will have near obligatorily included both Platinum and Taxane based lines) would definitely be investigational.
At my institution the gyn/med-oncs sometimes do Armstrong regimen in well selected patients with initially diagnosed, or platinum sensitive recurrences.
Regardless of the treatment method of choice (WART or IP chemo) patient should have a debulking surgery. Does her carcinomatosis extend into the abdominal cavity (liver serosa, diaphragm, stomach, etc.) or is it limited to the pelvis only?