⚠️ Teaching Case Note: This case has been de-identified and reconstructed for educational purposes. Clinical details reflect real surgical decision-making and outcomes. Patient identity is fully protected.
Five Years After Stage IIIC Ovarian Cancer — Still No Evidence of Disease
She was 62 years old when the bloating started. Gradual, persistent, easy to dismiss — until it wasn't. Three months of progressive abdominal distension, a dull ache in the lower abdomen, and a 5 kg weight loss brought her to the Gynecologic Oncology department at Fudan University Shanghai Cancer Center. What the workup revealed was one of the most challenging presentations in women's oncology: advanced high-grade serous ovarian carcinoma, with widespread peritoneal dissemination.
Five years later, she remains disease-free.
The Diagnosis: Widespread, But Not Unresectable
Gynecological examination revealed a firm, poorly mobile 8 cm mass posterior to the uterus, with scattered nodules palpable along the pelvic floor. The tumor marker profile was unambiguous: CA125 exceeded 1,000 U/mL; HE4 measured 212.2 pmol/L — both markedly elevated, consistent with advanced epithelial ovarian malignancy.
Pelvic MRI confirmed a right ovarian mass measuring 6×5×4 cm with large-volume ascites. Whole-body PET-CT revealed the full extent of disease: widespread peritoneal implants throughout the pelvis, omental "caking" (diffuse omental thickening with metabolic activity), and suspected metastatic deposits on the liver surface and spleen. Laparoscopic biopsy confirmed the diagnosis: high-grade serous ovarian carcinoma (HGSOC) — the most common and aggressive subtype of epithelial ovarian cancer.
The multidisciplinary team — gynecologic oncology, radiology, pathology, medical oncology, radiation oncology, and nutrition — convened to define the treatment strategy. The central question: primary debulking surgery (PDS) versus neoadjuvant chemotherapy (NACT) followed by interval debulking.
Despite the extent of peritoneal spread, the patient's performance status was excellent — ECOG 1, no surgical contraindications. The team's assessment: she was a candidate for upfront PDS with the goal of R0 resection. The decision was made to proceed.
The Surgery: R0 in 4 Hours 20 Minutes
Dr. Hua Ke led the operative team. Pre-operatively, 3D laparoscopic exploration was performed to precisely map tumor extent and confirm resectability — a critical step that informed the surgical plan and reduced intraoperative uncertainty.
The standard cytoreductive components were completed first: total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and systematic pelvic and para-aortic lymph node dissection. Pathological lymph node involvement was confirmed intraoperatively — pelvic nodes 5/12, para-aortic nodes 4/8.
The extended resection components addressed each site of macroscopic disease individually:
- Partial transverse colectomy with primary anastomosis — tumor had invaded the bowel wall; resection with anastomosis was required to achieve clear margins
- Partial splenectomy — metastatic nodules on the splenic surface were excised
- Liver surface metastasectomy — hepatic surface deposits were resected
- Diaphragmatic surface fulguration — diaphragmatic implants were ablated electrosurgically
- Pelvic peritoneal stripping — involved peritoneum was stripped from the pelvic sidewalls and cul-de-sac
Two technical innovations shaped the operative approach. Fluorescence-guided sentinel lymph node mapping was used intraoperatively to improve the accuracy of nodal staging. Strict no-touch oncological technique was applied throughout: specimens were extracted in retrieval bags to prevent tumor cell spillage, and peritoneal washings were sent for cytological analysis.
Total operative time: 4 hours 20 minutes. Estimated blood loss: 300 mL. Specimen weight: 1.2 kg. Final pathology confirmed cancer infiltration of the uterus, bilateral adnexa, omentum, bowel, spleen, and liver surface — and R0 resection, confirmed on post-operative CT with no residual macroscopic disease.
Post-Operative Treatment: Chemotherapy, Then Maintenance
Adjuvant chemotherapy began four weeks after surgery. The regimen: TC protocol — paclitaxel 175 mg/m² plus carboplatin AUC5, every three weeks for six cycles.
The response was rapid. CA125 fell from over 1,000 U/mL to 120 U/mL after cycle 1, and normalized after cycle 3. CT imaging after cycle 3 showed no evidence of recurrence.
Post-chemotherapy molecular profiling guided maintenance therapy selection. BRCA1/2 sequencing returned wild-type. HRD (homologous recombination deficiency) scoring was 32 — above the positive threshold — indicating a tumor with impaired DNA repair capacity and potential sensitivity to PARP inhibition.
PARP inhibitor maintenance was discussed in detail. The patient declined due to cost considerations. After shared decision-making, bevacizumab (15 mg/kg every three weeks) was selected as the maintenance strategy — 12 cycles in total. Bevacizumab targets tumor angiogenesis and has demonstrated progression-free survival benefit in advanced ovarian cancer, including in HRD-positive patients.
Surveillance: Five Years, No Recurrence
Structured follow-up was maintained throughout. Every three months: CA125, HE4, pelvic ultrasound, and CT abdomen/pelvis. Annual chest CT. Whole-body PET-CT annually.
As of March 2026 — five years post-surgery — the patient remains without evidence of disease. ECOG performance status: 0. No late chemotherapy toxicities: no peripheral neuropathy, no renal impairment. Quality of life assessment (EORTC QLQ-C30): scores in the good range across all functional domains.
Her own words: "When they told me the cancer had spread everywhere, I thought five years was impossible. The surgery, the chemotherapy, the follow-up — every step was explained, every decision was made together. Five years later, I'm still here."
Expert Commentary — Dr. Hua Ke
"This case reflects three core principles in the management of advanced ovarian cancer.
First, surgical completeness. R0 resection — no macroscopic residual disease — is the single most important determinant of long-term survival in advanced ovarian cancer. Even when multi-organ resection is required, the goal of R0 should be pursued aggressively in patients who can tolerate it.
Second, precision in maintenance therapy. Molecular profiling — BRCA status, HRD scoring — should guide maintenance decisions. In this patient, HRD positivity informed the discussion around PARP inhibition. When patient factors preclude the preferred agent, evidence-based alternatives such as bevacizumab remain viable options.
Third, multidisciplinary continuity. From pre-operative MDT planning through post-operative nutrition support, rehabilitation, and long-term surveillance, every phase of care requires coordinated expertise. This patient's five-year progression-free survival reflects the contribution of the entire team — surgical, pathological, medical oncological — and the patient's own commitment to the process."
About Dr. Hua Ke
Dr. Hua Ke is a senior gynecologic oncologist at Fudan University Shanghai Cancer Center, one of China's leading cancer institutions. Specializing in ovarian, cervical, and endometrial malignancies, Dr. Hua Ke leads complex cytoreductive procedures including multi-visceral resection and peritoneal stripping for advanced-stage disease. His practice integrates 3D laparoscopic exploration, fluorescence-guided surgery, and MDT-based individualized treatment planning to optimize outcomes in high-risk gynecologic oncology cases.
How CMCS Supported This Patient
China Medical Concierge – Shanghai (CMCS) coordinated the full care pathway: case review and specialist matching at Fudan University Shanghai Cancer Center, MDT scheduling and pre-operative imaging logistics, on-site Mandarin-English interpretation for all consultations, surgical consent discussions, and chemotherapy appointments, accommodation near the cancer center during the treatment period, and long-term follow-up coordination including molecular profiling logistics, maintenance therapy scheduling, and annual surveillance imaging.
For international patients facing advanced gynecologic malignancies in China — where surgical expertise, molecular diagnostics, and multidisciplinary coordination are all essential — CMCS provides end-to-end support from first inquiry to long-term surveillance.
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