UDLCO CRH: Advanced epithelial ovarian cancer neoadjuvant chemotherapy efficacy and also how commonly is it done without tissue diagnosis only blood tumor markers and CT imaging

 

[09/04, 07:21]: Neoadjuvant chemotherapy prior to cytoreductive surgery is a treatment option in selected patients with advanced EOC. Clinical, routine serial CA-125 assessments and CT serve as the mainstay for response assessment during this therapy. CT is usually performed as a baseline study and after 3 cycles of chemotherapy to determine eligibility for cytoreductive surgery. Alternatively, in insufficient response, medical treatment is continued.

https://www.emjreviews.com/radiology/article/imaging-of-ovarian-cancer-from-early-detection-to-post-treatment-relapse/

[09/04, 07:29]: Question for oncology practitioners or enthusiasts:

How common is it to start neoadjuvant chemotherapy without any tissue diagnosis but solely depend on CT staging and tumor markers for apparently advanced (on the basis of CT and tumor markers) epithelial ovarian carcinoma?

[09/04, 07:31] : The methodology of the original trial recommending neoadjuvant chemotherapy in similar situations suggests that they recruited:

"Eligible patients who had biopsy-proven stage IIIC or IV invasive epithelial ovarian carcinoma, primary peritoneal carcinoma, or fallopian-tube carcinoma. If a biopsy specimen was not available, a fine-needle aspirate showing an adenocarcinoma was acceptable under the following conditions: the presence of a pelvic (ovarian) mass."

https://www.nejm.org/doi/full/10.1056/NEJMoa0908806#:~:text=Neoadjuvant%20chemotherapy%20is%20not%20inferior,or%20postoperative%20morbidity%20or%20mortality.

Have the recommendations changed after that and is a tissue diagnosis not necessary?

[09/04, 08:04] : After that 2010 nejm landmark RCT there's been multiple reviews and re-evaluations of the neoadjuvant chemotherapy NACT approach and the problems pointed out are inability to visualise and assess the tumor and it's spread properly during interval debulking but again I couldn't find if NACT was common without a tissue diagnosis but just based on CT imaging and peripheral blood tumor markers alone

https://pmc.ncbi.nlm.nih.gov/articles/PMC4206650/

[09/04, 08:17] : A recent 2025 Cochrane review may dampen the enthusiasm for NACT as it shows there is likely little or no difference in primary survival outcomes between primary cytoreductive surgery (PCRS ) and NACT for those with advanced EOC who are suitable for either treatment option. NACT reduces the risk of postoperative mortality and likely reduces the risk of serious adverse events, especially those around the time of (PCRS) surgery, and the need for stoma formation. https://pubmed.ncbi.nlm.nih.gov/39927569/

[09/04, 08:44]: Bottom-line for TLDR people:

Although my original question remains unanswered with one center study coming remotely close to answering it, with "Between 1994 and 2007, 149 patients were identified. Initial diagnosis was made on the basis of: cytology (paracentesis, thoracentesis, or fine needle aspirate) 72% (108 patients); histology (core biopsy, surgery) 18% (26), clinical (Radiology and CA-125) 10% (15). The final diagnosis was consistent with invasive EOC in 96% of patients. The diagnostic accuracies of the 3 strategies were: cytology 98%, histology 92%, and clinical 87%, (p=0.04). https://pubmed.ncbi.nlm.nih.gov/20591472/, 

the above suggesting that 2 patients out of 15 given NACT with just tumor markers and CT imaging could have had an inaccurate diagnosis and given the overall low survival rate of both PCRS and NACT, I am now wondering (perhaps like Steve Jobs) about how much worse or better could it be if we did none of these (NACT or PCRS) and simply resorted to palliative therapy in advanced EOC? 

Now can we find any comparative studies with palliative care (doing nothing other than symptomatic relief) vs the usual PCRS and NACT care that appears to be the current usual care?

CC licence: https://commons.m.wikimedia.org/wiki/File:Ovarian_carcinoma.JPG#mw-jump-to-license

The Lung puzzle - unraveling the enigma of recurrent respiratory infections

The Lung puzzle - unraveling the enigma of recurrent respiratory infections

Medical history-

A 56-year-old homemaker from Hyderabad presented with a complex medical history spanning over a decade. 

Her medical journey began in 2009 when she was diagnosed with pulmonary tuberculosis (TB) and treated with anti-tubercular therapy (ATT) for 6 months

Initial Diagnosis and Treatment (2009)

In 2009, the patient developed symptoms of daily cough with sputum, low-grade evening rise of temperature, and weight loss for 20 days. Her sputum tested positive for Acid-Fast Bacilli (AFB), and a chest X-ray (CXR) showed features of pulmonary Koch's. She was diagnosed with pulmonary TB and started on ATT, which she took for 6 months. Following treatment, her sputum converted to negative, and she remained asymptomatic for the next 10 years.

Relapse and Re-Treatment (2018)

In 2018, at the age of 50, the patient experienced a relapse of symptoms, including cough, fever, and weight loss. Her sputum tested positive for AFB and Cartridge-Based Nucleic Acid Amplification Test (CBNAAT). She was diagnosed with drug-sensitive TB and started on ATT again for 6 months. Following treatment, her symptoms improved, and her sputum converted to negative.

Road Traffic Accident and Respiratory Complications (2023)

Road Traffic Accident and Respiratory Complications (2023)

In October 2023, the patient was involved in a road traffic accident, resulting in:

- A fracture of the head of the humerus

- Right radial nerve injury, leading to wrist drop

During a subsequent surgical procedure, complications arose when the patient was positioned in the left lateral decubitus position:

- Desaturation (twice)

- Wheezing

- Shortness of breath

The procedure was aborted, and the patient was referred for pulmonology consultation.

Pulmonology Consultation and Investigations

A High-Resolution Computed Tomography (HRCT) chest scan revealed:

- Few old tuberculosis (TB) changes

- ? Active

Few old tuberculosis (TB) changes

- ? Active

However:

- Sputum test results were negative

- Interferon-Gamma Release Assay (IGRA) results were negative

- No features of pulmonary TB were present

The procedure was subsequently performed under general anesthesia. Initially, the patient was asymptomatic and followed up for a few months before being lost to follow-up.

Bronchoscopy and Non-Tuberculous Mycobacteria (NTM) Diagnosis

Pre-Travel Health Check-Up and Subsequent Findings (April 2024)

As part of her routine pre-travel health check-up in April 2024, the patient underwent a chest X-ray, which revealed:

- Left lung collapse

To determine the underlying cause, the patient's sputum and routine screening tests were conducted, but all results were negative. A staged bronchoscopy was performed, involving:

- Cryoablation

- Balloon bronchoplasty

Pus collected during the procedure was sent for cultures, and PCR results showed:

- Non-Tuberculous Mycobacteria (NTM)

- Speciation could not be determined

Initial Management and Second Opinion-

The patient was initially managed with antibiotics and supportive medications. However, due to increasing symptoms post-bronchoscopy,  sought a second opinion at another hospital.

A CT scan was performed, revealing:

- Few infiltrates on her right lung (?spillage)

Initially, the patient continued on her medications, including:

- Injection amikacin (750 mg IV) on alternate days for 2 months

- Tablet rifampicin (600 mg OD)

- Tablet clarithromycin (500 mg BD)

- Tablet ethambutol (1000 mg OD)

The patient showed initial symptomatic improvement.

August 2024 - symptoms aggravated and was given cephalosporin oral for 2weeks

Worsening Symptoms and Peripheral Neuropathy

Exacerbation of Symptoms and Hospitalization (November 2024)

In November 2024, the patient presented with:

- Cough

- Shortness of breath (SOB)

- Reduced appetite

- Weight loss for 10 days, prompting hospitalization.

Investigations and Findings-

Routine investigations and screening tests were negative. However, a repeated High-Resolution Computed Tomography (HRCT) chest scan revealed:

- New patchy consolidations

- Nodular parenchymal opacities in the right lung

The patient was initially started on Polymyxin B for 2 days but developed:

- Tingling

- Numbness of lower limbs

- Ataxia

A neurology opinion was sought, and peripheral neuropathy was suspected. Nerve Conduction Studies (NCS) showed near-normal results.

Revised Treatment Plan-

The patient was then treated with a combination of:

- Aztreonam

- Ceftazidime + Avibactam for 2 weeks.

Readmission and Video Bronchoscopy (2025)

On January 31, 2025, the patient was readmitted with similar complaints that had persisted for 10 days. The following diagnostic procedures were performed:

- Video bronchoscopy

- Endobronchial Ultrasound (EBUS) Transbronchial Needle Aspiration (TBNA) on February 4, 2025

Diagnostic Findings

The EBUS Fine Needle Aspiration Cytology (FNAC) report revealed:

- Reactive lymphadenitis (stations 7 and 4R)

- No evidence of granuloma or neoplasia

All other reports were negative, but Non-Tuberculous Mycobacteria (NTM) was isolated on PCR in March.

Microbiological Reports and Treatment

The patient received drug sensitivity and culture reports, which showed:

- Mycobacterium abscessus was isolated

- Sensitivity to amikacin, linezolid, tigecycline, and clarithromycin

Consequently, the patient was started on all these antibiotics from March 11, 2025, and continues on this treatment regimen to date.

Current Clinical Status

The patient's current state is characterized by:

- Significant weight loss: 52 kg to 42 kg over 8 months

- Persistent symptoms:

    - Intermittent, low-grade fever

    - Easy fatiguability

    - Shortness of breath (Grade 3)

    - Hoarseness of voice

    - Painful oral ulcerations with inflamed tongue, leading to reduced oral food intake

- Appetite: slightly improved

Past Medical History

- No known history of:

    - Diabetes Mellitus (DM)

    - Hypertension (HTN)

    - Asthma

    - Coronary Artery Disease (CAD)

    - Epilepsy

Family History

- No relevant family history

Immunization History

- Yearly influenza vaccination

- 5-yearly pneumococcal vaccination

Personal History

- Diet: Vegetarian

- Appetite: Reduced

- Bowel and bladder habits: Regular

- Sleep pattern: Slightly reduced

Concerns and Questions

1. Duration of antibiotic consumption:The patient has been on antibiotics for an extended period, which increases the risk of antibiotic resistance, side effects, and interactions.

2. Potential side effects: The patient is at risk of developing side effects from her medications, such as nephrotoxicity, ototoxicity, and peripheral neuropathy.

3. Alternative management options: Considering the patient's persistent symptoms and reduced quality of life, it is essential to explore alternative management options, including surgical interventions or other medical therapies.

4. Improving quality of life:The patient's significant weight loss, persistent symptoms, and reduced appetite have severely impacted her quality of life. It is crucial to address these issues and develop a plan to improve her overall well-being.The patient is at risk of developing side effects from her medications, such as nephrotoxicity, ototoxicity, and peripheral neuropathy.