Nursing Objectives
 

Describe the clinical presentation of ovarian cancer.

 

Discuss the principles of medical management of ovarian cancer.

 

Describe the WOC Nurse Specialist's roles as caregiver, educator, and collaborator in managing complex wounds in a patient with ovarian cancer.

 

Identify the quality of life issues experienced by patients undergoing treatment of ovarian cancer complicated by wounds caused by necrotizing fasciitis.

More than 25,000 women will be diagnosed with ovarian cancer in the United States this year. Approximately14,500 women die from this disease annually. Ovarian cancer causes more deaths than any other gynecologic cancer and it is the fifth most common cancer in women.¹  The etiology of ovarian cancer is unknown. Although several risk factors have been implicated, a high-risk population has not been defined.²  Most cases are diagnosed in women between 50 and 59 years of age.³  At diagnosis, 60% to 70% of women have advanced diseases, stage III or IV (Tables 1 and 2), accounting for the high mortality rate.⁴ Epithelial carcinomas represent 85% to 90 % of all ovarian neoplasms. Tumors may also arise from the germ cells (eg, dysgerminomas, chorio-carcinomas) or from stromal cells (eg, granulosa and thecal cell tumors).⁵ This paper focuses on the management approaches for epithelial carcinoma of the ovary.

Signs and symptoms of ovarian cancer are vague (dyspepsia, indigestion, flatulence, eructation, anorexia, pelvic pressure, or urinary frequency ), and are often attributed to stress or changes associated with aging.² These nonspecific complaints do not usually prompt physicians to pursue a diagnostic work-up for ovarian cancer. Unfortunately, diagnostic evaluation only occurs when a woman presents with late signs and symptoms, including a palpable abdominal or pelvic mass, ascites, pleural  effusion, intestinal obstruction, or weight changes.⁴

Treatment of ovarian cancer involves extensive evaluation, surgical staging, and cytoreduction. Preoperative procedures are conducted to determine bowel, bladder, liver, and pulmonary involvement. A surgical staging laparotomy is essential for accurate evaluation of pelvic and abdominal structures. Surgical procedures include total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO); peritoneal cytology; omentectomy; lymph node biopsies or removal; multiple biopsies of the bladder, bowel, liver, and diaphragm; appendectomy; and debulking cytoreduction of all visible tumor. Adjuvant therapy using chemotherapy (paclitaxel and cisplatin or carboplatin), radiation therapy for metastatic disease, and biotherapy are indicated in the management of stages III and IV epithelial ovarian cancer. Hormonal therapy (eg, megestrol acetate and tamoxifen citrate) may be used in salvage therapy.⁴

Technical advances in surgery, and the development of new chemotherapeutic agents in the last 20 years, have improved relative 5-year survival rates. Thirty years ago only one third of patients survived 5 years.⁶ Most women with ovarian cancer experience disease recurrence and ultimately die from the disease. Morbidity and mortality follow the occurrence of abdominal carcinomatosis. If the bowel and mesentery are involved, intestinal obstruction, malabsorption, electrolyte and fluid imbalances, sepsis, or cardiovascular collapse may occur. Treatment toxicity, concurrent medical problems, and pulmonary embolus may also contribute to the cause of death.²

No maintenance therapy regimen has been established to prevent or delay recurrence in patients who achieve a clinical complete remission. No evidence exists to support the theory that a second look surgery affects survival or disease free survival. Clinical trials are ongoing to evaluate effects of intraperitoneal therapy, whole-abdominal therapy, continuation of chemotherapy and high dose  chemotherapy in patients with a complete remission.⁶

Case Study

RP was a 55 year old, married, Hispanic woman from south Texas who began experiencing abdominal pain, bloating, nausea, and vomiting in February 1999. Her family physician suspected that she had ovarian cancer after reviewing results of her abdominal CT and paracentesis. He advised her to seek treatment at M.D. Anderson Cancer Center. She was seen in the Gynecologic Oncology Center and had surgery on March 19. Once the peritoneum was entered, 8 L of bloody ascites were drained. Mrs. P underwent optimal tumor reductive surgery with TAH, BSO low anterior resection of the colon, and creation of an end-descending colostomy. A 5cm x 5cm tumor encasing and infiltrating the sigmoid colon was resected, and an omentectomy was done to remove the omental cake, which extended from the hepatic flexure to the spleen. Residual tumor included a 1 cm mass around the spleen tip and small implants on the  diaphragm. Reanastomosis of the bowel was not possible because the hepatic flexure mesentery was too shortened. The malignancy was staged as stage IIIC ovarian cancer.

The patient had an uneventful post operative course during which she and her husband learned to care for her colostomy. Mrs. P had a 13 year history of diabetes mellitus. She had controlled  her blood  glucose with oral medication and diet. Her glucose remained within an acceptable range after surgery. However her serum albumin level was 1.5 g/dL on March 27 (normal range: 3.5 to 4.7 g/dL) and clinicians believed that the cancer or diabetes-related nephropathology, or a combination of both caused the decline. Nine days after surgery, Mrs. P tolerated her first doses of  carboplatin and paclitaxel well. The next day, her abdominal incision staples were removed. A slight amount of drainage from the distal htmlect of the incision was noted, the area was probed but held, and steri-strips were applied. Later that day, the wound separated and measured 4 cm in length by 0.5-1 cm in depth. The fascia was intact but subcutaneous edema was noted. Wound care (normal saline-moistened gauze packing was initiated, the family was taught dressing technique, and the local home nursing care agency was alerted for follow-up. Mrs. P was eager to leave the hospital to spend Easter with her family. She was discharged on March 29, with plans to return in 1 month for chemotherapy.

During the next 3 weeks, Mrs. P was seen by her local physician, who hospitalized her for treatment of hypokalemia. She also was treated with ciprofloxacin for a week when her wound drainage became purulent. Mrs. P became progressively weaker and had difficulty standing and maintaining urinary continence. Her family became increasingly concerned with her failure to improve and brought her back to M.D. Anderson on April 27, before her scheduled clinic visit. She was admitted to the hospital with a sever wound infection, abdominal pain, and severe pain in her legs, upper thigh, and perineal area. The wound measured 9cm long, 4cm wide, and 2.5 cm deep. A cotton-tipped applicator was passed laterally at least 14 cm toward the colostomy stoma. The wound was lined with yellow necrotic tissue and produced milky, gray, odorous drainage. Further diagnostic work-up found that Mrs. P had subcutaneous air in the tissues of the abdomen, groin, mons, inner thighs, and buttocks, with communication between sites. Significant laboratory values were: albumin 2.2 g/dL; glucose 288; potassium 5.2; hemoglobin 9.7 g/dL; and WBC, 30,000/uL. She also had a pleural effusion. She was examined by several surgeons and was given broad-spectrum antibiotics and antifungal therapy for suspected necrotizing fasciitis.

Wound assessment and debridement of necrotic fascia, skin, muscle, and subcutaneous tissue were done in the OR four time over the next 6 days. Tissue cultures identified methicillin-resistant Staphylococcus aureus, Burkholderia, Klebsiella, Pseudomonas, Ecoli, and Enterococcus. Appropriate medications were administered, and total parenteral nutrition was initiated. The necessary isolation procedure was observed.

On May 4, the abdominal wound was 21 cm wide x 13 cm long x 2-3 cm deep; the left thigh wound was 22 cm long x 8cm wide; and the right thigh wound was24 cm long x 3.5 cm wide. The Gynecologic Oncology Service Staff consulted with physicians from Plastic and Reconstructive Surgery (PRS) and from Physical Medicine and Rehabilitation (PM & R). A plan of care was devised for extensive wound care by means of negative pressure therapy. When Mrs. P's nutritional status could be improved and the wounds were clean, the wounds would be skin grafted. Mrs. P would also require long-term physical therapy during treatment and recovery.

Vacuum-Assisted Closure Wound Therapy

Vacuum-assisted closure (VAC) therapy (KCI, San Antonio, TX) involves application of controlled negative pressure to achieve wound closure. VAC therapy removes excess stagnant fluid in surrounding tissues, thereby reducing edema, improving blood flow, and decreasing bacterial colonization, Epithelial cell growth and local vascularization are promoted by stretching and distorting cells in the moist wound environment ^7,8 VAC therapy is indicated for the treatment of chronic wounds, acute wounds, meshed grafts,  dehisced surgical incisions, and tissue flaps. Therapy is contraindicated for wounds with fistulas, excess necrotic tissue, untreated osteomyelitis, or cutaneous malignancy.⁹

The VAC dressing is changed once every 48 hours. universal precautions should be followed during removal of soiled dressings, cleansing wounds, dressing wounds, and  waste disposal. The dressing technique involves cutting a surgical sponge to fit the dimensions of each wound. Fenestrated tubing is laid on the foam sponge. The tubing and sponge are covered with transparent film drape to ensure an occlusive seal. Coating with a skin prep or framing the wound with a hydrocolloid dressing before drape application can protect periwound skin.

To begin VAC therapy, the canister is pushed into the VAC pump unit. The canister's tubing is connected to the dressing tubing . The unit is activated, specific parameters are set, and therapy is begun, causing the foam sponge to compress within the wound bed. Negative pressure can be set to run on a continuous or intermittent schedule and at various pressures, depending on the type of wound and on patient tolerance.

Wound, Ostomy, Continence Nursing Intervention

A wound, ostomy, continence nurse (WOCN) had established a relationship between Mrs. P and her family during her first clinic visit and subsequent hospitalization at M.D. Anderson. During that time, preoperative education, stoma marking, and self-care teaching were done to prepare her for living with a colostomy. Her husband and her son willingly began to develop proficiency and confidence in performing colostomy care. Mrs. P and her entire family also had to cope with the stresses of her ovarian cancer diagnosis and treatment. Her chemotherapy and surgery, active cancer disease, nutritional deficiencies, and diabetic history had all compromised her immune system, making Mrs. P extremely susceptible to aggressive and potentially life-threatening infections.

At M.D. Anderson, the WOC nurses are responsible for application and management of VAC therapy. Therapy began May 4 and continued for 20 days. The first and second dressing changes were done in the operating room. The patient was sedated with general endotracheal anesthesia and placed in the dorsal lithotomy position. Necessary sharp debridement was performed before dressing the three wounds (Figures 1 to 5). The Gynecologic Oncology, Plastic Surgery, and Orthopedic Services were all involved in assessment of the wounds.

Subsequent VAC dressing changes were done at the bedside. Avoidance of pain was of great concern for the patient, the family, and all care providers. Therefore, the Conscious Sedation Team became responsible for pain management. The WOCN coordinated scheduling of the Conscious Sedation Team for dressing changes to be done three times a week. She informed the medical staff of the scheduled dressing changes to facilitate their wound inspection and intervention.

Each dressing change required participation of several members of the WOCN team - two performed wound care and at least two others were needed to position the patient in the dorsal lithotomy position. The inpatient unit's nursing staff was involved in monitoring the patient and maintaining  an adequate seal over the  foam sponges between dressing changes. They also provided compassionate nursing care and emotional support to Mrs. P and her family during this physically and emotionally taxing time.

On May 21, the wound dimensions were: abdomen, 21cm x 8cm; left groin, 14 cm x 6 cm; and right groin, 13 cm x 4 cm. There was a 4 cm deep tunnel extending downward over the symphysis pubis bone. The PRS Service deemed that healing had progressed enough to proceed with skin grafting of the open wounds. Three days later, Mrs. P returned to the OR, where her wounds were irrigated, debrided, and curetted to clean appearing granulation tissue (Figure6)Meshed split-thickness skin grafts were applied to the abdominal wound but not to the exposed periosteum of the pubic bone. The entire left groin wound was grafted. The right groin wound was grafted except for a 2 cm x 3 cm area over the ischium, which did not appear clean. The grafts were sutured and then covered with nonadhering dressing. VAC foam sponges wee applied over the skin grafts. over the suprapubic bony are, and to the right ischial area.

Over the next four days, Mrs. P's activity was limited to bed rest to ensure healing of the grafts. She had previously been placed on an alternating pressure mattress. This support surface therapy was continued until her activity was liberalized.

On May 28, Mrs. P returned to the operating room. Under sedation, the VAC dressings were removed. The plastic surgeon noted that the split-thickness skin grafts in all areas were 100% successful (Figure 7 and 8) Vacuum-assisted closure was no longer needed. Ongoing healing of the skin grafts was accomplished with topical moist dressings. The suprapubic wound was debrided and partially closed. The remaining area (5 cm deep x 1 cm wide) was packed with normal saline-moistened gauze and eventually with a ribbon of Convatec Aquacel hydrofiber wound dressing during the daily dressing changes.

Because infection and wound resolution were  the highest priorities, Mrs. P's cancer therapy  was deferred until she could better tolerate the effects of chemotherapy. By early June, her CA-125 level had risen to 576 (preoperative 1,600, postoperative 250), she was experiencing anasarca, and wound healing had slowed. Mrs. P was anxious about the delay in treatment. She received her second dose of carboplatin on June 9.  Mrs. P worked with physical and occupational therapists throughout her hospitalization. By the end of June, she transferred to M.D. Anderson's inpatient PM&R unit. Over the next 2 weeks she was weaned off total parenteral nutrition and was able to meet daily nutritional requirements orally. Mrs. P and her son worked with the diabetes nurse educator to learn diabetic management. Her spirits and appetite improved after the addition of sertraline (Zoloft^®) to her medication regiment. The WOCN and PRS services continued to monitor wound healing during rehabilitation. At discharge, the abdominal and inguinal wounds were completely healed,. The suprapubic wound was 3.5 cm deep and the pubic bone was visible (Figures 9-12). Mrs. P's husband and the son were taught daily wound care to promote healing and to maintain skin integrity. Signs and symptoms of infection were also reviewed with the family. All other issues were addressed before discharge, and home nursing referral was made to monitor and support Mrs. P during her recovery. She tolerated the third dose of carboplatin, and three days later on July 9, 1999, was discharged.

During the ensuing months, Mrs. P continued to receive chemotherapy every 4-6 weeks for a total of 8 courses. her CA-125 level dropped to within normal range by the end of the year. All skin-grafted areas remained closed, but healing of the suprapubic wound has been protracted. In January 2000 Mrs. P began to receive tamoxifen. She was scheduled  for further evaluation of her ovarian cancer and wound care.

References

1. Cancer Facts & Figures - 1999. Atlanta, GA American Cancer Society, Inc. 1999.

2. Walczak JR, Klemm PR: Gynecologic cancers. In: Groenwald SL, Frogge MH, Goodman M, et al, eds. Cancer Nursing Principals & Practice, 3rd ed. Boston, Jones & Bartlett, 1993, pp 1072-1084

3.Clark JC: Gynecologic cancers. In: Otto SE, ed. Oncology Nursing. St Louis, Mosby Year Book, 1994, pp 193, 201-205.

4. Flannery M: Nursing care of the client with genital cancer. In: Itano JK, Taoka KN, eds. Core Curriculum for Oncology Nursing 3rd ed. Philadelphia, WB Saunders Co, 1998, pp 535-539

5. Winn RJ: Ovarian cancer, Clinical practice guidelines and care pathways. In: Negotiating Optimal Ovarian Cancer Care: A clinician's Guide. Bala Cynwyd, PA, Meniscus Educational Institute, 1999, pp 2-9.

6. Ozols RF: Ovarian cancer, current treatment and controversies. In: Negotiating Optimal Ovarian Cancer Care: A Clinician's Guide. Bala Cynwyd, PA, Meniscus Educational Institute, 1999, pp 10-17

7. Mendez-Eastman S: Use of hyperbaric oxygen on negative pressure therapy in the multidisciplinary care of a patient with non healing wounds. J Wound Ostomy Continence Nurs 1999;26(2):67-76

8. Argenta LC Morykwas MJ: Vacuum-assisted closure, a new method for wound control and treatment. Clinical experience. Ann Plastic Surg 1997;38(6):563-576.

9. VAC Recommended Guidelines for Use in Wound Closure. Physician & Caregiver Reference Manual. KCI USA, Inc. 1999

Table 1: Staging for Ovarian Cancer*

Stage    Description

I            Growth limited to the ovaries

IA          Growth limited to one ovary; no tumor on the external surfaces; capsules intact

IB           Growth limited to both ovaries; no ascites; no tumor on the external
               surfaces; capsules intact

IC            Either stage IA or IB tumor but with tumor on surface of one or both ovaries,
                with capsule ruptured, with ascites present containing malignant cells, or
                with positive peritoneal washings

II              Growth involving one or both ovaries with pelvic extension

IIA            Extension and/or metastases to the uterus and/or tubes

IIB            Extension to other pelvic tissues

IIC            Either stage IIA or IIB tumor but with tumor on the surface of one or both
                ovaries, with capsule(s) ruptured, with ascites present and containing
                malignant cells, or with positive peritoneal washings

III              Tumor involving one or both ovaries, with peritoneal implants outside the
                 pelvis and/or positive retroperitoneal or inguinal nodes; superficial liver
                 metastasis equals stage III

IIIA            Tumor grossly limited to the true pelvis, with negative nodes but histologically
                 confirmed microscopic seeding of abdominal peritoneal surfaces

IIIB            Tumor of one or both ovaries, with histologically confirmed implants of
                  abdominal peritoneal surfaces, with none exceeding 2 cm in diameter;
                  nodes are negative

IIIC            Abdominal implants greater than 2 cm in diameter and/or positive
                 retroperitoneal or inguinal nodes

IV              Growth involving one or both ovaries with distant metastases; if pleural
                  effusion is present, cytology must be positive to allot a case to stage IV;
                  parenchymal liver metastasis equals stage IV

                    *International Federation of Gynecology and Obstetrics

Table 2: 5-year Survival Rates for Women With Ovarian Cancer

Stage                               5-Year Survival Rate %

I                                                       80

II                                                      60                                                          

IIa                                                    60  

IIIb                                                   30   

IIIc                                                  5-10

IV                                                      5