Case history:

Diagnosis of ovarian carcinoma in (approx. 5 years before this report)

Therefore, a surgical procedure was carried out on (shortly after diagnosis): ITAB + Omentectomy + appendectomy.

The results of the histology test were as follows:

Papillary serous ovarian carcinoma G1, p53 neg., E receptors + 70%, Rec. Prog. 90% +.

This was followed by adjuvant chemotherapy with carboplatin x 6 cycles from , the last being on (5 month period, also approx. 5 years earlier).

At the onset of the relapse in-(just under 2 years prior to this report) (very slight ascites attributable to carcinosis -> CAT scan: Numerous hepatic lesions, the largest being 4 cm; hepatic hilar lymph nodes, Spleen + paraaortic lymph nodes). The patient had Tax-JM 8 x 6 cycles with a relapse in the hepatic region. This was followed by Taxol maintenance, which was stopped after the 7th cycle due to a marker increase.

In (approx. 1 year prior to this report), the CAT scan was negative. The patient then took Nomafen 20 mg, 1 tablet a day, from (about 10 months earlier) for 8 weeks.

Due to left axillary lymph node and right supraclavicular dissemination, from--- (approx. 2-3 months prior to this report), the patient had 8 cycles of polychemotherapy with Caelyx-Oxaliplatin, achieving clinical and biochemical remission of more than 50% at the follow-up visit on: “reduced (<50%) mediastinal, paraaortic, hepatic hilus and celiac lymph nodes and a decrease in the marker (CA 125: 56.8 prior to last cycle). During the follow-up on (same time), it was confirmed that the patient should continue with the chemotherapy started on (6 cycles of Cae-Oxali) as scheduled, although reducing the dose due to toxicity.

Given the above, the questions are as follows:

1) Can you confirm the diagnosis?

2) Can you confirm the current therapy?

3) Are there any specialist centres for the diagnosis that was given?

Medical Report:

This report is primarily based on the enclosed paper of clinical information, a disk and without seeing the aforementioned patient. Nor is this report based on any official pathology report or revision.

The patient is a 61 year old patient that underwent resection of the uterus, adenexae, onsectonomy and appendectomy for grade 1 papillary serous carcinoma of the ovary. There is no further regarding tumor extent and stage at diagnosis and no information whether she underwent optimal or sub-optimal debulking surgery.

Between --- and --- (5 month period approx. 5 years earlier) she received six cycles of chemotherapy consisting of Carboplatin alone. (Dosage was not mentioned)

Tumor recurrence was diagnosed in (approx 2 years earlier), CT scan revealed numerous liver lesions, the largest being 4 cm in diameter and lymphodamopathy in the porta-hepatis, splean and retroperitoneum (para-atriortic lymph nodes). No further information regarding the liver lesions being paramchymal or on the surface of the peritoneum that covers the liver was disclosed.

Since then she received chemotherapy with Taxol. (JM is not a medical term. Does it mean Gemetabare? And is it in addition to the Paxol or anything else?)

Later the patient received Nomafen 20 mg x1 (probably Tamoxifen) with tumor progression after 8 weeks.

Patient is being treated with chemotherapy consisting of Caelyx Oxyplatin for tumor involving lymph nodes of the mediastinal, heptic hylus, para- aortic and celiac since ---(approx. 10 months earlier). After 8 cycles with this treatment it is believed to be the cause of some tumor regression and the decrease of CA-125.

To answer your questions:

1. Results of pathology should be confirmed by a pathologist that will review slides of pathology. Given the pathology is as mentioned above, there is no need of further pathology. For sure, we are dealing with the same tumor that recurred or progressed.

2. Since there is some degree of remission, I recommend that the patient continue with the same chemotherapy treatment (i.e. Oxilaplatin and Caelyx) until tumor progression. Should patient performance status stabilize, I would then consider a new line of chemotherapy.

3. There are several centers dealing with Gynecological Cancer in different areas. However what I think is the most relevant for this patient is to see Dr… a medical oncologist that specializes in this field. Dr … works in a center called …

Sincerely,

Dr.----

Medical Oncologist at ---- Institute of Oncology