Weekly chemotherapy vs. full dose for elderly patient?

Hello doctor,

I would like to know about weekly chemotherapy for peritoneal cancer in a 76-year-old lady. Instead of full-dose chemotherapy at 21-day intervals, weekly chemotherapy is done at a lower dose to have fewer side effects.

The first chemotherapy given to her caused severe side effects such as dysentery and diarrhea. Please confirm whether this is really beneficial. For elderly patients, whether the weekly scheme is as effective and less toxic.

My 76-year-old sister is suffering from primary peritoneal carcinoma. Four years ago, one doctor, while treating her for asthma, detected by clinical examination a huge lump in the abdomen. He ordered a USG of the lower abdomen and pelvis. The report says:

1. Kidneys: Both kidneys are normal in size but maintain shape, outline, and position. Cortical echogenicity is increased with maintained corticomedullary differentiation. No evidence of any hydronephrosis, renal calculus, or mass lesion is seen. Right kidney = 7.4 centimeter, Left kidney = 7.5 centimeter

2. Ureter: Both ureters are not visualized; hence, not dilated. Urinary bladder: Urinary bladder is normal in size, shape, and wall thickness. No intraluminal lesion is seen. Uterus and ovary: Not visualized (removed in 1996).

3. The suprapubic region mesentery is grossly thickened and appears as SOL (10.4 X 5.4 centimeters) with a displaced bowel loop around it.

Impression:

1. Mesenteric mass; suggest a CT scan.

2. Bilateral small-sized kidneys with Grade I renal parenchymal changes.

Next, she was seen by an oncologist. He ordered a noncontrast CT of the upper abdomen (noncontrast because her creatinine level was 1.9 milligrams per deciliter compared to a maximum of 1.0 milligrams per deciliter for females).

CT scan of the upper abdomen shows:

1. The liver is normal in size and contour with normal attenuation.

2. No intrahepatic biliary radical dilation.

3. The gallbladder is well distended with normal wall thickness.

4. The pancreas is normal in size and attenuation.

5. Peripancreatic fat planes are normal.

6. MPD not dilated.

7. Spleen is normal in size, contour, and attenuation.

8. No focal lesions.

9. Sections through the lower abdomen show omental fat stranding and nodularity.

10. Bilateral kidneys are mildly contracted.

11. Pelvicalyceal systems are normal.

12. Adrenals are seen.

13. No evidence of any focal lesions.

14. No evidence of ascites.

15. No retroperitoneal lymphadenopathy is noted.

16. Visualized bowel loops reveal normal position, caliber, and wall thickness.

17. Scoliosis noted with convexity towards the left side.

Impression: Omental stranding and nodularity.

The surgeon also asked for a contrast-enhanced MRI of the pelvis. The report shows:

1. Patient postoperative case of ovarian malignancy (no documents available). Study reveals omental thickening and nodularity (caking). There is a focal protrusion of the omentum through a defect in the umbilicus (postoperative).

2. Post-contrast study shows enhancement of the omentum. DWI images show restricted diffusion within the omentum. No abnormal lymphadenopathy was seen. Bones under review are within normal limits. Uterus and ovaries are not visualized (postoperative). There is minimal pelvic ascites.

3. Post-contrast study shows thin smooth peritoneal enhancement with a few nodules in places. Enhancement is also noted along the sigmoid and descending colon.

Impression: Nodular, cake-like omental thickening, smooth peritoneal enhancement with nodularity at places in a patient with previous malignancy; these features suggest the possibility of peritoneal carcinomatosis. (Advise omental biopsy)

Next, a core needle biopsy from the omental mass was ordered. The report shows:

1. USG-guided core biopsy from omental mass.

2. Microscopic examination shows deposition of malignant glands formed by cuboidal cells within fibrocollagenous tissue with desmoplastic stromal reaction.

Impression: Adenocarcinoma deposit.

I have forwarded to you four reports in respect of her for USG, CT scan, MRI, and biopsy. Probably, she is suffering from extra-ovarian primary peritoneal cancer (EOPCC), which happens in candidates whose ovary/uterus has already been removed.

For her, a hysterectomy was done some 20 years back when the biopsy report was normal. Please also note that her CA 125 is 2948 units per milliliter, almost 80 times the normal value.

Please advise in short whether the first dose of chemotherapy given caused severe side effects such as acute dysentery and diarrhea for her. Whether, at this age of 76 years, chemotherapy with one single drug is advisable.

As per the discussion with doctors here, this peritoneal cancer resembles ovarian cancer (treatment mode also the same), although the ovary was removed 20 years back.

Kindly help.

Thank you.