Robotic Resection of Stage IIIC Ovarian Cancer: Achieving an R0 Outcome

A 38-year-old woman with a history of endometriosis, fibroids, and a 4.6 cm left ovarian cyst underwent what was initially planned as a robotic myomectomy and ovarian cystectomy. Intraoperative frozen section of an unexpected uterine fundal implant revealed high-grade adenocarcinoma. Upon further exploration, small nodules were identified on the vesicouterine peritoneum, left pelvic sidewall, sigmoid colon, descending colon, and right diaphragm. Although no upper abdominal or chest imaging was performed preoperatively to calculate a Peritoneal Cancer Index (PCI), a Fagotti score of zero indicated a strong likelihood of achieving complete surgical resection (R0).

The patient underwent an extensive robotic cytoreductive procedure: total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic and paraaortic lymph node dissection, infracolic omentectomy, and resection of all visible nodules. Surgeons repaired a serosal defect on the sigmoid colon, then re-docked the robot to remove two diaphragmatic nodules and close a small defect without placing a chest tube. She left the operating room cancer-free (R0 resection) after a mere three hours, with minimal blood loss. Pathology confirmed a stage IIIC high-grade serous carcinoma of the ovary, involving the colonic lesion and diaphragmatic nodules. Immunohistochemistry was consistent with serous carcinoma (PAX-8, ER, CK7, p16 positive; p53 negative).

Three weeks post-surgery, the patient began six cycles of IV carboplatin and paclitaxel, completed successfully without delay. Her tumor profiling revealed no BRCA mutation but did confirm homologous recombination deficiency (HRD). As adjuvant therapy concluded, imaging showed no evidence of disease, and she started PARP inhibitor maintenance at a reduced dose due to anemia. At present, she has been without evidence of disease for 27 months since finishing chemotherapy, with consistently low CA-125 levels (12-16) and no clinical signs of recurrence.